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HESI Concepts From Start To Finish

Your Name Here:


Collected Works To Help Facilitate Success. Intended to

Supplement Existing Literature, Not Replace It.
Preliminary Version
Super Condensed Portable HESI Study Guide 2

General Usage Instructions/How to Use This Document:

1) Read your HESI BOOK!, textbooks, and notes.

2) If viewing this in MS Word, hit “Ctrl-F” on your keyboard and

then type in whatever you are looking for into the box and hit the
“Enter” key on your keyboard until you find what you are looking

3) If you are scrolling through this document each applicable section

is listed “Key Points”, “#” (which key point number), “subject
matter title”

4) Rinse and repeat.

Super Condensed Portable HESI Study Guide 3



To prepare for the exam (whether a subject exam or exit exam) use and have the
following materials/resources available:

1) HESI study book from evolve (ISBN# 9781416047759)

2) HESI case studies from evolve

3) HESI practice test CD which comes with the HESI book

4) HESI Practest 2009 questions from evolve

5) HESI related flashcards, not from evolve

6) HESI study notes compiled by faculty and previous ADN students (lab values,
meds, etc.)

7) HESI related powerpoints for remediation and instructional purposes, not from

To prepare for the test itself:

1) Become an expert at the nursing process r/t questions, answers, and related

2) Determine my optimum learning style

3) Practice visualization and guided imagery

4) Practice and refine test taking skills

5) Stress relief and coping skills developed and utilized

6) Determine areas of weakness in previous HESI exams (via the statistical report
provided after taking the test)

7) Practice the practice tests on the computer until i memorize/understand the

questions and related material (until I have it down cold via repetition)

8) Review the rationales on the Practest questions, case studies, and practice test
CD relentlessly (usually start with this first... essentially reverse engineer the
questions starting with the rationales and working backwards)
Super Condensed Portable HESI Study Guide 4

9) Memorize hints, meds, ranges, lab values, etc. as outlined in the HESI study
book (with an intent to not be caught off guard by material you haven't seen
before and to not forego any easy points)

10-A) Block off two weeks or more to constantly review the HESI book

10-B) Alternatively, study the HESI book as the semester progresses.

11) Foregoing studying from other non-evolve resources such as the saunders
book temporarily (rationale: HESI test comes from HESI/Evolve related products,

12) Host/goto HESI review sessions with other students about to take the test
(rationale: If you can teach it, you get a better understanding=proficiency,

Where to get some of the above resources:

Austin Community College. Test taking strategies. Available at:


Link for the hesi book + practice test 2009:


HESI online case studies only:


HESI case studies + practice test 2009:


HESI study book only:

Super Condensed Portable HESI Study Guide 5

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Accountability: After practicum No Practicum: After practicum No Practicum: No Practicum:
You only have yourself and 50 questions
your success or failure to 200 questions 200 questions throughout the day.
account to. Practicum ?? 50 questions 200 questions e.g. 25 Med- throughout the Not in one sitting
throughout the day. Surg; 25 Pedi day. Not in one 50-med surg
e.g. 25 Med-Surg; Not in one sitting sitting 50-pedi
100 questions (you may have 25 Pedi 50-med surg 50-med surg 50-psych
to get up extra early to After practicum 50-pedi 50-pedi 50-women’s health
complete them). No more than 50 50-psych 50-psych
questions. It will Books to have next 50-women’s health 50-women’s
not be productive to you: health
Goal: is to complete 800-1000 on a long day. Med-Surg
questions by Sunday before 5 Lab Ref.
p.m. e.g. 25 Med- Drug book
Surg; 25 Pedi Fundamentals
Med. Dictionary
Do not worry so much about
your grade for the exams—
the most important thing is to Do 4 HESI case
understand why you answered studies In addition to reviewing
the question(s) incorrectly. In addition to In addition to In addition to rationales, go back to your texts to
Review Meds-Pub reviewing In addition to reviewing reviewing read up if you were not familiar
Do 3 HESI case studies Dosage rationales, go back reviewing rationales, go rationales, go with the disorder/disease.
Calculations to your texts to rationales, go back back to your texts back to your texts
Review Meds-Pub read up if you were to your texts to read to read up if you to read up if you Due 6 HESI case studies
Therapeutic Communication not familiar with up if you were not were not familiar were not familiar
the familiar with the with the with the Review Meds-Pub on Nursing
disorder/disease. disorder/disease. disorder/disease disorder/disease Process

Do 5 HESI case Due 3 HESI case Due 6 HESI case Due 2 HESI case
studies studies studies studies

Review Meds-Pub Review Meds- Review Meds-

NCLEX review Pub on Nursing Pub on Nursing
prep. Process Process


Note: “Fear” of the unknown only serves us from moving forward. Your self-discipline, commitment to
working hard and faith will help get you through this.
Super Condensed Portable HESI Study Guide 6

Before the test:

The HESI and NCLEX tests use the steps of the nursing process (assessment, nursing
diagnosis, planning, intervention, and evaluation) to evaluate how you critically think
about and apply your knowledge about nursing principles and skills during the care of
patients. Do the following before the test:

1) Review the nursing process and critical thinking. You need to be very familiar
with the stages of the process and the nursing actions associated with each stage,
and be prepared to identify whether a certain action is used in the planning or
evaluation phase of the nursing process.

2) Review material which will refresh your knowledge on developmental issues at

all stages of life which will help with pediatric health questions.

3) Use an NCLEX study book to familiarize yourself with the type of questions to
expect and review the answers to understand why they are correct. Know the
common electrolyte values and signs of abnormal levels, common drugs. Don't
read things into the questions or assume things that are not part of the question.
After you read the test question only, close your eyes. Think about what the
question said and what you know about it, and only then, look at the answers.
Practice the questions with same time limit used in the NCLEX testing: 90
seconds per question.

During the test be careful about:

1. Reading too much into the questions. Look at what is there, what you know. Unless it
is specified, don't assume that you know the patient's gender, age, diagnoses, situation
or where the interaction is occurring (home, street, nursing unit).

2. Reading too much into the answers. See above.

3. Using the answer choices to search your brain for information.

a. Try covering up the answers and read the question. Think about the distracters
(unneeded/ irrelevant information and words like "all of the following”, ”except",
"not", etc).
b. Think about what you know about the subject. If you can't recall anything, look
at the words and think about their meaning (dys=not or abnormal, anti=against),
or what they sound like (sarcoma sounds like carcinoma, so a sarcoma is a type of
cancer), or what body system they might be a part of (autonomic=nervous
c. Then, think again about what you know and look at each answer to see if it
relates to what you know.
Super Condensed Portable HESI Study Guide 7

4. Becoming anxious. If you are feeling overwhelmed, discouraged, tired: STOP for a
minute or two. Do deep breathing or relaxation or visualization. Use positive,
affirmational self talk- NO negativity! You need your mental energy to concentrate, just
like you do in the hospital when patient care situations get tough, like severe bleeding or
a code.

5. Be sure to print out the test analysis at the end to have as proof of completion of the
test and to help guide future review work.


Initial = Assess

Essential = Safety

Base your Assessment on Malsow’s Hierarchy

Absolute Words– These words tend to make answers wrong:

 Deadly Words
 All
 Wholly
 Every
 Total
 Alone
 Sole
 Lone
 Nothing
 Always
 Forever
 Entire
 Whole
 Completely
 Each
 Only
 Any nobody
 Never
 None
 Everywhere

Dangerous Words– are words are strong words. These are words that are strong
but not as absolute as the “deadly” words.

If you see these words look carefully at the answer. There is a strong chance it is
Super Condensed Portable HESI Study Guide 8

 Main
 Paramount
 Primarily
 Inevitable
 Eliminate
 Regardless
 Impossible
 Too
 Chief
 Avoid
 Major
 Shall
 Will rarely
 Lack

Safe Words – Are qualified answers or hedging words make answers correct. These
words are usually “safe” to choose:

 Usually
 Frequently
 Potentially
 Sometimes
 Some
 Occasionally
 Essentially
 Generally
 Maybe
 Commonly
 Seldom
 Normally
 Almost
 Probably
 May
 Partial
 Might
 Should
 Few
 Nearly
 Could
 Average
 Often

Parts of the question

 The case (scenario) – description of client or what is happening to the client
 The stem – the part that ask the question
Super Condensed Portable HESI Study Guide 9

 Response – choosing correct response

 Distracters - incorrect but feasible choices
 Key word – determine the key words related to the client, problem or
specific/aspect of the problem



Details (What is asked?)

Client – age, sex, marital status may be relevant

Who is the focus of the question: nurse, client, spouse, child, family, etc.

Test taking tips & techniques:

 Problem solving applies to nursing
 Assess signs & symptoms
 Determining the nursing diagnosis
 Evaluating the outcome criteria


 Three obvious incorrect answers leaving the odd man wins

 “High blood pressure”, “Low blood pressure”
 “Increase IV drip”, “Stop IV”
 “Turn to the left”, “Turn to the right”

When there are two answers that are opposite, the two automatically eliminates the other
two choices but the downside is which of the two opposite answers is correct.


 Client has tachycardia, Client has a rapid heart beat
 Client has difficulty breathing, Client has dyspnea

Do not choose these answers, eliminate both, leaving the other two choices to be the
correct answers.


 Words in the question are found in the answer
 Caring in the question and the word caring is in the answer

Super Condensed Portable HESI Study Guide 10

Maslow’s Hierarchy


Love & Belonging




Use Maslow’s Hierarchy to answer your questions. Physiology needs will always be
your first choice when answering a question with the exception of Psychological

 “What actions take priority”
 “What should the nurse do first”
 “What should the nurse do initially”
 “What is essential for the nurse to do?”

Advising is always incorrect:
 “What you really ought to know…..?”
 “You shouldn’t have left……..?”
 “If I were you I……?”
 “What you really should do…..?”

Use the word DON’T: (incorrect answers)

 Don’t be sad
 Don’t cry
 Don’t be concerned

You should say instead: (correct answers)

 You seem sad
 I noticed you are crying, want to talk about it
 You sound concerned
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More incorrect answers:

 I know what you mean
 “Why are you upset?” (why in quotation marks is always the wrong answer)
 Everything will be alright (everything is an absolute

Wrong Answers Right Answers

Always Only Usually

All Frequently
Never Often
Every None Seldom

Qualified answers or heading words make answers correct. These words are usually are
“safe” to choose. “Safe” words are words such as: usually, almost.

Therapeutic – goal directed professional framework

 Silence – sitting quietly with client
 Offering Self – “I will stay with you.”, “Let me help you.” (conveys caring)
 Reinstatement & Reflection
o Client: “I had a terrible night last night”
o Nurse: “You didn’t sleep well?”
 Giving information
o Client: “Where is the bathroom?”
o Nurse: “Second door on the left” (Inappropriate response: “Do you need to
go to the bathroom?”)
 Focusing/Exploring
o “You seem to be upset over your mother’s visit.”
 Empathy
o “It must be difficult to be away from your family”
o “It must be hard to be here in the hospital”
 “What should the nurse say initially?” questions
o Empathy
o Reinstatement
o Reflection
Super Condensed Portable HESI Study Guide 12

HESI: Pharmacology

Half-Life: Time it takes to excrete half the amt of drug from body. Shorter half-life
drugs are given more often – approx. 5 half-lives and drug removed from

First pass: Amt of metabolism of drug before entering the bloodstream

Absorption: Getting medication into the bloodstream. (Liquids metabolized quickest;

enteric coated takes longest)

Distribution: Moving medication to their specific sites

Metabolism: Breaking down medications (liver) ALT (1-21) AST (7-27)


Excretion: Elimination medication from body (kidney) BUN (10-20) Serum

Creatinine (0.6 – 1.5)

Teratogen: Substances that cause birth defects. 1st Trimester all major organs forming.
Weeks 3-8 are most critical. Drugs cross placenta easier in the 3 rd
trimester however. Known Teratogens: Thalomid, Lithium, Coumadin,
Accutane, Dilantin, Tetracycline

Hemolytic Reaction: Happens when patient received wrong blood type (cells lyse and
gluconate (clump together). Often apparent within the first 50 mL of
administration. S/S: Fever, chills, Low back pain, Chest Tightness,

Therapeutic index: Relationship between the desired effect and toxicity. Therapeutic
effect is the “desired effect”.

Tolerance: Increased amounts of a drug are needed to produce the same effect.

Polypharmacy: Multiple drugs taken at the same time for multiple conditions. This
increases the risk of drug interactions.

Parenteral: Medication given via IV or injection. (IV, IM, SubQ, Intradermal)

Idiosyncratic reaction or paradoxical reaction: Unexpected reaction to a medication.

NOT an allergic reaction.

Additive effect: Taking 2 or more drugs that have similar actions.

Super Condensed Portable HESI Study Guide 13

Cross Sensitivity: When allergic to one drug, a similar type drug will cause the same
sensitivity. EX: Penicillin and Cephalosporin’s.

Cell-Cycle Specific: Anti-neoplastic drug only works in a “specific” cycle of the tumor-
cell reproduction.

Cell-Cycle nonspecific: Anti-neoplastic drug that works in any cycle of the tumor-cell

Redman Syndrome: Caused by infusion VANCOMYCIN too quickly. Must infuse over
60 minutes. S/S: Sudden drop in BP, Rash on face, neck, chest,
Tachycardia, Fever and chills. Caused by a sudden release of Histamine.
Treat by slowing infusion and give Benadryl.

Anterograde Amnesia: a form of amnesia, or memory loss, where new events are not
transferred to long-term memory.

Reye’s Syndrome: Fatal complication if a patient, ages 0-16, is given ASA whilst
experiencing a viral infection

Pseudo membranous Colitis: Super infection of the GI tract. Caused by Clostridium

Difficil. S/S Diarrhea, abd pain, cramping and low-grade fever. Take stool
culture and treat with VANCOMYCIN.

Medications and Antidotes:

Heparin - Protamine

Streptokinase - Aminocaproic Acid

Coumadin - Vitamin K

Morphine - Narcan

Valium - Flumazicon

Tylenol - Mucomist

Digoxin - Digibind

Conditions and Medications

MRSA - Vancomycin

C. Difficil (Pseudomemb. Colitis) - Vancomycin

Super Condensed Portable HESI Study Guide 14

Neuroleptic Syndrome - Physostigmine

Fatal HTN Crisis - Nipride

Selected Values

Serum Creatinine 0.6 – 1.5 pH 7.35 – 7.45

BUN 10 – 20 PCO2 35 - 45

AST 7 – 27 HCO3 22 - 28

ALT 1 – 21 PaO2 80 - 100

Na 135 – 145

K+ 3.5 – 5.3

Magnesium 1.5 – 2.3

Calcium 8.5 – 10.5

Chloride 95 – 105

Phosphate 2.5 – 4.5

Normal Urine output 30 mL/hr minimum

Super Condensed Portable HESI Study Guide 15

Ammonia Detoxicant/Stimulant Laxative



CODEINE PO *30-45 MINUTES *do not administer if solution is discolored
IM – SQ/SC *10-30 MINUTES *used as antidiarrheal or antitussuve
Super Condensed Portable HESI Study Guide 16

DILIAUDID PO *30 MINUTES *fast acting, potent narcotic

(Hydromorphone) IM *15 MINUTES *increase likely to cause appetite loss

DEMEROL PO *15 MINUTES *use in clients allergic to morphine

(Meperidine) IM *10-15 MINUTES *Caution in renal failure-metabolites
IV * 1 MINUTE accumulate
*S&S of toxicity CNS irritability
*most commonly used for post op pain, sickle
*children 48 hours or less


MORPHINE PO *60-90 MINUTES *drug of choice for pain relief associated with
SULFATE IM *10-30 MINUTES Myocardial Infarction
IV *10 MINUTES *monitor for hypotension
*drug of choice for chronic cancer pain

PROPOXYPHENE PO *15-60 MINUTES *can cause false decrease in urinary steroid

HCL secretion test (adrenal gland testing)

FENTANYL IM *7-15 MINUTES *synthetic narcotic like morphine

CITRATE IV *in 5 MINUTES *quicker action and less duration than
(Duragesic) INTRADERMAL *IN 12 HOURS morphine


Super Condensed Portable HESI Study Guide 17

*ORAL *preferred method
*drug level peak 1-2 hours

*INTRAMUSCULAR *management of acute & short term pain

*onset 30 minutes – peak 1-3 hours – duration 4 hours

*RECTAL *for client with nausea or unable to take oral medication

*useful in home care & elderly as an alternative to oral
and (IV) administration
*reduced effectiveness with constipation

*IV BOLUS (OR) IV PUSH *most rapid onset (5 minutes) with shortest duration
*management of acute pain

*CONTINUOUS EPIDURAL *catheter threaded into epidural space by physician with

a continuous infusion of Fentanyl, Morphine or other
*”high risk” for respiratory depression

PATIENT-CONTROLLED *pain control allowing the client to prevent or manage
*physician prescribes drug, dose, lockout interval, &
maximum dose
*pump records all data related to interactions by the
nurse, physician, client
*risk of drug overdose if someone other than the client
regulates the dosage

TRANSDERMAL PATCHES *applied to clean, dry skin

*remove old patch & clean skin before applying new
patch to new site
*document patch removal, new patch site
*document on patch date, time when applying patch
*duration of patch is based on the type of medication &

CONTINUOUS *client who cannot take oral medications & require long
SUBCUTANEOUS NARCOTIC term pain management (parental narcotics)
INFUSION *provides a continuous level of analgesia
(CSI) *sites are inspected every 8 hours
*sites rotated every 7 days
Super Condensed Portable HESI Study Guide 18


Population Groups across the Lifespan & Health Risks

Number 1 cause of injury or death is suffocation followed by Motor Vehicle Accident
then Homicide.
Sudden Infant Death Syndrome
Infection is the most significant cause of illness in infants and children.
Obesity – Healthy people objectives have addressed youth fitness and obesity
Defined by using BMI which is a ratio of weight to height
Risks for childhood obesity were related to obesity in the parents
Obesity rates higher populations such as Native American, Hispanic, and
African Americans groups. Lower socioeconomic groups in urban settings
have been associated with higher rates

Injuries and Accidents- Number one cause of death in ages 1 – 24 yrs.

Motor vehicles accidents are the leading cause of death among children and teenagers.
Toddlers experience a large number of falls, poisonings, and motor vehicle accidents
School age children has the lowest injury death rate; however, this group has difficulty
judging speed and distance, placing them at risk for pedestrian and bicycle accidents.
Adolescents injury accounts for 75% of all deaths and risk-taking becomes more
conscious at this time especially among males.
Suicide is the second leading cause of death among youths between the ages of 15
and 24. Suicide s the third leading cause of death among youth between the ages of
10 and 24 years.

Acute Illness- also a significant cause of illness in children.

Chronic Health Problems- improved medical technology has increased the number of
children surviving with chronic health problems. Examples: Down Syndrome, spina
bifida, cerebral palsy, asthma, diabetes, congenital heart disease, cancer, hemophilia,
broncopulmonary dysplasia, and AIDS

Routine immunizations have been very successful in preventing selected diseases.

Good nutrition is essential for healthy growth and development and influences disease
prevention in later life.

The women’s health movement was pivotal in bringing national recognition to women’s
health issues.
Super Condensed Portable HESI Study Guide 19

Women have a longer life expectancy than men

Women are more likely to have acute and chronic conditions that require them to use
more services than men.
Women of color are more statistically more likely to have poor health outcomes because
of poor understanding of health, lack of access to health care, and lifestyle practices.
Heart disease leading cause of death in women
Lung Cancer leading cause of cancer in women and 2nd leading cause of death

Men are physiologically the more vulnerable gender, shorter life span and higher infant
mortality rate
Life expectancy of men in the US is one of the lowest in the developed countries
Men engage in more risk-taking behaviors than women
Men tend to avoid diagnosis and treatment of illnesses that may result in serious health

Steadily growing population
Increase in chronic conditions, demand for services, and strained health care budgets
More older adults live in the community
Nurses address the chronic health concerns of elders with a focus on maintaining or
improving self-care and preventing complications to maintain the highest possible
quality of life.
Assessing the elderly incorporates physical, psychological, social, and spiritual domains.
Individual and community focused interventions involve all three levels of prevention
through collaborative practice.

U.S. Healthcare problems

More than 43 million people in the United States are uninsured, and many more simply
lack access to adequate health care.

Health care reform measures seek to make changes in the cost, quality, and access of the
present system.

The integration of primary care and public health is necessary for the future health of the

To achieve the specific health goals of programs such as healthy People 2010, primary
care and public health must work within the community for community-based care.

The most sustainable individual and system changes come when people who live n the
community have actively participated.

Nurses are more than able to fill the gap between personal care and public health because
they have skills in assessment, health promotion, and disease and injury prevention;
Super Condensed Portable HESI Study Guide 20

knowledge of community resources; and ability to develop relationships with community

members and leaders.
Home Visits- give a more accurate assessment of the following than do clinical visits:
- the family structure
- the natural or home environment
- behavior in that environment

Home visits provide opportunities to identify both barriers and supports for reaching
family health promotion goals.

Home visits afford the opportunity to gain a more accurate assessment of the family
structure and behavior in the natural environment.
Home visits also provide opportunities to observe the home environment and to identify
both barriers and supports to reducing health risks and reaching family health goals.

Parish nurses: nurses who respond to health and wellness needs within the faith context
of population of faith communities and are partners with the church in fulfilling the
mission of health ministry.

Parish nursing: a community-based and population-focused professional nursing

practice with faith communities to promote whole person health to its parishioners
usually focused on primary prevention.

Parish nurse coordinator: a parish nurse who has completed a certificate program
designed to develop the nurse as a coordinator of a parish nursing service.

Parish nurse services respond to health, healing, and wholeness within the context of the
church. Although the emphasis is on health promotion and disease prevention throughout
the life span, the spiritual dimension of nursing is central to the practice.

The parish nurse partners with the wellness committee and volunteers to plan programs
and consider health-related concerns within faith communities

To promote a caring faith community, usual functions of the parish nurse include personal
health counseling, health teaching, facilitating linkages and referrals to congregation and
community resources, advocating and encouraging support resources, and providing
pastoral care.

Parish nurses collaborate to plan, implement, and evaluate health promotion activities
considering the faith community’s beliefs, rituals, and polity. Healthy People 2010
guidelines are basic to the partnering for the programs.

Nurses working in the parish nursing specialty must seek to attain adequate educational
and skill preparation for the accountability to those served and to those who have
entrusted the nurse to serve
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Nurses are encouraged to consider innovative approaches to creating caring communities.

These may be in congregations as parish nurses, among several faith communities in a
single locale, or regionally; or in partnership with other community agencies or models
such as block nursing.

To sustain oneself as a parish nurse healer, the nurse takes heed to heal and nurture self
while supporting individuals, families, and congregation communities in their healing

Hospice: palliative system of health care for terminally ill people; takes place in the
home with family involvement under the direction and supervision of health
professionals, especially the visiting nurse. Hospice care takes place in the hospital when
sever complications of terminal illness occur or when family becomes exhausted or does
not fulfill commitments.

Professional Preparedness
 Requires nurses and other personnel to be aware of and understand the disaster plans
at their workplace and community- participate in mock drills
 Adequately prepared nurses will function in leadership capacity and assist towards
smoother recovery phase
 Fieldwork, shelter management requires creativeness and willingness
 American Red Cross provides training for health professionals to adapt existing skills
to disaster setting

Role of Community Health Nurse

 Can initiate or update disaster plans at workplace and community and ensure
education, drill participation
 Knowledge of vulnerable populations, available community resources
 Assessing and reporting of environmental hazards, unsafe equipment, faulty
structures, disease outbreaks, e.g., measles, flu

Before anything happens: Prepare for Safety in a Disaster : Four steps

1. Find out what could happen to you:
a. Determine what types of disasters are most likely to happen
b. Learn about warning signals in community
c. Ask about care for pets
d. Review the disaster plans at workplace, and other places where families
spend time together
e. Determine how to help the elderly or disabled

2. Create a disaster plan

a. Discuss types of disasters that are likely to happen and review what to do
b. Pick 2 types of places to meet
c. Choose an out-of-state friend to contact
Super Condensed Portable HESI Study Guide 22

d. Review evac. Plans

3. Complete this checklist

a. Post emergency numbers next to phone
b. Teach how to call 911
c. Determine when and how to turn of water, gas, and electricity
d. Check adequacy of insurance coverage
e. Locate and review use of fire extinguishers
f. Install and maintain smoke detectors
g. Conduct a home hazard hunt
h. Stock emergency supplies
i. CPR certification
j. Locate all escape routes
k. Find safe spots

4. Practice and maintain your plan

a. Review every 6 mos.
b. Conduct drills
c. Replace stored water every 3 mos. and stored food every 6 mos.
d. Test and recharge fire extinguisher
e. Test smoke detectors

Personal Preparedness
Nurses who are disaster victims themselves and provide care to others will experience
considerable stress.

American Red Cross and Federal Emergency Management Agency (FEMA) are two
well known authorities on disaster preparedness, response, and recovery

Three levels
1st level – Personal Preparedness
2nd level- Professional Preparedness
3rd level- Community Preparedness

Most states and counties have an Office of Emergency Management (OEM) that is
responsible for developing and coordinating emergency response plans within their
defined area. The state office supports local OEMs and other state agencies that
participate in disaster response. It provides planning and training services to local
governments, including financial and technical assistance. During an actual
emergency or disaster, the state OEM coordinates a state response and recovery
program if necessary. County OEMs are in charge of creating a comprehensive, all-
hazard plan that should address realistic dangers to the community and list
available resources.

**Nurses need to review the disaster history of community, including how past
disasters have affected the health care delivery system, how their particular
Super Condensed Portable HESI Study Guide 23

organizations fit into the plan, and what role they and their organizations are
expected to play in a disaster.

Stages: Preparedness, Response, and Recovery

Preparedness: Know who is at risk, Personal, Professional and Community


Personal Preparedness
 Entails plan for keeping oneself ready for disaster, both mentally and physically
 Individuals not personally prepared will have less to give to family, community,
job, and other disaster victims
 Nurses can be disaster victims- personal preparation needed to attend to patients
 Checklist helpful to prepare

Professional Preparedness
 Requires nurses and other personnel to be aware of and understand the disaster plans
at their workplace and community- participate in mock drills
 Adequately prepared nurses will function in leadership capacity and assist towards
smoother recovery phase
 Fieldwork, shelter management requires creativeness and willingness
 American Red Cross provides training for health professionals to adapt existing skills
to disaster setting

Community Preparedness
 Level of preparedness only as high as people/ organizations in the community make it
 Well-prepared communities have written disaster plans, conduct drills, have adequate
warning system, and backup evacuation plan
 Office of Emergency Management- state/ county office coordinating regional plans
 Understanding past disasters can influence planning for future, liabilities in resources


The primary objective of disaster response is to minimize morbidity and mortality.

The level of disaster determines FEMA’s response. Levels are not determined by the
number of casualties but by the amount of resources needed.

FEMA Levels of Disaster Response

 Level III- a minor disaster, involves a minimal level of damage but could result in
the president declaring an emergency. A minimal request for federal help
 Level II- moderate disaster- likely to result in major disaster being declared.
Regional federal resources engaged, other outside area may be called on
 Level I- massive disaster, severe damage or multistate scope. Full engagement of
federal regional and national resources
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 Citizens and health professionals must be attached to official agencies with

disaster management responsibilities to avoid further risk

American Red Cross

3 ways to classify a disaster :
 Type- agent that caused the event, such as hurricane, hazmat, transportation

 Level- anticipated or actual Red Cross response and relief costs

Level I. costs less than $10,000
Level II costs $10,000 or more, but less than $50,000
Level II costs $50,000 or more, but less than $250,000
Level IV costs $250,000 or more but less than $2.5 million
Level V costs $2.5 million or more

 Scope- magnitude of the event, units affected and responding ,e.g., single-family,
local, state, major, federally declared
Single family – affects an individual or single family- occurs within the
jurisdiction of a single Red Cross chapter
Local Disaster- Affects more than one family, occurs within the jurisdiction of a
single Red Cross chapter
State Disaster- Affects multiple families, occurs within the jurisdiction of one or
More Red Cross chapters within a single state
Major Disaster- has one or more of the following characteristics
-coordinated response of multiple Red Cross units
- affects more than a single state
- creates national news
- result in emergency or disaster declaration by the President etc.

Presidentially Declared Disaster- requires full or partial implementation of the

National Response Plan

The National Response Plan

Once a federal emergency has been declared, the National Response Plan may take effect,
depending on specific needs arising from the disaster. The NRP is a concerted effort to
prevent terrorist attacks within the US; reduce American’s vulnerability to terrorism,
major disasters, and other emergencies; and minimize the damage and recover from
attacks, major disasters, and other emergencies that occur.

Role of the Nurse

 Role in disaster response depends on nurse’s past experience, role in community
disaster preparedness, specialized training, special interest

 Community health nurses valued for skills in community assessment, case

finding, prevention, education, surveillance, working with aggregates
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 Plans for triage must begin as soon as rescue workers arrive- highest priority
given to life-threatening injuries with high probability of survival- nurse’s
accurate assessment info will help match available resources to population’s
emergency needs

The recovery stage of disaster occurs as all involved agencies pull together to restore the
economic and civic life of the community. For example: the government takes the lead
in rebuilding efforts whereas the business community tries to provide economic support.

Nurse’s Role in Recovery

 Multifaceted responsibilities- flexibility required to assist in successful recovery
 Teaching health promotion, disease prevention, assessment of physical,
psychological problems incurred in cleanup efforts, as well as threat of
communicable disease
 Case finding, referral for mental distress
 Assessment and reporting of environmental health hazards resulting from event

Get community back to normal, deal with emotional matters and after effects
Assess what might be going on in community using primary, secondary and tertiary care

Role of the Nurse:
 Help people cope with the aftermath of terrorism
 Allay public concerns and fears of bioterrorism
 Identify the feelings that you and others may be experiencing
 Assist victims to think positively and move to the future
 Prepare nursing personnel to be effective in a crisis situation

Nurses are concerned with anthrax and small pox and should have awareness of these

Need to have vaccine for small pox

Levels of prevention r/t Disaster Management

Primary Prevention- Participate in developing a disaster management plan for the


Secondary Prevention- Assess disaster victims and triage for care

Tertiary Prevention- Participate in home visits to uncover dangers that may cause
additional injury to victim or cause other problems (e.g. house fires from faulty wiring).

Population at Greatest Risk for Disruption After a Disaster

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Persons with disabilities

Persons living on a low income, including the homeless
Non-English speaking persons and refugees
Persons living alone
Single-parent families
Persons new to the area
Institutionalized persons or those with chronic mental illness
Previous disaster victims or victims of traumatic events
People who are not citizens or legally documented immigrants
Substance abusers

The five components to a comprehensive public health response to outbreaks of illness

are the following
- Detecting the outbreak
- Determining the cause
- Identifying factors that place people at risk
- Implementing measures to control the outbreak
- Informing the medical and public communities about treatments, health
consequences, and preventative measures

Triage: the process of separating casualties and allocating treatment on the basis of the
victims’ potentials for survival.
- Highest priority is always given to victims who have life threatening injuries but
who have a high probability of survival once stabilized
- Second priority is given to victims with injures that have systemic complications
that are not yet life threatening and could wait 45 – 60 minutes for treatment
- Last priority is given to those victims with local injuries without immediate
complications and who can wait several hours for medical attention.

Rationale from Saunders

In an emergency department, triage is classifying clients according to their need for care
and includes establishing priorities of care. The kind of illness, the severity of the
problem, and the resources available govern the process. Clients with trauma, chest pain,
severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits,
and those who sustained chemical splashes to the eyes are classified as emergent and are
the number 1 priority.
Clients with conditions such as a simple fracture, asthma without respiratory distress,
fever, hypertension, abdominal pain, or the client with a renal stone have urgent needs
and are classified as number 2 priorities.
Clients with conditions such as a minor laceration, sprain, or cold symptoms are
classified as nonurgent and are the number 3 priority.

Older adult health risks

Nutrition, safety, social isolation, and depression
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Need to assess the health literacy of the client first

Program outcomes: smoking cessation, weight management, diabetic management

- look at the evaluation of the specific outcome
- Identifying changes in the client’s health status that result from nursing care
provides nursing data that demonstrate the contribution of nursing to the health
care delivery system.

Research studies using the tracer or sentinel method to identify clients’ outcomes and
client satisfaction surveys can be used to measure outcome standards.

From data, strengths and weaknesses in nursing care delivery can be determined.

The most common measurement methods are direct physical observations and

Primary Care- refers to organized community efforts designed to prevent disease and
promote health (education).

Secondary Care- an intermediate level of health care that includes diagnosis and
treatment. Screening.

Tertiary Care- rehabilitation and return of a patient to a status of maximum usefulness

and a minimum risk of recurrence of a physical or mental disorder

Levels of Prevention

Primary Prevention- Counsel clients in health behaviors related to lifestyle

Secondary Prevention- Implement a family-planning program to prevent unintended

pregnancies or young couples who attend the primary clinic

Tertiary Prevention- Provide a self-management asthma program for children with

chronic asthma to reduce their need for hospitalization (prevent from getting worse)

Federal Agencies

Many federal agencies are involved in government health care functions. The agency
most directly involved with the health and welfare of Americans is the U.S. Department
of Health and Human Services

U.S. Department of Health and Human Services (USDHHS)

Largest health program in the world, its mission is to enhance the health and well-being
of the American people through the following:
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- Alcohol, drug abuse, and mental health programs

- Disease tracking and identification
- Health care access for all and integrity of the nation’s health entitlement and
safety net programs
- Identification and correction of health hazards
- Medical assistance after disasters
- Medical research
- Promotion of exercise and healthy habits
- Protection of the nation’s food and drug supply

The Health Resources and Services Administration of the USDHHS contains the Bureau
of Health Professions, this bureau includes separate divisions for nursing, medicine,
dentistry, public health, and allied health professions
The Division of Nursing administers nurse education legislation, interprets trends and
nursing needs of the nation’s health care delivery system, and serves as a liaison with the
nursing community and with international, state, regional, and local health interests

Two other agencies with the DHHS:

The National Institute for Nursing Research (NINR) and Healthcare Research and
Quality (AHRQ)
This institution is the focal point of the nation’s nursing research activities. It promotes
the growth and quality of research in nursing and patient care, provides important
leadership, expands the pool of experienced nurse researchers, and serves as a point of
interaction with other bases of health care research

Nurses can apply for support for research, projects, or training from a variety of agencies
within the federal government besides the NINR of the Division of Nursing.

Other federal agencies: Dept. of Commerce, Dept. of Defense, Dept. of Labor (includes
OSHA), Dept. of Agriculture (includes WIC), Dept. of Justice, Food and Drug

Voluntary and Private Nonprofit Agencies

Voluntary and private agencies are grouped together as nonprofit home health agencies,
voluntary agencies are supported by charities such as United Way, Medicare, Medicaid,
other third-party payers, and client payment.

The amount of financial assistance the voluntary agency receives depends on the
community it serves. With Medicare, the private nonprofit agency emerged as an
alternative agency to the public-supported program. These agencies included
rehabilitation agencies, based in either rehabilitation facilities or skilled facilities.

Nurses use assessment skills to detect potential and actual exposure pathways and
outcomes for clients cared for in the acute, chronic, and healthy communities of practice.
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Risk communication is an important skill and must acknowledge the outrage factor
experienced by communities with environmental hazards.

Vulnerable populations- are those groups who have an increased risk to develop adverse
health outcomes, vulnerable populations often experience multiple cumulative risks and
they are particularly sensitive to the effects of those risks.

Vulnerable populations often are more likely than the general populations to suffer from
health disparities.

Examples of areas that show health disparities across populations groups are infant
mortality, childhood immunization rates, and disease-specific mortality rates.

Vulnerable Population Groups of Special Concern to Nurses

- Poor and homeless people
- Pregnant adolescents
- Migrant workers and immigrants
- Severely mentally ill individuals
- Substance abusers
- Abused individuals and victims of violence
- Persons with communicable disease and those at risk
- Persons who are human immunodeficiency virus (HIV positive) or have Hep B or
sexually transmitted disease.

Behavioral (Lifestyle) Health Risk Assessment

Families are the major source of factors that can promote or inhibit positive lifestyles. It
is important to look at risks for the family as a unit.

Critical dimensions of lifestyle risks include the following:

- Value placed on behavior
- Knowledge of the behavior and its consequences
- Effect of the behavior on the family
- Effect of the behavior on the individual
- Barriers to performing the behavior
- Benefits of the behavior

It is important to assess the frequency, intensity, and regularity of specific behaviors. It

also is important to evaluate the resources available to the family for implementing the

Modifiable Risk and Unmodifiable Risks

Risk factors that are "unmodifiable," are things that neither you nor your patients can do
anything about. You need to know the "unmodifiable" risk factors, because they help you
to define high-risk individuals and groups for whom treating or controlling the
"modifiable" risk factors is a priority.
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Modifiable risks can be changed such as smoking.

Epidemiology – how to calculate a rate

 The denominator includes the numerator

Example Crude birth rate Number of live births during 1 year X1000
Midyear population

Evaluating Outcomes
Outcomes can be measured by looking at changes from before and after the intervention
to solve the problems. Changes in the following can be used to see the outcomes of the
- Demographics
- Socioeconomic factors
- Environmental factors
- Individual and community health status
- Use of health services

In the example of infant malnutrition, one would look for the number of cases of infant
malnutrition in the community before providing education to other health providers about
assessment of infant development. A time period for evaluation would be chosen and
perhaps 1 year later (the time frame). The number of cases of infant malnutrition would
be measured to see if a change had occurred and there were fewer cases.

Incidence rate- the frequency or rate of new cases of an outcome in a populations;

provides an estimate of the risk of disease in that population over the period of

Prevalence: number of existing cases in a population at a given time

Nursing Process- Always assess before starting an intervention

Community assessment

Most nurses are familiar with the nursing process as it applies to individually
focused nursing care. Using it to promote community health makes this same
nursing process community focused.

Community assessment- the process of critically thinking about the community and
involves getting to know and understand the community as partner. The community
assessment phase involves a logical, systematic approach to the initial phase of the
nursing process. Community assessment helps as follows:
- To identify community needs
- To clarify problems
- To identify strengths and resources
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Assessing the community health requires the following three steps:

- Gathering relevant existing data and generating missing data
- Developing a composite database
- Interpreting the composite database to identify community problems and strengths

Data Collection and Interpretation

The primary goal of data collection is to get usable information about the community and
its health. The systematic collection of data about community health requires the
- Gathering or compiling existing data
- Generating missing data
- Interpretation of data
- Identifying community health problems and community abilities

Data gathering is the process of obtaining existing, readily available data. The following
data usually describe the demography of a community
- Age of residents
- Gender distribution of residents
- Socioeconomic characteristics
- Racial distributions
- Vital statistics, including selected mortality and morbidity data

Identify needs, problems, strengths, resources and apply what you know.

Windshield survey- are the motorized equivalent of simple observation. They involve
the collection of data that “will help define the community, the trends, stability, and
changes that will affect the health of the community”

School Nurse:
- Primary -The school nurse monitors the children for all of their state-mandated
immunizations for school entry.
- Secondary- School nurse is involved in screening children for illnesses and
providing direct nursing care
- Tertiary – The school nurse cares for children with long-term health needs,
including asthma and disabling conditions

School nurses carry out catheterizations, suctioning, gastrostomy tube feedings, and other
skills in school.

The concern for health promotion of adolescents is safety because of their propensity to
take part in risky behavior.

To effectively reach a population group you must connect with someone in the
community and establish trust.

Occupational Exposure
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Job categories Exposure Work-related diseases and conditions

Farm workers pesticides, infectious HTN, mood disorders, cardiovascular
Agents, gases, sunlight disease
Provides hospital insurance and medical insurance to persons ages 65 years and older,
permanently disabled persons, and persons with end-stage renal failure
Part A – covers: hospital care and home care (home care or hospice – can’t have both),
skilled nursing care
Part B- covers: (non-institutional care insurance) Medical care, diagnostic services and

Medicaid- Financial assistance to states and counties to pay for medical services for poor
older adults, the blind, the disabled, and families with dependent children.

WIC- a special supplemental food program administered by the Department of

Agriculture through the state health departments; provides nutritious food that add to the
diets of pregnant and nursing women, infants, and children younger than 5 years.
Eligibility is based on income and nutritional risk as determined by a health professional

Outreach worker: a health worker who makes a special, focused effort to find people
with specific health problems for the purpose of increasing their access to health services
- evaluate effectiveness find out if successful and use ways to measure success

Epidemiologic triangle – agent, host, and environment – changes in one of the elements
of the triangle can influence the occurrence of disease by increasing or decreasing a
person’s risk for disease. Risk is the probability that an individual will experience an
Agent: an animate or inanimate factor that must be present or lacking for a disease or
condition to develop
Host: a living species (human or animal) capable of being infected or affected by an
Environment- all that is internal or external to a given host or agent and that is
influenced and influences the host and/or agent

Agent- an animate or inanimate factor that must be present or lacking for a disease or
condition to develop
- causive – example: E. coli
- Infectious agents (bacteria, viruses, fungi, parasites)
- Chemical agents (heavy metal, toxic chemicals, pesticides)
- Physical agents (radiation, heat, cold, machinery)

Host- a living species (human or animal) capable of being infected or affected by an

- anything capable of being infected
- Genetic susceptibility
- Immutable characteristics (age, sex)
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- Acquired characteristics (immunologic status)

- Lifestyle factors (diet, exercise)

Environment- all that is internal or external to a given host or agent and that is
influences the host and or agent
- anything external
- climate (temperature, rainfall)
- Plant and animal life (agents or reservoirs or habitats for agents)
- Human population distribution (crowding, social support)
- Socioeconomic factors (education, resources, access to care)
- Working conditions (levels of stress, noise, satisfaction)

Relationship between the above 3 cause disease, try to break the connection, if a
break then there will be no disease.

Web of Causality- complex interrelations of factors interacting with each other to

influence the risk for or distribution outcomes.
- recognizes the complex interrelationships of many factors interacting, sometimes
in subtle ways, to increase (or decrease) the risk of disease.
- Associations are sometimes mutual, with lines of causality going in both

Family assessment

Ecomap- represents the family’s interactions with other groups and organizations,
accomplished by using a series of circles and lines.
- It is represented by a circle in the middle of the page
- Other groups and organizations are then indicated by circles
- Lines representing the flow of energy are drawn between the family circle and the
circles representing other groups and organizations
- An arrowhead at the end of each line indicates the direction of the flow of energy
(into or out of the family)
- The weight of the line indicates the intensity of the energy

Genogram- is a pictorial display of a person's family relationships and medical history. It

goes beyond a traditional family tree by allowing the user to visualize hereditary patterns
and psychological factors that punctuate relationships. It can be used to identify repetitive
patterns of behavior and to recognize hereditary tendencies.

Prevention Strategies for Violence

Individual and Family levels

- Assess during routine examination (secondary)
- Assess for marital discord (secondary)
- Educate on developmental stages and needs of children (primary)
- Counsel for at-risk parents (secondary)
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- Teach parenting techniques (primary)

- Assist with controlling anger (secondary)
- Treat for substance abuse (tertiary)
- Teach stress-reduction techniques (primary)

Community Level
- Develop policy
- Conduct community resource mapping
- Collaborate with community to develop systematic response to violence
- Develop media campaign
- Develop resources such as transition housing and shelters

High school students and middle school students- steer away from violence and
teach to work on their own skills and build their self-esteem.
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1. List 4 common symptoms of pneumonia the nurse might note on a physical exam.
- Tachypnea, fever with chills, productive cough, bronchial breath sounds.

2. State 4 nursing interventions for assisting the client to cough productively.

- Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen secretions, suction
airway to stimulate coughing.

3. What symptoms of pneumonia might the nurse expect to see in an older client?
- Confusion, lethargy, anorexia, rapid respiratory rate.

4. What should the O2 flow rate be for the client with COPD?
- 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus to breathe, a
COPD client has hypoxic drive to breathe.

5. How does the nurse prevent hypoxia during suctioning?

- Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.

6. During mechanical ventilation, what are three major nursing intervention?

- Monitor client’s respiratory status and secure connections, establish a communication mechanism
with the client, keep airway clear by coughing/suctioning.

7. When examining a client with emphysema, what physical findings is the nurse likely to
- Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields.

8. What is the most common risk factor associated with lung cancer?
- Smoking

9. Describe the pre-op nursing care for a client undergoing a laryngectomy.

- Involve family/client in manipulation of tracheostomy equipment before surgery, plan acceptable
communication method, refer to speech pathologist, discuss rehabilitation program.

10. List 5 nursing interventions after chest tube insertion.

- Maintain a dry occlusive dressing to chest tube site at all times. Check all connections every 4
hours. Make sure bottle III or end of chamber is bubbling. Measure chest tube drainage by
marking level on outside of drainage unit. Encourage use of incentive spirometry every 2 hours.
11. What immediate action should the nurse take when a chest tube becomes disconnected
from a bottle or a suction apparatus? What should the nurse do if a chest tube is
accidentally removed from the client?
- Place end in container of sterile water. Apply an occlusive dressing and notify physician STAT.

12. What instructions should be given to a client following radiation therapy?

- Do NOT wash off lines; wear soft cotton garments, avoid use of powders/creams on radiation site.

13. What precautions are required for clients with TB when placed on respiratory isolation?
- Mask for anyone entering room; private room; client must wear mask if leaving room.
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14. List 4 components of teaching for the client with tuberculosis.

- Cough into tissues and dispose immediately into special bags. Long-term need for daily
medication. Good handwashing technique. Report symptoms of deterioration, i.e., blood in


1. Differentiate between acute renal failure and chronic renal failure.

- Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure:
irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine.
Eventually dialysis is required.

2. During the oliguric phase of renal failure, protein should be severely restricted. What is the
rationale for this restriction?
- Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein

3. Identify 2 nursing interventions for the client on hemodialysis.

- Do NOT take BP or perform venipunctures on the arm with the A-V shunt, fistula, or graft. Assess
access site for thrill or bruit.

4. What is the highest priority nursing diagnosis for clients in any type of renal failure?
- Alteration in fluid and electrolyte balance.

5. A client in renal failure asks why he is being given antacids. How should the nurse reply?
- Calcium and aluminum antacids bind phosphates and help to keep phosphates from being
absorbed into blood stream thereby preventing rising phosphate levels, and must be taken with

6. List 4 essential elements of a teaching plan for clients with frequent urinary tract infections.
- Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking hours; take all
prescribed medications; wear cotton undergarments.

7. What are the most important nursing interventions for clients with possible renal calculi?
- Strain all urine is the MOST IMPORTANT intervention. Other interventions include accurate intake
and output documentation and administer analgesics as needed.

8. What discharge instructions should be given to a client who has had urinary calculi?
- Maintain high fluid intake 3-4 liters per day. Follow-up care (stones tend to recur). Follow
prescribed diet based in calculi content. Avoid supine position.

9. Following transurethral resection of the prostate gland (TURP), hematuria should subside
by what post-op day?
- Fourth day

10. After the urinary catheter is removed in the TURP client, what are 3 priority nursing
- Continued strict I&O; continued observations for hematuria; inform client burning and frequency
may last for a week.

11. After kidney surgery, what are the primary assessments the nurse should make?
- Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very
vascular and excess bleeding can occur); pain assessment; urinary assessment most importantly,
assessment of urinary output.


1. How do clients experiencing angina describe that pain?

Super Condensed Portable HESI Study Guide 37

- Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged.

2. Develop a teaching plan for the client taking nitroglycerin.

- Take at first sign of anginal pain. Take no more than 3, five minutes apart. Call for emergency
attention if no relief in 10 minutes.

3. List the parameters of blood pressure for diagnosing hypertension.

- >140/90

4. Differentiate between essential and secondary hypertension.

- Essential has no known cause while secondary hypertension develops in response to an
identifiable mechanism.

5. Develop a teaching plan for the client taking antihypertensive medications.

- Explain how and when to take med, reason for med, necessary of compliance, need for follow-up
visits while on med, need for certain lab tests, vital sign parameters while initiating therapy.

6. Describe intermittent claudication.

- Pain related to peripheral vascular disease occurring with exercise and disappearing with rest.

7. Describe the nurse’s discharge instructions to a client with venous peripheral vascular
- Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do
NOT use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing.

8. What is often the underlying cause of abdominal aortic aneurysm?

- Atherosclerosis.

9. What lab values should be monitored daily for the client with thrombophlebitis who is
undergoing anticoagulant therapy?
- PTT, PT, Hgb, and Hct, platelets.

10. When do PVCs (premature ventricular contractions) present a grave danger?

- When they begin to occur more often than once in 10 beats, occur in 2s or 3s, land near the T
wave, or take on multiple configurations.

11. Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac
- Left-sided failure results in pulmonary congestion due to back-up of circulation in the left ventricle.
Right-sided failure results in peripheral congestion due to back-up of circulation in the right

12. List 3 symptoms of digitalis toxicity.

- Dysrhythmias, headache, nausea and vomiting

13. What condition increases the likelihood of digitalis toxicity occurring?

- When the client is hypokalemic (which is more common when diuretics and digitalis preparations
are given together).

14. What life style changes can the client who is at risk for hypertension initiate to reduce the
likelihood of becoming hypertensive?
- Cease cigarette smoking if applicable, control weight, exercise regularly, and maintain a low-
fat/low-cholesterol diet.

15. What immediate actions should the nurse implement when a client is having a myocardial
- Place the client on immediate strict bedrest to lower oxygen demands of heart, administer oxygen
by nasal cannula at 2-5 L/min., take measures to alleviate pain and anxiety (administer prn pain
medications and anti-anxiety medications).
Super Condensed Portable HESI Study Guide 38

16. What symptoms should the nurse expect to find in the client with hypokalemia?
- Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia.

17. Bradycardia is defined as a heart rate below ___ BPM. Tachycardia is defined as a heart
rate above ___ BPM.
- bradycardia 60 bpm; tachycardia 100 bpm

18. What precautions should clients with valve disease take prior to invasive procedures or
dental work?
- Take prophylactic antibiotics.


1. List 4 nursing interventions for the client with a hiatal hernia.

- Sit up while eating and one hour after eating. Eat small, frequent meals. Eliminate foods that are

2. List 3 categories of medications used in the treatment of peptic ulcer disease.

- Antacids, H2 receptor-blockers, mucosal healing agents, proton pump inhibitors.

3. List the symptoms of upper and lower gastrointestinal bleeding.

- Upper GI: melena, hematemesis, tarry stools. Lower GI: bloddy stools, tarry stools. Similar: tarry

4. What bowel sound disruptions occur with an intestinal obstruction?

- Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or
absent bowel sounds.

5. List 4 nursing interventions for post-op care of the client with a colostomy.
- Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild
soap/water after each colostomy bag change; pouch opening should extend at least 1/8 inch
around the stoma.

6. List the common clinical manifestations of jaundice.

- Sclera-icteric (yellow sclera), dark urine, chalky or clay-colored stools

7. What are the common food intolerances for clients with cholelithiasis?
- Fried/spicy or fatty foods.

8. List 5 symptoms indicative of colon cancer.

- Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with
nausea, weight loss.

9. In a client with cirrhosis, it is imperative to prevent further bleeding and observe for
bleeding tendencies. List 6 relevant nursing interventions.
- Avoid injectons, use small bore needles for IV insertion, maintain pressure for 5 minutes on all
venipuncture sites, use electric razor, use soft-bristle toothbrush for mouth care, check stools and
emesis for occult blood.

10. What is the main side effect of lactulose, which is used to reduce ammonia levels in clients
with cirrhosis?
- Diarrhea.

11. List 4 groups who have a high risk of contracting hepatitis.

- Homosexual males, IV drug users, recent ear piercing or tattooing, and health care workers.

12. How should the nurse administer pancreatic enzymes?

- Give with meals or snacks. Powder forms should be mixed with fruit juices.
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1. What diagnostic test is used to determine thyroid activity?

- T3 and T4

2. What condition results from all treatments for hyperthyroidism?

- Hypothyroidism, requiring thyroid replacement

3. State 3 symptoms of hyperthyroidism and 3 symptoms of hypothyroidism.

- Hyperthyroidism: weight loss, heat intolerance, diarrhea. Hypothyroidism: fatigue, cold
intolerance, weight gain.

4. List 5 important teaching aspects for clients who are beginning corticosteroid therapy.
- Continue medication until weaning plan is begun by physician, monitor serum potassium, glucose,
and sodium frequently; weigh daily, and report gain of >5lbs./wk; monitor BP and pulse closely;
teach symptoms of Cushing’s syndrome

5. Describe the physical appearance of clients who are Cushinoid.

- Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin.

6. Which type of diabetic always requires insulin replacement?

- Type I, Insulin-dependent diabetes mellitus (IDDM)

7. What type of diabetic sometimes requires no medication?

- Type II, Non-insulin dependent diabetes mellitus (NIDDM)

8. List 5 symptoms of hyperglycemia.

- Polydipsia, polyuria, polyphagia, weakness, weight loss

9. List 5 symptoms of hypoglycemia.

- Hunger, lethargy, confusion, tremors or shakes, sweating

10. Name the necessary elements to include in teaching the new diabetic.
- Teach the underlying pathophysiology of the disease, its management/treatment regime, meal
planning, exercise program, insulin administration, sick-day management, symptoms of
hyperglycemia (not enough insulin)

11. In less than ten steps, describe the method for drawing up a mixed dose of insulin (regular
with NPH).
- Identify the prescribed dose/type of insulin per physician order; store unopened insulin in
refrigerator. If opened, may be kept at room temperature for up to 3 months. Draw up regular
insulin FIRST. Rotate injection sites. May reuse syringe by recapping and storing in refrigerator.

12. Identify the peak action time of the following types of insulin: rapid-acting regular insulin,
intermediate-acting, long-acting.
- Rapid-acting regular insulin: 2-4 hrs. Immediate-acting: 6-12 hrs. Long-acting: 14-20 hrs.

13. When preparing the diabetic for discharge, the nurse teaches the client the relationship
between stress, exercise, bedtime snacking, and glucose balance. State the relationship
between each of these.
- Stress and stress hormones usually increase glucose production and increase insulin need;
exercise can increase the chance for an insulin reaction, therefore, the client should always have
a sugar snack available when exercising (to treat hypoglycemia); bedtime snacking can prevent
insulin reactions while waiting for long-acting insulin to peak.

14. When making rounds at night, the nurse notes that an insulin-dependent client is
complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool
and moist. What is the client most likely experiencing?
Super Condensed Portable HESI Study Guide 40

- Hypoglycemia/insulin reaction.

15. Identify 5 foot-care interventions that should be taught to the diabetic client.
- Check feet daily & report any breaks, sores, or blisters to health care provider, wear well-fitting
shoes; never go barefoot or wear sandals, never personally remove corns or calluses, cut or file
nails straight across; wash daily with mild soap & warm water.


1. Differentiate between rheumatoid arthritis and degenerative joint disease in terms of joint
- Rheumatoid arthritis occurs bilaterally. Degenerative joint disease occurs asymmetrically.

2. Identify the categories of drugs commonly used to treat arthritis.

- NSAIDs (nonsteroidal anti-inflammatory drugs) of which salicylates are the cornerstones (used
when arthritic symptoms are severe).

3. Identify pain relief interventions for clients with arthritis.

- Warm, moist heat (compresses, baths, showers), diversionary activities (imaging, distraction, self-
hypnosis, biofeedback), and medications.

4. What measures should the nurse encourage female clients to take to prevent
- Estrogen replacement after menopause, high calcium and vitamin D intake beginning in early
adulthood, calcium supplements after menopause, and weight-bearing exercise.

5. What are the common side effects of salicylates?

- GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation.

6. What is the priority nursing intervention used with clients taking NSAIDs?
- Administer or teach client to take drugs with food or milk.

7. List 3 of the most common joints that are replaced.

- Hip, knee, finger.

8. Describe post-op stump care (after amputation) for the 1 st 48 hours.

- Elevate stump first 24 hours. Do not elevate stump after 48 hours. Keep stump in extended
position and turn prone three times a day to prevent flexion contracture.

9. Describe nursing care for the client who is experiencing phantom pain after amputation.
- Be aware that phantom pain is real and will eventually disappear. Administer pain medication;
phantom pain responds to medication.

10. A nurse discovers that a client who is in traction for a long bone fracture has a slight fever,
is short of breath, and is restless. What does the client most likely have?
- Fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness,
fever and petechiae.

11. What are the immediate nursing actions if fat embolization is suspected in a
fracture/orthopedic client?
- Notify physician STAT, draw blood gas results, assist with endotracheal intubation and treatment of
respiratory failure.

12. List 3 problems associated with immobility.

- Venous thrombosis, urinary calculi, skin integrity problems.

13. List 3 nursing interventions for the prevention of thromboembolism in immobilized clients
with musculoskeletal problems.
Super Condensed Portable HESI Study Guide 41

- Passive range of motion exercises, elastic stockings, and elevation of foot of bed 25 degrees to
increase venous return.

1. What are the classifications of the commonly prescribed eye drops for glaucoma?
- Parasympathominetics for pupillary constriction. Beta-adrenergic receptor-blocking agents to
inhibit formation of aqueous humor. Carbonic anhydrase inhibitors to reduce aqueous humor
production, and prostaglandin agonists to increase aqueous humor outflow.

2. Identify 2 types of hearing loss.

- Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to 8 th
cranial nerve)

3. Write 4 nursing interventions for the care of the blind person and 4 nursing interventions
for the care of the deaf person.
- Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, guide
by walking in front of client with his/her hand in your elbow. Care of deaf: reduce distraction
before beginning conversation, look and listen to client, give client full attention if they are a lip
reader, face client directly.

4. In your own words describe the Glasgow Coma Scale.

- An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of
7 or less indicative of coma.

5. List 4 nursing diagnoses for the comatose client in order of priority.

- Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased
cardiac output.

6. State 4 independent nursing interventions to maintain adequate respirations, airway, and

oxygenation in the unconscious client.
- Position for maximum ventilation (prone or semi-prone and slightly to one side), insert airway if
tongue obstructing; suction airway efficiently, monitor arterial pO2 and pCO2 and hyperventilate
with 100% oxygen before suctioning.

7. Who is at risk for cerebral vascular accidents?

- Persons with history of hypertension, previous TIAs, cardiac disease (atrial flutter/fibrillation),
diabetes, oral contraceptive use, and the elderly.

8. Complications of immobility include the potential for thrombus development. State 3

nursing interventions to prevent thrombi.
- Frequent range of motion exercises, frequent (q2h) position changes, and avoidance of positions
which decrease venous return.

9. List 4 rationales for the appearance of restlessness in the unconscious client.

- Anoxia, distended bladder, covert bleeding, or a return to consciousness

10. What nursing interventions prevent corneal drying in a comatose client?

- Irrigation of eyes PRN with sterile prescribed solution, application of opthalmic ointment q8h, close
assessment for corneal ulceration/drying.

11. When a comatose client on IV hyperalimentation begin to receive tube feedings instead?
- When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel

12. What is the most important principle in a bowel management program for a neurologic
- Establishment of REGULARITY

13. Define cerebral vascular accident.

Super Condensed Portable HESI Study Guide 42

- A disruption of blood supply to a part of the brain, which results in sudden loss of brain function.

14. A client with a diagnosis of CVA presents with symptoms of aphasia, right hemiparesis, but
no memory or hearing deficit. In what hemisphere has the client suffered a lesion?
- Left

15. What are the symptoms of spinal shock?

- Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion.

16. What are the symptoms of autonomic dysreflexia?

- Hypertension, bladder and bowel distention, exaggerated autonomic responses, headache,
sweating, goose bumps, and bradycardia

17. What is the most important indicator of increased ICP?

- A change in the level of responsiveness

18. What vital sign changes are indicative of increased ICP?

- Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities
and temperature increase.

19. A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by
his very hyperactive dog. He is wondering what symptoms would indicate the need to visit
an emergency room. What should the nurse tell him to do?
- Call his physician now and inform him/her of the fall. Symptoms needing medical attention would
include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia
(imbalance), or seizure.

20. What activities and situations should be avoided that increase ICP?
- Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular
veins, coughing, vomiting, or straining of any kind.

21. How do Hyperosmotic agents (osmotic diuretics) used to treat intracranial pressure act?
- Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent
reabsorption, and by drawing fluid from the extravascular spaces into the plasma.

22. Why should narcotics be avoided in clients with neurologic impairment?

- Narcotics mask the level of responsiveness as well as pupillary response.

23. Headache and vomiting are symptoms of many disorders. What characteristics of these
symptoms would alert the nurse to refer a client to a neurologist?
- Headache which is more severe upon awakening and vomiting not associated with nausea are
symptoms of a brain tumor.

24. How should the head of the bed be positioned for post-craniotomy clients with
infratentorial lesions?
- Infratentorial – FLAT; Supratentorial – elevated

25. Is multiple sclerosis thought to occur because of an autoimmune process?


26. Is paralysis always a consequence of spinal cord injury?

- NO

27. What types of drugs are used in the treatment of myasthenia gravis?
- Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to
promote the accumulation of acetylcholine at receptor sires, which should improve neuronal
transmission to muscles.

Super Condensed Portable HESI Study Guide 43

1. List 3 potential causes of anemia.

- Diet lacking in iron, folate and/or vitamin B12; use of salicylates, thiazides, diuretics; exposure to
toxic agents such as lead or insecticides.

2. Write 2 nursing diagnoses for the client suffering from anemia.

- Activity intolerance and altered tissue perfusion.

3. What is the only intravenous fluid compatible with blood products?

- Normal saline

4. What actions should the nurse take if a hemolytic transfusion reaction occurs?
- Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample.
Keep vein patent with normal saline.

5. List 3 interventions for clients with a tendency to bleed.

- Use a soft toothbrush, avoid salicylates, do not use suppositories.

6. Identify 2 sites, which should be assessed for infection in immunosuppressed clients.

- Oral cavity and genital area.

7. Name 3 food sources of vitamin b12.

- Glandular meats (liver), milk, green leafy vegetables.

8. Describe care of invasive catheters and lines.

- Use strict aseptic technique. Change dressings 2 to 3 times/week or when soiled. Use caution
when piggybacking drugs, check purpose of line and drug to be infused. Use lines for obtaining
blood samples to avoid “sticking” client when possible.

9. List 3 safety precautions for the administration of antineoplastic chemotherapy.

- Double check order with another nurse. Check for blood return prior to administration to ensure
that medication does not go into tissue. Use a new IV site daily for peripheral chemotherapy.
Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact
with toxic substances.

10. Describe the use of Leucovorin.

- Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.

11. Describe the method of collecting the trough and peak blood levels of antibiotics.
- Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak:
draw blood 30 minutes after administration of antibiotic.

12. What is the characteristic cell found in Hodgkin’s disease?

- Reed-Sternberg

13. List 4 nursing interventions for care of the client with Hodgkin’s disease.
- Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional
support to client and family.

14. List 4 topics you would cover when teaching an immunosuppressed client about infection
- Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to
prevent spread of microorganisms.


1. What are the indications for a hysterectomy in the client who has fibromas?
- Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics,
severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain.
Super Condensed Portable HESI Study Guide 44

2. List the symptoms and conditions associated with cystocele.

- Symptoms include incontinence/stress incontinence, urinary retention, and recurrent bladder
infections. Conditions associated with cystocele include multiparity, trauma in childbirth, and

3. What are the most important nursing interventions for the postoperative client who has had
a hysterectomy with an A&P repair?
- Avoid rectal temps and/or rectal manipulation; manage pain; and encourage early ambulation.

4. Describe the priority nursing care for the client who has had radiation implants.
- Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small
children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room.
Keep supplies and equipment within client’s reach.

5. What screening tool is used to detect cervical cancer? What are the American Cancer
Society’s recommendations for women ages 30 to 70 with three consecutive normal
- Pap smear. Women ages 30 to 70 with 3 consecutive normal results may have pap smear every 2
to 3 years.

6. Cite 2 nursing diagnoses for a client undergoing a hysterectomy for cervical cancer.
- Altered body image related to uterine removal. Pain related to postoperative incision.

7. What are the 3 most important tools for early detection of breast cancer? How often should
these tools be used?
- Breast self-exam monthly; mammogram baseline at age 35 followed by exams every 1 to 2 years
in 40s and every year after age 50; physical examination by a professional skilled in examination
of the breast.

8. Describe 3 nursing interventions to help decrease edema post mastectomy.

- Position arm on operative side on pillow. Avoid BP measurements, injections, or venipunctures in
operative arm. Encourage hand activity and use.

9. Name 3 priorities to include in a discharge plan for the client who has had a mastectomy.
- Arrange for Reach-to-Recovery visit. Discuss the grief process with the client. Have physician
discuss with the client the reconstruction options.

10. What is the most common cause of nongonococcal urethritis?

- Chlamydia trachomatis
11. What is the causative agent for syphilis?
- Treponema pallidum (spirochete bacteria)

12. Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD?

- Trichomonas vaginalis

13. Which STD is characterized by remissions and exacerbations in both males and females?
- Herpes Simplex Type II

14. Outline a teaching plan for the client with an STD.

- Signs and symptoms of STD. Mode of transmission. Avoid sex while infected. Provide concise
written instructions regarding treatment and request a return verbalization to ensure the client
understands. Teach “safer sex” practices.


1. List 4 categories of burns.

- Thermal, radiation, chemical, electrical
Super Condensed Portable HESI Study Guide 45

2. Burn depth is a measure of severity. Describe the characteristics of superficial partial-

thickness, deep partial-thickness, and full-thickness burns.
- Superficial partial-thickness: 1 st degree = pink to red skin (i.e., sunburn), slight edema, and pain
relieved by cooling. Deep partial-thickness: 2 nd degree = destruction of epidermis and upper
layers of dermis; white or red, very edematous, sensitive to touch and cold air, hair does not pull
out easily. Full-thickness: 3rd degree = total destruction of dermis and epidermis; reddened areas
do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery eschar.

3. Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of
the burned client.
- Stage I (Emergent phase): Replacement of fluids is titrated to urine output. Stage II (Acute
phase): Maintain patent infusion site in case supplemental IV fluids are needed; heparin lock is
helpful; may use colloids. Stage III (Rehabilitation phase): No extra fluids needed, but high-protein
drinks are recommended.

4. Describe pain management of the burned client.

- Administer pain medication, especially prior to dressing wound (usually Morphine 10 mg). Teach
distraction/relaxation techniques. Teach use of guided imagery.

5. Outline admission care of the burned client.

- Provide a patent airway as intubation may be necessary. Determine baseline data. Initiate fluid
and electrolyte therapy. Administer pain medication. Determine depth and extent of burn.
Administer tetanus toxoid. Insert NG tube.

6. Nutritional status is a major concern when caring for a burned client. List 3 specific dietary
interventions used with burned clients.
- High-calorie, high-protein, high-carbohydrate diet. Medications with juice or milk. NO “free” water.
Tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily.

7. Describe the method of extinguishing each of the following burns: thermal, chemical and
- Thermal: remove clothing, immerse in tepid water. Chemical: flush with water or saline. Electrical:
separate client from electrical source.

8. List 4 signs of an inhalation burn.

- Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs
including: assymetry of respirations, rales or wheezing.

9. Why is the burned client allowed NO “free” water?

- Water may interfere with electrolyte balance. Client needs to ingest food products with highest
biological value.

10. Describe an autograft.

- Use of client’s own skin for grafting.



1. After the 4th group meeting, the informal leader makes a statement that she believes she
can help the group more than the assigned facilitator and has better credentials. Identify
the group dynamics and stage of development.
- The informal leader is “testing,” which is a behavior indicative of a new group trying to establish
trust. This group is still in the orientation phase of development.

2. On an in-patient psychiatric unit, clients are expected to get up at a certain time, attend
breakfast at a certain time, and come for their medication at the correct time. What form of
therapy is incorporated into this unit? - Milieu.
Super Condensed Portable HESI Study Guide 46

3. The wife of a man killed in a motor vehicle accident has just arrived at the emergency room
and is told of her husband’s death. What nursing actions are appropriate for dealing with
this crisis?
- Take woman to a quiet room, ask her if there are family, friends, or clergy you can call for her.
Assess her need for medication and discuss with physician. Stay with her, be firm and directive,
and assess previous successful coping strategies.

4. A 10 yr. old is admitted to the children’s unit of the psychiatric facility after stabbing his
sister. His behavior is extremely aggressive with the other children on the unit. Using a
behavior modification approach with positive reinforcement, design a treatment plan for
this child.
- Assess what activities he enjoys. Set up a token system – when he displays non-aggressive
behavior, he earns a token good towards participating in the activity selected. He loses a token
when he becomes aggressive.

5. The 10 yr. old, his sister, mother, and the mother’s live in boyfriend are asked to attend a
therapy meeting. Who is the “client” that will be treated during this session?
- The entire family.

6. A 66 yr. old woman is admitted to the psychiatric unit with agitated depression. She has
not responded to antidepressants in the past. What would be the medical treatment of
choice for this client?
- Electroconvulsive therapy (ECT).

7. Describe the nurse’s role in preparing clients for electroconvulsive therapy (ECT).
- Give accurate, non-judgmental information about the treatment. Explore client’s concerns.
Administer the following as ordered: Atropine sulfate to dry oral secretions, a quick-acting
barbiturate to induce anesthesia such as Brevital Sodium, and a muscle relaxant such as
Anectine. Check emergency equipment and O2 are available.

8. Describe the nursing interventions used to care for a client during and after
electroconvulsive therapy.
- Maintain patent airway. Check vital signs every 15 minutes until alert. Remain with client
following treatment until conscious. Reorient, if confused.


1. State 5 autonomic responses to anxiety.

- Shortness of breath, heart palpitations, dizziness, diaphoresis, frequent urination.

2. Identify the defense mechanism used by a person who feels guilty about masturbating as a
child, and develops a hand-washing compulsion as an adult.
- Undoing.

3. Identify anxiety-reducing strategies the nurse can teach.

- Deep breathing techniques, visualization, relaxation techniques, exercise, biofeedback.

4. Which levels of anxiety facilitate learning?

- Mild to moderate.

5. A Vietnam veteran is plagued by nightmares and is found trying to strangle his roommate
one night. List, in order of priority, the appropriate nursing interventions.
- Protect roommate from harm. Stay with client. If the client is agitated, administer anti-anxiety
medications as ordered. Arrange for private room. Place client on homicidal precautions at night.

6. A client displays a phobic response to flying. Describe the desensitization process, which
would probably be implemented.
Super Condensed Portable HESI Study Guide 47

- Talk about planes. Look at pictures of planes. Make plans to accompany client during a visit to
airport. Accompany client into a plane. Allow the client to board a plane alone. Accompany the
client on a short flight while listening to a relaxation tape.

7. A client is in the middle of an extensive ritual, which focuses on food during lunch.
However, the client is scheduled for group therapy, which is about to start. What action
should the nurse take?
- Allow client to complete the ritual. Discuss with the group leader the possibility of allowing the
client to enter the group late. Arrange for client to begin lunch either so that the ritual can be
completed prior to scheduled activities.


1. Describe the difference between primary and secondary gains.

- Primary gain is a decrease in anxiety, which results from some effort made to deal with stress.
Secondary gain is the advantage, other than reduced anxiety, which occurs from the sick role.

2. Explain the difference between somatization and hypochondriasis.

- Somatization is used to describe a person who has many recurrent complaints with no organic
basis as opposed to someone with hypochondriasis who has unrealistic or exaggerated that they
interfere with social and occupational functioning.

3. An air traffic controller suddenly suddenly develops blindness. All physical findings are
negative. The client’s history reveals an increased anxiety about job performance and fear
about job security. What type of disorder is this? What purpose is the blindness serving?
What nursing interventions are indicated?
- Conversion reaction. Decreases the anxiety about job. Assist with ADL, encourage expression of
anger, teach relaxation techniques, and assist with the identification of anxiety related to job
security and performance.

4. A 42 yr. old secretary has visited 7 different doctors in the last year with a complaint of
chest pain, heart palpitations, and shortness of breath. She is certain she is having a heart
attack in spite of the physician’s reassurance that all tests are normal. What type of
disorder is this? What nursing actions are indicated?
- Hypochondriacal disorder. Decrease anxiety, teach relaxation techniques, explore relationship
between the symptoms and past experiences with heart disease. Focus interactions away from
bodily concerns.

5. Five years ago, a woman was involved in a motor vehicle accident that killed her friend who
was a passenger in the car she was driving. Since that time, she has been unable to work
because of sever back pain. The pain in unrelieved by prescribed medications. What type
of disorder is this? What are the contributing causes? Describe the nursing care.
- Somatization disorder. Unresolved grief, anxiety. Evaluate pain medication use and/or abuse.
Document duration and intensity of pain. Assist client to identify precipitating factors related to
request for medication.


1. Describe the difference between psychogenic amnesia and a psychogenic fugue.

- Psychogenic amnesia is the sudden inability to recall certain events in one’s life. A psychogenic
fugue state is characterized by the individual leaving home and being unable to recall their identity
or their past.

2. What is a multiple personality disorder?

- Presence of two or more distinct personalities within an individual. The personalities emerge
during stress.

3. List 3 possible causes of psychogenic amnesia.

Super Condensed Portable HESI Study Guide 48

- Traumatic event such as a threat of death or injury, an intolerable life situation, or a natural

4. Describe depersonalization disorder.

- A temporary loss of one’s reality, a loss of the ability to feel and express emotions, or a sense of
“strangeness” in the surrounding environment. These individuals express a fear of “going crazy.”


1. Obsessive-Compulsive Personality = Orderliness, rigid.

2. Passive-Aggressive Personality = Passively resistant
3. Antisocial Personality = Inability to conform to social norms
4. Borderline Personality = Needy, always in a crisis, self-mutilating, unable to sustain
relationships, splitting behavior
5. Dependent Personality = Unable to make decisions for self, allows others to assume
responsibility for his/her life.
6. Narcissistic Personality = Feelings of self-importance and entitlement. May exploit others to get
own needs met.
7. Histrionic Personality = Dramatic, flamboyant, needs to be the center of attention
8. Paranoid Personality = Suspicious, shows, mistrust of others, is watchful and secretive
9. Schizoid Personality = Isolated and introverted, has no close friends
10. Maladaptive Personality = Does not think anything he/she does is wrong, e.g., authorities are
“out to get them.”


1. Describe the clinical symptoms of anorexia nervosa.

- weight loss of at least 15% of ideal/original body weight; hair loss; dry skin; irregular heart rate;
decreased pulse; decreased blood pressure; Amenorrhea; dehydration; electrolyte imbalance.

2. State 2 psychodynamic differences between anorexia and bulimia.

- Anorexia nervosa deals with issues of control and a struggle between dependence and
independence. Bulimia deals with loss of control (Binge eating) and guilt (purging).

3. An anorectic client has her friend bring her several cookbooks so she can plan a party
when she is discharged. What nursing intervention is appropriate in addressing this
- Discuss activities that don’t involve food, which may take place after discharge. Discuss the
cookbooks with the treatment team and, if the treatment plan indicates, take books from client.

4. Anorexia nervosa may be precipitated by what etiologic factors?

- Mother-daughter conflicts usually focusing on independence/dependence issues; discomfort with
maturation; need for control; desire for perfection

5. What might the initial treatment include for a client admitted to the hospital with a
diagnosis of bulimia nervosa?
- Blood work to evaluate electrolyte status; replenish electrolytes and fluids as indicated; carefully
monitor for evidence of vomiting.


1. Identify physiologic changes, which often occur with depression.

- Weight change (loss or gain), constipation, fatigue, lack of sexual interest, somatic complaints,
and sleep disturbances.

2. A client, who has been withdrawn and tearful, comes to breakfast one morning smiling and
interacting with her peers. Prior to breakfast, she gave her roommate her favorite necklace.
What actions should the nurse take and why?
Super Condensed Portable HESI Study Guide 49

- Assess for suicidal ideation, plan and means to carry out plan. Place on precautions as indicated.
A sudden change in mood and giving away possessions are two possible signs that a suicide plan
has been developed.

3. Name the components of a suicide assessment.

- Existence of a plan, method, availability of method chosen, lethality of method chosen, identified
support system, and history of previous attempts.

4. A client on your unit refuses to go to group therapy. What is the most appropriate nursing
- Accompany client to the group; do not give client option. Client needs to be mobilized.

5. A client is standing on a table loudly singing the “Star Spangled Banner” encircled by
sheets, which have been set afire. In order of priority, describe appropriate nursing
- Remove client and other persons in the vicinity to a safe area and activate hospital fire plan.
When area is safe, place client in quiet environment with low stimulation and medicate as


1. A client is sitting alone, talking quietly. There is no one around. What nursing action
should be taken?
- Quietly approach client and note the behavior. Assess content of the hallucinations, e.g., “I
noticed you talking. Are you hearing voices? Can you tell me about the voices you are hearing?”

2. A client dials 222-2222 and asks for his fiance, Candice Bergen. This is an example of what
type of thought disorder?
- Delusion of grandeur

3. A client has been sitting in the same position for 2 hours. He is mute. What type of
schizophrenia is this client experiencing? Describe appropriate nursing interventions for
this client?
- Catatonic: Spend time with client; assist with ADL; be alert to potential for violence toward
self/others; be aware of fluid and nutrition needs.

4. A client is very agitated. He believes that the CIA has tapped the phone, is sending
messages through the television, and that you are an agent who has been planted by the
agency. In order of priority, list the appropriate nursing actions to intervene in this
situation. What type of delusion is this client experiencing?
- Approach client and offer solitary activity to distract. Assess need for medication. Encourage
verbalization of feelings and promote outlet for expression. Paranoid disorder with delusions of
reference (CIA).

5. The nurse asks the client, “What brought you to the hospital?” The client’s response is,
“The bus.” What type of thinking is this client exhibiting?
- Concrete.


1. Three days ago, a client was admitted to the medical unit for a GI bleed. His BP and pulse
rate gradually increased, and he developed a low-grade fever. What assessment data
should the nurse obtain? What kind of anticipatory planning should the nurse develop?
- Obtain a drug and alcohol consumption assessment including type, frequency, and time of last
dose/drink. Call the physician and report findings. Anticipate withdrawal/delirium tremens.
Provide a quiet, safe environment. Place on seizure precautions. Anticipate giving a medication
like Librium.

2. What physical signs might indicate that a client is abusing intravenous medications?
Super Condensed Portable HESI Study Guide 50

- Needle track marks; cellulitis at puncture site; poor nutritional status.

3. What behaviors would indicate to the nurse manager that an employee has a possible
substance abuse problem?
- Change in work performance, withdrawal, increase in absences (especially Monday or Friday),
increase in number of times tardy, long breaks, late returning from lunch.

4. A client becomes extremely agitated, abusive, and very suspicious. He is currently

undergoing detoxification from alcohol with Librium 25 mg q6h. What nursing actions are
- Notify the physician immediately and anticipate an increase in dose or frequency of Librium.
Provide a quiet, safe environment. Approach in a quiet, calm manner. Avoid touching client.

5. A client, in the third week of cocaine rehabilitation program, returns from an unsupervised
pass. The nurse notices that he is euphoric and is socializing with the other clients more
than he has in the past. What nursing actions are indicated?
- Notify the physician of observed behavior change. Get a urine drug screen as ordered. Confront
client with observed behavior change.


1. What family dynamics are often seen in child abuse cases?

- Parent sees child as “different” from other children. Parent sees child to meet their own needs.
Parent seldom touches or responds to child. Parent may be very critical of child. Family history of
frequent moves, unstable employment, marital discord, and family violence. One parent answers
all the questions.

2. What behavior might the nurse observe in a child who is abused?

- Child may appear frightened and withdrawn in the presence of parent or adult.

3. Identify nursing interventions for dealing with an abused child.

- Must report all cases of suspected abuse to appropriate local/state agency. Take color
photographs of injuries. Document factual, objective statements of child’s physical condition,
child-family interactions, and interviews with family. Establish trust, and care for the child’s
physical problems. These are the PRIMARY and IMMEDIATE needs of these children.
Recognize own feelings of disgust and contempt for the parents. Teach basic child development
and parenting skills to family.

4. When does battering of women often begin or escalate?

- During pregnancy.

5. What dynamics prevent a battered spouse from leaving the battering situation?
- A woman in a battering relationship usually lacks self-confidence and feels trapped. She is often
embarrassed to tell friends and family, so she becomes isolated and dependent upon the abuser.

6. Why is elder abuse so under reported?

- It is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or
being abandoned.

7. What types of abuse are seen in the elderly?

- Abuse can be physical, verbal, psychosocial, exploitive, or physical neglect.

8. Identify nursing interventions for working with a rape survivor?

- Communicate non-judgmental acceptance. Provide physical care to treat injuries. Give clear,
concise explanations of all procedures to be performed. Notify police, encourage victim to
prosecute. Collect and label evidence carefully in the presence of a witness. Document factual,
objective statements of physical condition; record client’s EXACT WORDS in describing the
assault. Notify Rape Crisis Team or counselor if available in the community. Allow discussion of
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feelings about the assault. Advise of potential for venereal disease, HIV, or pregnancy and
describe medical care available.


1. List 5 causes of delirium.

- Infection, alcohol withdrawal, electrolyte imbalance, sleep deprivation, brain injury, i.e., subdural
2. Describe the nursing care for a client with Alzheimer’s disease.
- Provide a safe, consistent environment. (Do not make changes if possible. Change increases
anxiety and confusion.) Stick to routines. If client wanders, make sure they have a nametag.
Provide assistance as needed with ADL. Make sure bathroom is clearly labeled.

3. Identify 3 or more causes of dementia.

- Alzheimer’s disease, multi-infarcts (brain), Huntington’s chorea, multiple sclerosis, Parkinson’s


1. A 7 yr. old boy is disruptive in the classroom and is described by his parents as
“hyperactive.” What is the most probable psychiatric disorder? What are the signs and
symptoms of this disorder? What drug is usually prescribed for this disorder?
- Attention deficit disorder (ADD/ADHD). More prevalent in boys, failure to listen or follow
instructions. Difficulty playing quietly, disruptive, impulsive behavior, difficulty sitting still,
distractibility to external stimuli, excessive talking, shifts from one unfinished task to another, and
underachievement in school performance. Ritalin.

2. A 15 yr. old boy is threatening to drop out of school. His parents, both alcoholics, say they
can’t stop him. He has just been arrested for stealing a car and breaking into a house.
What is the most probable disorder? Develop nursing diagnoses and interventions for this
- Conduct disorder.
A. Potential for violence related to…depending on client.
B. Disturbance in self-esteem related to…depending on client.
C. Ineffective family coping related to…depending on client.
D. Assess verbal/nonverbal cues for escalating behavior to decrease outbursts. Use a non-
authoritarian approach. Avoid asking “why” questions. Initiate a “show of force” for a child
who is out of control. Initiate suicide precautions when assessment indicates risk. Use “quiet
room” when external control is needed. Clarify expressions or jargon if meaning is unclear.
Redirect angry feelings to “safe” alternative such as pillow or punching bag. Implement
behavior modification therapy if indicated. Role-play new coping strategies.



1. When does birth length double? = by 4 years

2. When does the child sit unsupported? = 8 months

3. When does a child achieve 50% of adult height? = 2 years

4. When does a child throw a ball overhand? = 18 months

5. When does a child speak 2-3 word sentences? = 2 years

6. When does a child use scissors? = 4 years

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7. When does a child tie his/her shoes? = 5 years


1. List 2 contraindications for live virus immunization.

- Immunocompromised child or a child in a household with an immunocompromised individual.

2. List 3 classic signs and symptoms of measles.

- Photophobia, confluent rash that begins on the face and spreads dowward, and Koplik’s spots on
the buccal mucosa.

3. List the signs and symptoms of iron deficiency.

- Anemia, pale conjunctiva, pale skin color, atrophy of papillae on tongue, brittle/ridged/spoon-
shaped nails, and thyroid edema.

4. Identify food sources for Vitamin A.

- Liver, sweet potatoes, carrots, spinach, peaches, and apricots.

5. What disease occurs with vitamin C deficiency?

- Scurvy.

6. What measurements reflect present nutritional status?

- Weight, skinfold thickness, and arm circumference.

7. List the signs and symptoms of dehydration in an infant.

- Poor skin turgor, absence of tears, dry mucous membranes, weight loss, depressed fontanel and
decreased urinary output.

8. List the laboratory findings that can be expected in a dehydrated child.

- Loss of bicarbonate/decreased serum pH, losso f sodium (hyponatremia), loss of potassium
(hypokalemia), elevated Hct, and elevated BUN.

9. How should burns in children be assessed?

- Use the Lund-Browder chart, which takes into account the changing proportions of the child’s

10. How can the nurse BEST evaluate the adequacy of fluid replacement in children?
- Monitor urine output.

11. How should a parent be instructed to “child proof” a house?

- Lock all cabinets, safely store all toxic household items in locked cabinets, and examine the house
from the child’s point of view.

12. What interventions should the nurse do FIRST in caring for a child who has ingested a
- Assess the child’s respiratory, cardiac, and neurological status.

13. List 5 contraindications to administering syrup of ipecac.

- Coma, seizures, CNS depression, ingestion of petroleum-based products, and ingestion of

14. What instructions should be given by phone to a mother who knows her child has ingested
a bottle of medication?
- Administer syrup of ipecac if the child is conscious. Bring any emesis or stool to the emergency
room. Bring the container in which the medicine was stored to the emergency room.

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1. Describe the purpose of bronchodilators.

- Reverse bronchospasm

2. What are the physical assessment findings for a child with asthma?
- Expiratory wheezing, rales, right cough, and signs of altered blood gases.

3. What nutritional support should be provided for the child with cystic fibrosis?
- Pancreatic enzyme replacement, fat-soluble vitamins, and a high carbohydrate, high protein,
moderate fat diet.

4. Why is genetic counseling important for the cystic fibrosis family?

- The disease is autosomal recessive in its genetic pattern.

5. List 7 signs of respiratory distress in a pediatric client.

- Restlessness, tachycardia, tachypnea, diaphoresis, flaring nostrils, retractions, and grunting

6. Describe the care of a child in a mist tent.

- Monitor child’s temperature. Keep tent edges tucked in. Keep clothing dry. Assess child’s
respiratory status. Look at child inside tent.

7. What position does the child with epiglottis assume?

- Upright, sitting, with chin out and tongue protruding (“tripod” position).

8. Why are IV fluids important for the child with an increased respiratory rate?
- The child is at risk for dehydration and acid/base imbalance.

9. Children with chronic otitis media are at risk for developing what problem?
- Hearing loss

10. What is the most common post-operative complication following a tonsillectomy?

Describe the signs and symptoms of this complication.
- Hemorrhage; frequent swallowing, vomiting fresh blood, and clearing throat.


1. Differentiate between a right to left and left to right shunt in cardiac disease.
- A left to right shunt moves oxygenated blood back through the pulmonary circulation. A right to left
shunt bypasses the lungs and delivers unoxygenated blood to the systemic circulation causing

2. List the 4 defects associated with Tetralogy of Fallot.

- VSD, overriding aorta, pulmonary stenosis and right ventricular hypertrophy

3. List the commons signs of cardiac problems in an infant.

- Poor feeding, poor weight gain, respiratory distress/infections, edema and cyanosis

4. What are the 2 objectives in treating congestive heart failure?

- Reduce the workload of the heart and increase cardiac output.

5. Describe nursing interventions to reduce the workload of the heart.

- Small, frequent feedings or gavage feedings. Plan frequent rest periods. Maintain a neutral
thermal environment. Organize activities to disturb child only as indicated.

6. What position would best relieve the child experiencing a “tet” spell?
- Knee-chest position, or squatting.

7. What are common signs of digoxin toxicity?

- Diarrhea, fatigue, weakness, nausea and vomiting. The nurse should check for bradycardia prior
to administration.
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8. List 5 risks of cardiac catheterization.

- Arrythmia, bleeding, perforation, phlebitis, and obstruction of the arterial entry site.
9. What cardiac complications are associated with rheumatic fever?
- Aortic valve stenosis and mitral valve stenosis.

10. What medications are used to treat rheumatic fever?

- Penicillin, erythromycin, and aspirin.


1. What are the physical features of a child with Down syndrome?

- Simian creases of palms, hypotonia, protruding tongue, and upward/outward slant of eyes.

2. Describe “scissoring.”
- A common characteristic of spastic cerebral palsy in infants. The legs are extended and crossed
over each other, the feet are plantar flexed.

3. What are 2 nursing priorities for a newborn with myelomeningocele?

- Prevention of infection of the sac and monitoring for hydrocephalus (measure head circumference;
check fontanel; assess neurological functioning).

4. List the signs and symptoms of increased ICP in older children.

- Irritability, change in LOC, motor dysfunction, headache, vomiting, unequal pupil response, and

5. What teaching should parents of a newly shunted child receive?

- Signs of infection and increased ICP (decreased pulse, increased blood pressure). Shunt should
not be pumped. Child will need revisions due to growth. Provide guidance for growth and

6. State the 3 main goals in providing nursing care for a child experiencing a seizure.
- Maintain patent airway, protect from injury, and observe carefully.

7. What are the side effects of Dilantin?

- Gingival hyperplasia of the gums, dermatitis, ataxia, and GI distress.

8. Describe the signs and symptoms of a child with meningitis?

- Fever, irritability, vomiting, neck stiffness, opisthotonos, positive Kernig’s sign, positive Brudzinski’s
sign. Infant does not show all classic signs, but is very ill.
9. What antibiotics are usually ordered for bacterial meningitis?
- Ampicillin, penicillin, and/or Chloramphenicol.

10. How is a child usually positioned after brain tumor surgery?

- Flat on his/her side.

11. Describe the function of an osmotic diuretic.

- Osmotic diuretics remove water from the CNS to reduce cerebral edema.

12. What nursing interventions increase intracranial pressure?

- Suctioning and positioning/turning.

13. Describe the mechanism of inheritance for Duchenne muscular dystrophy.

- Duchenne muscular dystrophy is inherited as an X-linked recessive trait.

14. What is “Gower’s sign?”

- Gower’s sign is an indicator of muscular dystrophy. The child has to “walk” up legs using hands to
Super Condensed Portable HESI Study Guide 55


1. Compare the signs and symptoms of acute glomerulonephritis (AGN) with nephrosis.
- AGN: gross hematuria, recent strep infection, hypertension, and mild edema. Nephrosis: severe
edema, massive proteinuria, frothy-appearing urine, anorexia.

2. What antecedent event occurs with acute glomerulonephritis?

- Beta-hemolytic strep infection

3. Compare the dietary interventions for acute glomerulonephritis and nephrosis.

- AGN: low-sodium diet with no added salt. Nephrosis: high-protein, low-salt diet.

4. What is the physiologic reason for the lab finding of hypoproteinemia in nephrosis?
- Hypoproteinemia occurs because the glomeruli are permeable to serum proteins.

5. Describe safe monitoring of prednisone administration and withdrawal.

- Long term prednisone should be given every other day. Signs of edema, mood changes, and GI
distress should be noted and reported. The drug should be tapered, not discontinued suddenly.

6. What interventions can be taught to prevent urinary tract infections in children?

- Avoid bubble baths, void frequently; drink adequate fluids especially acidic fluids such as apple or
cranberry juice, and clean genital area from front to back.

7. Describe the pathophysiology of vesicoureteral reflux.

- a malfunction of the valves at the end of the ureters allowing urine to reflux out of the bladder into
the ureters and possibly the kidneys.

8. What are the priorities for a client with Wilms’ tumor?

- Protect the child from injury to the encapsulated tumor. Prepare the family/child for surgery.

9. Explain why hypospadias correction is done before the child reaches preschool age.
- Preschoolers fear castration, are achieving sexual identity, and acquiring independent toileting


1. Describe feeding techniques for the child with cleft lip or palate.
- Lamb’s nipple, or prosthesis. Feed child upright with frequent bubbling.

2. List the signs and symptoms of esophageal atresia with TEF.

- choking, coughing, cyanosis, and excess salivation.

3. What nursing actions are initiated for the newborn with suspected esophageal atresia with
- NPO immediately and suction secretions.

4. Describe the post-op nursing care for an infant with pyloric stenosis.
- Maintain Iv hydration and provide small, frequent oral feedings of glucose and/or electrolyte
solutions within 4-6 hours. Gradually increase to full strength formula. Position on right side in
semi-Fowler’s position after feeding.

5. Describe why a barium enema is used to treat intussusception.

- A barium enema reduces the telescoping of the intestine through hydrostatic pressure without
surgical intervention.

6. Describe the pre-op nursing care for a child with Hirschsprung’s disease.
- Check vital signs and take axillary temps. Provide bowel cleansing program and teach about
colostomy. Observe for bowel perforation; measure abdominal girth.
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7. What care is needed for the child with a temporary colostomy?

- Family needs education about skin care and appliances. Referral to an enterostomal therapist is

8. What are the signs of anorectal malformation?

- A newborn who does not pass meconium within 24 hours, meconium appearing from a fistula or in
the urine, or an unusual appearing anal dimple.
9. What are the priorities for a child undergoing abdominal surgery?
- Maintain fluid balance (I&O, NG suction, monitor electrolytes), monitor vital signs, care of drains if
present, assess bowel function, prevent infection of incisional area and other post-op
complications, and support child/family with appropriate teaching.


1. Describe what information families should be given when a child is receiving oral iron
- Give oral iron on an empty stomach and with vitamin C. Use straws to avoid discoloring teeth.
Tarry stools are normal. Increase dietary sources of iron.

2. List dietary sources of iron.

- Meat, green leafy vegetables, fish, liver, whole grains, legumes.

3. What is the genetic transmission pattern of hemophilia.

- It is an X-linked recessive chromosomal disorder, transmitted by the mother and expressed in
male children.

4. Describe the sequence of events in a vaso-occlusive crisis in sickle cell anemia.

- A vaso-occlusive crisis is caused by clumping of red blood cells which cannot get through the
capillaries, causing pain and tissue/organ ischemia. Lowered oxygen tension affects the HgbS,
which causes sickling of the cells.

5. Explain why hydration is a priority in treating sickle cell disease.

- Hydration promotes hemodilution and circulation of the red blood cells through the blood vessels.

6. What should families and clients do to avoid triggering sickling episodes?

- Keep child well hydrated. Avoid known sources of infections. Avoid high altitudes. Avoid
strenuous exercise.

7. Nursing interventions and medical treatment for the child with leukemia are based on what
3 physiological problems?
- Anemia (decreased erythrocytes). Infection (neutropenia). Bleeding thrombocytopenia
(decreased platelets).


1. List normal findings in a neurovascular assessment.

- Warm extremity, brisk capillary refill, free movement, normal sensation of the affected extremity,
and equal pulses.

2. What is compartment syndrome?

- Damage to the nerves and vasculature of an extremity due to compression.

3. What are the signs and symptoms of compartment syndrome?

- Abnormal neurovascular assessment: cold extremity, severe pain, inability to move the extremity,
and poor capillary refill.

4. Why are fractures of the epiphyseal plate a special concern?

- Fractures of the epiphyseal plate (growth plate) may affect the growth of the limb.
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5. How is skeletal traction applied?

- Skeletal traction is maintained by pins or wires applied to the distal fragment of the fracture.

6. What discharge instructions should be included for a child with spica cast?
- Check circulatio. Keep cast dry. Do not stick anything under cast. Prevent cast soilage during
toileting or diapering. DO NOT TURN with abductor bar.

7. What are the signs and symptoms of congenital dislocated hip in infants?
- Unequal skin folds of the buttocks, ortalani sign, limited abduction of the affected hip, and unequal
leg lengths.

8. How would the nurse conduct scoliosis screening?

- Ask the child to bend forward from the hips with arms hanging free. Examine the child for a curve
of the spine, rib hump, and hip asymmetry.

9. What instructions should the child with scoliosis receive about the Milwaukee brace?
- Wear the brace 23 hours per day. Wear t-shirt under brace. Check skin for irritation. Perform
back and abdominal exercises. Modify clothing. Encourage the child to maintain normal activities
as able.

10. What care is indicated for a child with juvenile rheumatoid arthritis?
- Prescribed exercise to maintain mobility, splinting of affected joints, and teaching medication
management and side effects of drugs.



1. What PO2 value indicates hypoxemia?

- Below 50 mmHg

2. What blood value indicates hypercapnia?

- PCO2 above 45 mmHg

3. Identify the condition that exists when the PO2 is less than 50 mmHg and FiO2 is greater
than 60%.
- Hypoxemia

4. List 3 symptoms of respiratory failure in the adult.

- Dyspnea/tachypnea, intercostal retractions, cyanosis.

5. List 4 common causes of respiratory failure in children.

- Congenital heart disease, infection or sepsis. Respiratory distress syndrome, aspiration, fluid
overload or dehydration.

6. What percentage of O2 should a child in severe respiratory distress receive?

- 100% O2


1. Define shock.
- Widespread, serious reduction of tissue perfusion which leads to generalized impairment of
cellular function.

2. What is the most common cause of shock?

- Hypovolemia

3. What cause septic shock?

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- Release of endotoxins from bacteria which act on nerves in vascular space in periphery, causing
vascular pooling, reduced venous return, and decreased cardiac output, resulting in poor systemic

4. What is the goal of treatment for hypovolemic shock?

- Quick restoration of cardiac output and tissue perfusion

5. What intervention is used to restore cardiac output when hypovolemic shock exists?
- Rapid infusion of volume-expanding fluids

6. It is important to differentiate between hypovolemic and cardiogenic shock. How might the
nurse determine the existence of cardiogenic shock?
- History of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary

7. If a client is in cardiogenic shock, what might result from administration of volume

expanding fluids, and what intervention can the nurse expect to perform in the event of
such an occurrence?
- Pulmonary edema, administer cardiotonic drugs such as digitalis preparations

8. List 5 assessment findings found in most shock victims.

- Tachycardia. Tachypnea. Hypotension. Cool clammy skin. Decrease in urinary output.

9. What is the normal central venous pressure for an adult?

- 4 to 10 cm of H2O

10. Once circulating volume is restored, vasopressors may be prescribed to increase venous
return. List the main drugs that are used.
- Epinephrine (Bronkaid). Dopamine (Dopram). Dobutamine (Dobutrex). Norepinephrine
(Levophed). Isoproterenol (Isuprel).

11. What is the established minimum renal output per hour?

- 30 cc/hr

12. List 4 measurable criteria that are the major expected outcomes of a shock crisis.
- BP mean of 80 to 90 mmHg. PO2 >50 mmHg. CVP above 6 cm of H2O. Urine output at least 30

13. Define DIC.

- A coagulation disorder in which there is paradoxical thrombosis and hemorrhage

14. What is the effect of DIC on PT, PTT, platelets, FSPs (FDPs)?
- PT: prolonged. PTT: prolonged. Platelets: decreased. Fribin split products: increased.

15. What drug is used in the treatment of DIC?

- Heparin

16. Name 4 nursing interventions to prevent injury in clients with DIC.

- Gently provide oral care with mouth swabs. Minimize needle sticks and use the smallest gauge
needle possible when injections are necessary. Eliminate pressure by turning the client frequently.
Minimize the number of BPs taken by cuff. Use gentle suction to prevent trauma to mucosa.
Apply pressure to any oozing site.


1. What is the first priority when a client with an unwitnessed cardiac arrest is found?
- Begin CPR

2. Define myocardial infarction.

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- Necrosis of the heart muscle due to poor perfusion of the heart.

3. What criteria should alert a client with known angina who takes nitroglycerin tablets
sublingually to call the EMS?
- Unrelieved chest pain after 3 nitroglycerin tabs in 15 minutes.

4. After calling out for help and asking someone to dial for emergency services, what is the
next action in CPR?
- According to American Heart Association guidelines published September 2000, you should call
for help first for unresponsive adults and then begin the ABC’s of CPR. For unresponsive infants
& children, CPR should be performed for 1 minute before placing a 911 call for help.

5. True or False: In feeling of presence of a carotid pulse, no more than 5 seconds should be
- FALSE: palpate for at least 5 to 10 seconds, recognizing that arrythmias or bradycardia could be

6. During one-rescuer CPR, what is the ratio of compressions to ventilations for an adult?
During one-rescuer CPR, what is the ratio of compressions to ventialations for a child?
- 15:2 X 4 cycles for adult. 5:1 for a child and neonate.

7. What is the FIRST drug most likely to be used for an in-hospital cardiac arrest?
- Epinephrine

8. A client in cardiac arrest is noted on bedside monitor to be in pulseless ventricular

tachycardia. What is the first action that should be taken?
- Defibrillation with 200 to 360 joules.

9. True or False: A precordial thump is routine activity for an in-hospital cardiac arrest.
- FALSE: only indicated in pulseless VT or VF or when ventricular asystole on monitor responds to a
thump with a QRS complex.

10. How would the nurse assess the adequacy of compressions during CPR? How would the
nurse assess for adequacy of ventilations during CPR?
- Check for a pulse. Watch for chest excursion and auscultate bilaterally for breath sounds.

11. If a person is choking, when should the rescuer intervene?

- When the person points to his/her throat and can no longer cough, talk, or make sounds.

12. One should NEVER make blind sweeps into the mouth of a choking child or infant. Why?
- Because the object might be pushed further down into the throat.

13. Why do ACLS guidelines recommend a decreased reliance on the use of bicarbonate
during adult CPR?
- Because acidosis should be relieved with improved ventilation. Bicarbonate administration can
actually contribute to increased CO2.


1. List 4 common caused of fluid volume deficit.

- GI causes: vomiting, diarrhea, GI suctioning. Decrease in fluid intake. Increase in fluid output
such as sweating. Massive edema. Ascites.

2. List 4 common causes of fluid volume overload.

- CHF, renal failure; cirrhosis; excess ingestion of table salt or over-hydration with sodium-
containing fluids.

3. Identify 2 examples of isotonic fluids.

- Ringer’s lactate. Normal saline.
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4. List 3 systems which maintain acid-base balance.

- Lungs. Kidneys. Chemical buffers.

5. Cite the ABG normals for the following: pH, pCO2, HCO3.
- pH: 7.35-7.45. pCO2: 35 to 45 mmHg. HCO3: 22-26 mEq/L

6. Determine the following acid-base disorders:

A. pH- 7.50, pCO2 – 30, HCO3 – 26 = Respiratory alkalosis
B. pH- 7.30, pCO2 – 42, HCO3 – 20 = Metabolic acidosis
C. pH- 7.48, pCO2 – 42, HCO3 – 32 = Metabolic alkalosis
D. pH- 7.29, pCO2 – 55, HCO3 – 26 = Respiratory acidosis


1. List 5 variables that increase surgical risk.

- Age: very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia,
preoperative infection, use of anticoagulants preoperative (aspirin)

2. Why is a client with liver disease at increased risk for operative complications?
- Impairs ability to detoxify medications used during surgery. Impairs ability to produce prothrombin
to reduce hemorrhage.

3. Preoperative teaching should include demonstration and explanation of expected

postoperative client activities. What activities should be included?
- Respiratory activities: breathing, use of spirometer. Exercises: range of motion, leg exercises,
turning. Pain management: medications, splinting. Dietary restrictions: NPO to progressive diet.
Dressings and drains. Orientation to recovery room environment.

4. What items should the nurse assist the client in removing before surgery?
- Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prosthesis, make-up and nail

5. How and why is the client positioned in the immediate postoperative period?
- Usually on the side or with head to side in order to prevent aspiration of any emesis.

6. List 3 nursing actions to prevent postoperative wound dehiscence/evisceration.

- Splint incision when coughing, encourage coughing/deep breathing in EARLY postoperative period
when sutures are STRONG. Monitor for signs of infection, malnutrition, and dehydration.
Encourage high-protein diet.

7. Identify 3 nursing interventions to prevent postoperative urinary tract infections.

- Avoid postoperative catheterization. Increase oral fluid intake. Empty bladder q4 to 6 hours, early

8. Identify nursing/medical interventions to prevent postoperative paralytic ileus.

- Early ambulation. Limit use of narcotic analgesics. NG tube decompression.

9. List 4 nursing interventions to prevent postoperative thrombophlebitis.

- Perform in-bed leg exercises. Early ambulation. Apply antiembolus stockings. Avoid
positions/pressure which obstruct venous flow.

10. During the intraoperative period, what activities should the operating room nurse do to
ensure safety during surgery?
- Ascertain correct sponge, needle, and instrument count. Position client to avoid injury. Apply
ground during electrocautery use. Strict use of surgical asepsis.

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1. Identify the way HIV is transmitted.

- Transmitted through blood and body fluids, e.g., unprotected sexual contact with an affected
person, sharing needles among drug abusing persons, infected blood products (rare), maternal to
fetus transmission through breast milk, or breaks in universal precautions (needle sticks or similar

2. Vertical transmission (from mother to fetus) occurs how often if mother is treated during
- Vertical transmission occurs 30 to 50% of the time.

3. Describe universal precautions.

- Protection from blood and body fluids is the goal of standard precautions. Standard precautions
initiate barrier protection between caregiver and client through: Hand washing, use gloves, use
gown and masks, eye protection as indicated, depending on activity of care and the likelihood of
exposure. Prevent needle sticks by not capping needles.

4. What are the side effects of Amphotericin B?

- Side effects of amphotericin B (can be quite severe) include: Anorexia, Chills, Cramping, Muscle
and joint pain, Circulatory problems.

5. What does the CD4 T cell count describe?

- CD4 T cell count describes the number of infection-fighting lymphocytes the person has.

6. Why does the CD4 T cell count drop in HIV infections?

- CD4 T cell count drops because the virus destroys CD4 T cells as it invades them and replicates.

7. Describe the ways a pediatric client might acquire HIV infection.

- Through infected blood products. Through sexual abuse. Through breast milk.


1. What modalities are associated with the Gate control pain theory?
- Massage, heat and cold, acupuncture, TENS.

2. How does past experiences with pain influence current pain experience?
- The more pain experienced in childhood, the greater the perception of pain in adulthood or with
current pain experience.

3. What modalities are thought to increase the production of endogenous opiates?

- Acupuncture, administration of placebos, TENS.

4. What 6 factors should the nurse include when assessing the pain experience?
- Location, intensity, comfort measures, quality, chronology and subjective view of pain.

5. What mechanism is involved in the reduction of pain through the administration of NSAIDs
- NSAIDs act by a peripheral mechanism at the level of damaged tissue by inhibiting prostaglandin
synthesis and other chemical mediators involved in pain transmission.

6. If narcotic agonist/antagonist drugs are administered to a client already taking narcotic

drugs, what may be the result?
- Initiation of withdrawal symptoms

7. List 4 side effects of narcotic medications.

- Nausea/vomiting. Constipation. CNS depression. Respiratory depression.

8. What is the antidote for narcotic-induced respiratory depression?

- Narcan (Naloxone).
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9. What is the 1st sign of tolerance to pain analgesics?

- Decreased duration of drug effectiveness

10. Which route of administration for pain medications has the quickest onset and the shortest
- IV push or bolus.

11. List the 6 modalities that are considered non-invasive, non-pharmacologic pain relief
- Heat and cold applications. Transcutaneous electrical nerve stimulation (TENS). Massage.
Distraction. Relaxation techniques. Biofeedback techniques.


1. Identify the 5 stages of death and dying.

- Denial. Anger. Bargaining. Depression. Acceptance.

2. A client has been told of a positive breast biopsy report. She asks no questions and leaves
the healthcare provider’s office. She is overheard telling her husband, :the doctor didn’t
find a thing.” What coping style is operating at this stage of grief?
- Denial

3. Your client, an incest survivor, is speaking of her deceased father, the perpetrator. “He was
a wonderful man, so good and kind. Everyone thought so.” What would be the most
useful intervention at this time?
- Gently point out both the positive and negative aspects of her relationship wit her father. Try to
minimize the idealization of the deceased.

4. Your client feels responsible for his sister’s death because he took her to the hospital where she
died. “If I hadn’t taken her there, they couldn’t have killed her.” It has been one month since her
death. Is this response indicative of a normal or complicated grief reaction?
- This is a normal expression of anger and guilt, which occurs. Try to minimize the rumination of
these thoughts.

5. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and
continues to set a place at the table for him nightly. Is this response indicative of a normal
or complicated grief reaction?
- This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her
grief work.


1. Identify the waveforms found in a normal EKG?

- P wave, QRS complex, T wave, ST segment, PR interval

2. In an EKG reading, which wave represents depolarization of the atrium?

- P wave

3. In an EKG reading, what complex represents depolarization of the ventricle?

- QRS complex

4. What does the PR interval represent?

- The time rquired for the impulse to travel from the atria through the A-V node

5. If the U wave is most prominent, what condition might the nurse suspect?
- Hypokalemia
6. Describe the calculation of the heart rate using an EKG rhythm strip.
- Count the number of the R-R intervals in the 30 large squares and multiply by 10
Super Condensed Portable HESI Study Guide 63

7. What is the most important assessment data for the nurse to obtain on a client with
- Ability of the client to tolerate the arrhythmia

8. Calculate the rate of this rhythm strip.

- 90 to 100 depending on which set of 6 squares you use.


1. What are normal memory changes that occur as one ages?

- Short-term memory declines while long-term memory undergoes minimal change.

2. What symptoms might the nurse expect to see in an older person who has had an overload
of changes as well as a respiratory infection?
- Confusion.

3. Why can the BP of older adults be expected to increase?

- Heart work increases in response to increased peripheral resistance.

4. What is the major cause of respiratory disability in the elderly?


5. List 5 nursing interventions to promote adequate bowel functioning for older persons.
- Determine what is normal GI functioning for each individual, increase fiber and bulk in the diet,
provide adequate hydration, encourage regular exercise, and encourage eating, small, frequent

6. How can a female nurse increase the older client’s ability to hear her speak?
- Lower the pitch or tone of her voice.

7. What is the most common visual problem occurring in the elderly?

- Cataracts.

8. Describe the following conditions which occur in the elderly: Presbyopia, Arcus senilis,
- Presbyopia – decreased ability of the eye to accommodate for close work.
- Arcus senilis – glossy white ring encircling the periphery of the cornea
- Presbycusis – decrease in hearing acuity, auditory threshold, pitch and tone discrimination, and
speech intelligibility.

9. Describe the onset of Alzheimer’s disease.

- Slow, insidious onset with progressive downward course.

10. What is the purpose of a reality orientation group?

- To keep the client oriented to time, place, and person.

11. What are the 2 factors that cause decrease in excretion of drugs by the kidneys?
- Decrease in glomerular filtration and slowed organ functioning.



1. State the objective signs that signify ovulation

- abundant, thin, clear cervical mucus; open cervical os; slight drop in BBT and then 0.5-1.0 F rise;
ferning under the microscope

2. Ovulation occurs how many days before the next menstrual period?
Super Condensed Portable HESI Study Guide 64

- 14 days.

3. State three ways to identify the chronological age of a pregnancy (gestation)?

- 10 lunar months, 9 calendar months consisting of 3 trimesters of 3 months each, 40 weeks, 280

4. What maternal position provides optimum fetal maternal/placental perfusion during

- The knee-chest position, but the ideal position of COMFORT for the mother which supports
fetal/maternal/placental perfusion is the side-lying position off the abdominal vessels (vena cava,

5. Name the major discomforts of the first trimester and one suggestion for amelioration of
- Nausea and vomiting: crackers before rising. Fatigue: teach the need for rest periods/naps and 7-
8 hours sleep at night.

6. If the first day of a woman’s last normal menstrual period was May 28, what is the
estimated delivery date (EDD) using Nagele’s rule?
- Count back 3 months and add 7 days: March 7 (always give February 28 days).

7. At twenty weeks gestation, the fundal height would be ______ , the fetus would weigh
approximately _______ and look like _____ .
- At the umbilicus; 300-400 grams; a baby with hair, lanugo and verniz, but without subcutaneous

8. State the normal psychosocial responses to pregnancy in the 2nd trimester

- Ambivalence wanes and acceptance of pregnancy occurs; pregnancy becomes “real;” signs of
maternal-fetal bonding occur.
9. Hemodilution of pregnancy peaks at ______ weeks and results in a/an ______ in a women’s
- 28-32 weeks; increase in Hct

10. State three principles relative to the PATTERN of weight gain in pregnancy.
- Total gain should average 24-30 lbs. Gain should be consistent throughout pregnancy. An
average of 0.9 lb/week should be gained in the 2nd & 3rd trimester.

11. During pregnancy a woman should add ____ calories to her diet, and drink ____ of
- 300 calories; 1 quart of milk

12. Fetal heart rate can be auscultated by Doppler at ____ weeks gestation.
- 10-12 weeks

13. Describe the schedule for prenatal visits for a low-risk pregnant woman.
- Once a month until 28 weeks, then once every week until delivery.


1. Name 5 maternal variables associated with diagnosis of a high risk pregnancy

- Age (under 17 years or over 34 years of age), parity (over 5), <3 months between pregnancies,
diagnosis of PIH, diabetes mellitus, or cardiac disease.

2. Is one ultrasound examination useful in determining the presence of intrauterine growth

retardation (IUGR)?
- no, serial measurements are needed to determine IUGR.

3. What does the biophysical profile (BPP) determine?

- Fetal well-being
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4. List 3 necessary nursing actions prior to an ultrasound exam for a woman in the first
trimester of pregnancy.
- Have client fill bladder. Do not allow client to void. Position supine with uterine wedge.

5. State the advantage of CVS over amniocentesis.

- Can be done between 8-12 weeks gestation with results returned within one week, which allows
for decision about termination while still in 1st trimester.

6. Why are serum or amniotic AFP levels done prenatally?

- To determine if alpha-fetoprotein levels are elevated which may indicate the presence of neural
tube defects; or low levels, which may indicate trisomy 21.

7. What is the most important determinant of fetal maturity for extrauterine survival?
- L/S ratio (lung maturity, lung surfactant development)

8. Name the 3 most common complications of amniocentesis.

- Spontaneous abortion, fetal injury, infection.

9. Name the 4 periodic changes of the fetal heart rate, their causes, and one nursing treatment
for each.
- Acceleration: caused by burst of sympathetic activity; they are reassuring and require no
treatment. Early decelerations: caused by head compression, are benign and caution the nurse to
monitor for labor progress and fetal descent. Variable decelerations: caused by cord compression;
change of position should be tried first. Late decelerations: are caused by UPI (uteroplacental
insufficiency) and should be treated by placing client on her side and administering O2.

10. What is the most important indicator of fetal autonomic nervous system integrity/health?
- Fetal heart rate variability

11. Name 4 causes of decreased FHR variability.

- Hypoxia, acidosis, drugs, fetal sleep

12. State the most important action to take when a cord prolapse is determined.
- Examiner should position mother to relieve pressure on the cord with fingers until emergency
delivery is accomplished.

13. What is a “reactive” non-stress test?

- FHR acceleration of 15 beats per minute for 15 seconds in response to fetal movement.

14. What are the dangers of nipple-stimulation stress test?

- The inability to control “oxytocin” dosage and the chance of tetany/hyperstimulation.

15. Normal fetal scalp pH in labor is ____ and values below ____ indicate true acidosis.
- 7.25-7.35 normal pH; 7.2 indicates true acidosis.


1. List five prodromal signs of labor the nurse might teach the client.
- lightening, braxton-hicks contractions increase, bloody show, loss of mucous plug, burst of energy,
and nesting behaviors.

2. How is true labor discriminated from false labor?

- true labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen
sweeping around from the back, and cervical changes. False labor: irregular rhythm, abdominal
pain (not in back) that decreases with ambulation.

3. State 2 ways to determine if the membranes have truly ruptured (ROM).

Super Condensed Portable HESI Study Guide 66

- Nitrazine testing: paper turns dark blue or black. Demonstration of fluid “ferning” under

4. Are psychoprophylactic breathing techniques prescribed for use by the stage and phase of
- No, clients should use these techniques according to their discomfort level and change techniques
when one is no longer working for relaxation.

5. Identify two reasons to withhold anesthesia and analgesia until the mid-active phase of
Stage 1 labor.
- if given too early, can retard labor; if given too late, can cause fetal distress

6. Hyperventilation often occurs to the laboring client. What results from hyperventilation
and what actions should the nurse take to relieve the condition?
- Respiratory alkalosis occurs which is caused by blowing off CO2 and is relieved by breathing into
a paper bag or cupped hands.

7. Describe maternal changes that characterize the transition phase of labor.

- irritability, unwillingness to be touched but does not want to be left alone, nausea and vomiting,
and hiccupping.

8. When should a laboring client be examined vaginally?

- Vaginal exams should be done prior to analgesia/anesthesia, to rule out cord prolapse, to
determine labor progress if it is questioned, and to determine when pushing can begin.

9. Define cervical effacement.

- the taking up of the lower cervical segment into the upper segment; shortening of the cervix
expressed in percent from 0-100% or complete effacement.

10. Where is the fetal heart rate best heard?

- through the fetal back in vertex, OA positions.

11. Normal fetal heart rate in labor is _____ = 110-160 bpm

Normal maternal BP in labor is _____ = <140/90
Normal maternal pulse in labor is _____ = <100 bpm
Normal maternal temperature in labor is _____ = <100.4 F

12. List four nursing actions for the 2nd stage of labor.
- make sure cervix is completely dilated before pushing is allowed. Assess FHR with each
contraction. Teach woman to hold breath for no longer than 5 seconds. Teach pushing technique.

13. List 3 signs of placental separation.

- gush of blood; lengthening of cord, and globular shape of uterus

14. When should the postpartum dosage of Pitocin be administered? Why is it administered?
- give immediately after placenta is delivered to prevent postpartum hemorrhage/atony.

15. State one contraindication to the use of ergot drugs (Methergine).

- Hypertension

16. State 5 symptoms of respiratory distress in the newborn.

- tachypnea, dusky color, flaring nares, retractions, and grunting.

17. If meconium was passed in utero, what action must the nurse take in the delivery room?
- arrange for immediate endotracheal tube observation to determine the presence of meconium
below the vocal cords (prevents pneumonitis/meconium aspiration syndrome)

18. What score is considered a good Apgar score?

- 7 to 10
Super Condensed Portable HESI Study Guide 67

19. What is the purpose of eye prophylaxis for the newborn?

- prevent opthalmia neonatorum, which results from exposure to gonorrhea in vagina.

20. What is the danger associated with regional blocks?

- hypotension resulting from vasodilation below the block, which pools blood in periphery reducing
venous return.

21. What is the major cause of maternal death when general anesthesia is administered?
- Aspiration of gastric contents

22. Why are PO medications avoided in labor?

- gastric activity stops or slows in labor, decreasing absorption from PO route, may cause vomiting.

23. State the best way to administer IV drugs in labor.

- at beginning of contraction, push a little medication in while uterine blood vessels are constricted,
thereby reducing dose to fetus.

24. When is it dangerous to administer butorphanol (Stadol), an agonist/antagonist narcotic?

- when the client is an undiagnosed drug abuser of narcotics, it can cause immediate withdrawal

25. Hypotension often occurs after the laboring client receives a regional block. What is one of
the first signs the nurse might observe?
- Nausea

26. State three actions the nurse should take when hypotension occurs in a laboring client.
- turn client to left side. Adminsiter O2 by mask at 10L/min. increase speed of intravenous infusion
(if it does not contain medication).

27. The fourth stage is defined as:

- the first 1 to 4 hours after delivery placenta.

28. What actions can the nurse take to assist in preventing postpartum hemorrhage?
- massage the fundus (gently) and keep the bladder emptied.

29. To promote comfort, what nursing interventions are used for a 3 rd degree episiotomy, which
extends into the anal sphincter?
- ice pack, withc hazel compresses, and no rectal manipulation

30. What nursing interventions are used to enhance maternal-infant bonding during the 4 th
stage of labor?
- withhold eye prophylaxis up to 2 hours. Perform newborn admission/routine procedures in room
with parents. Encourage early initiation of breastfeeding. Darken room to encourage newborn to
open eyes.

31. List 3 nursing interventions to ease the discomfort of afterpains.

- keep bladder empty. Provide warm blanket to abdomen. Administer analgesics ordered by doctor.

32. List symptoms of a full bladder, which might occur in the 4th stage of labor.
- fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine

33. What action should the nurse take first when a soft, boggy, uterus is palpated?
- perform fundal massage

34. What are the symptoms of hypovolemic shock?

- pallor, clammy skin, tachycardia, lightheadedness, and hypotension
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35. How often should the nurse check the fundus during the 4 th stage of labor?
- q15 minutes X 4 (1 hour), q30 minutes X 2 hours if normal.


1. A nurse discovers a postpartum client with a boggy uterus, displaced above and to the
right of the umbilicus. What nursing action is indicated?
- Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder
because cardinal signs of bladder distention are present.

2. Which women experience afterpains more than others?

- Breastfeeding women, multiparas, and women who experienced over distention of the uterus.

3. Upon admission to the postpartum room, 3 hours after delivery, a client has a temperature
of 99.5F. What nursing actions are indicated?
- Probably elevated due to dehydration and work of labor; force fluids and retake temperature in an
hour; notify physician if above 100.4F.

4. A client feels faint on the way to the bathroom. What nursing assessments should be
- Assess BP sitting and lying, assess Hgb and Hct for anemia.

5. What factor places the postpartum client at risk for thromboembolism?

- Increased clotting factors.

6. A breastfeeding mother complains of very tender nipples. What nursing actions should be
- Have her demonstrate infant position on breast (incorrect positioning often causes tenderness).
Leave bra open to air-dry nipples for 15 minutes 3X daily. Remove all “smothering” creams.

7. Three days postpartum, a lactating mother has full, warm, taut, tender breasts. What
nursing actions should be taken?
- She is engorged; have newborn suckle frequently; use measures to increase milk flow; warm
water, breast massage and supportive bra.

8. What information should be given to a client regarding resumption of sexual intercourse

after delivery?
- Avoid until postpartum exam. Use water soluble jelly. Expect slight discomfort due to vaginal

9. A woman has decided to take birth control pills as her contraceptive method. What should
she do if she misses taking the pill two consecutive days?
- Take two pills for two days and use an alternate form of birth control.

10. A woman asks why she is urinating so much in the postpartum period. The nurse bases
the response on what information.
- Up to 3,000 cc per day can be voided due to the reduction of the 40% plasma volume increase
during pregnancy.

11. A woman’s white blood count returns 17,000; she is afebrile and has no symptoms of
infection. What nursing action is indicated?
- Continue routine assessments; normal leukocytosis occurs during postpartal period because of
placental site healing.

12. What is the most common cause of uterine atony in the first 24 hours postpartum?
- full bladder

13. What is the purpose of giving docusate sodium (Colace) to the postpartum client?
Super Condensed Portable HESI Study Guide 69

- to soften the stool in mother’s with 3 rd and 4th degree episiotomies, hemorrhoids, or Cesarean
section delivery.

14. What should the fundal height be at three days postpartum for a woman who has had a
vaginal delivery?
- 3 fingerbreadths/cm below the umbilicus.

15. List 3 signs of positive bonding between parents and newborn?

- Calling infant by name, exploration of newborn head to toe, en face position.


1. The newborn transitional period consists of the first ____ of life.

- 6 to 8 hours of life

2. The nurse anticipates which newborn will be more at risk for problems in the transitional
period. State 3 predisposing factors to respiratory depression in the newborn.
- Cesarean delivery; magnesium sulfate given to mother in labor; asphyxia/fetal distress in labor.

3. What is the danger of heat loss to the newborn in the first few hours of life?
- Leads to depletion of glucose (very little glycogen storage in immature liver); begins to use brown
fat for energy producing ketones causing subsequent ketoacidosis and shock.

4. Normal newborn temperature is ____ = 97.7 – 99.4F

Normal newborn heart rate is ____ = 110-160 bpm
Normal newborn respiratory rate is ____ = 30-60 bpm
Normal blood pressure is ____ = 80/50

5. The nurse records a temperature below 97F on admission of the newborn. What nursing
actions should be taken?
- Place newborn in isolette or under radiant warmer and attach a temperature skin probe to regulate
isolette or radiant warmer temperature. Wrap newborn double if no isolette or warmer available
and put cap on head. Watch for signs of hypothermia and hypoglycemia.

6. True or False: the newborn’s head is usually smaller than the chest.
- FALSE: head is usually 2 cm larger unless severe molding occurred.

7. During the physical exam of the newborn, the nurse notes the cry is shrill, high-pitched,
and weak. What are the possible causes?
- CNS anomalies, brain damage, hypoglycemia, drug withdrawal.

8. The nurse notes a swelling over the back part of the newborn head. Is this normal newborn
- It depends on the exam. If it crosses suture lines and is a caput (edema), it is normal. If it does
not cross suture lines, it is a cephalhematoma with bleeding between the skull and periosteum.
This could cause hyperbilirubinemia. This is an abnormal variation.

9. What symptoms are common to most newborns with Down Syndrome?

- Low set ears, simian crease on palm, protruding tongue, Brushfield’s spots in iris, epicanthal folds.

10. Identify 3 ways t determine presence of congenital hip dislocation in the newborn.
- Hip click determination, asymmetrical gluteal folds, unequal limb lengths.

11. Should the normal newborn have a positive or negative Babinski reflex?
- Positive. The transient reflex is present until 12-18 months of age.

12. A small-for-gestational age newborn is identified as one who ____.

- Has a weight below the 10th percentile for estimated weeks of gestation.
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13. When suctioning the newborn with a bulb syringe, which should be suctioned first, the
mouth or the nose?
- Mouth; stimulating the nares can initiate inspiration which could cause aspiration of mucus in oral

14. A new mother asks the nurse if circumcision is medically indicated in the newborn. How
should the nurse respond?
- There is controversy concerning this issue, but we do know it causes pain and trauma to the
newborn, and the medical indication may be unfounded.

15. Normal blood glucose in the term neonate is ____. = 40-80 mg/dl.

16. Why does the newborn need vitamin K in the 1st hour after birth?
- Sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vitamin K; vitamin K is
needed in the clotting cascade to prevent hemorrhagic disorders.

17. Physiologic jaundice in the newborn occurs _____. It is caused by _____.

- Jaundice occurs at 2-3 days of life and is caused by immature liver’s inability to keep up with
bilirubin production of normal RBC destruction.

18. When is the screening test for phenylketonuria done?

- At 2-3 days of life or after enough milk ingestion to determine body’s ability to metabolize amino
acid phenylalanine.

19. A term newborn needs to take in _____ calories per pound per day. After the initial weight
loss is sustained, the newborn should gain _____ per day.
- 50 calories; 1 ouncce or 30 grams.

20. List 5 signs and symptoms new parents should be taught to report immediately to a doctor
or clinic.
- Lethargy; temperature >100F, vomiting, green stools, refusal of 2 feeds in a row.


1. What instructions should the nurse give the woman with a threatened abortion?
- Maintain strict bedrest for 24-48 hrs. Avoid sexual intercourse for two weeks.

2. Identify the nursing plans and interventions for a woman hospitalized with hyperemesis
- Weight daily; uring ketone checks 3X daily; progressive diet; check FHR q8h; monitor for
electrolyte imbalances.

3. Describe discharge counseling for a woman after hydatidiform mole evacuation by D&C.
- Prevent pregnancy for one year. Return to clinic/MD for monthly hCG levels for 1 yr. Post-op D&C
instructions; call if bright red vaginal bleeding or foul smelling vaginal discharge occurs, or
temperature spike over 100.4F.

4. What condition should the nurse suspect if a woman of childbearing age presents to an
emergency room with bilateral or unilateral abdominal pain with or without bleeding?
- Ectopic pregnancy

5. List 3 symptoms of abruptio placentae and 3 symptoms of placenta previa.

- Abruption: fetal distress; rigid, board-like abdomen; pain; dark red or absent bleeding. Previa:
painless, bright red vaginal bleeding; fetal heart rate normal; soft uterus.

6. What specific information should the nurse include when teaching human papillomavirus
detection & treatment?
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- Detection of dry; wart-like growths on vulva or rectum. Need for pap smear in the prenatal period.
Treatment with laser ablation (cannot use Podophyllin in pregnancy). Associated with cervical
carcinoma in mother and respiratory papillomatosis in neonate.

7. State 3 principles pertinent to counseling and/or teaching a pregnant adolescent.

- Nurse must establish trust/rapport before counseling/teaching begins. Adolescents do not
respond to an authoritarian approach. Consider the developmental tasks of identity and
social/individual intimacy.

8. What complications are pregnant adolescents more prone to develop?

- PIH, IUGR, CPD, STDs, Anemia.

9. All pregnant women should be taught preterm labor recognition. Describe the warning
symptoms of preterm labor.
- More than 5 contractions/hour, cramps, low, dull backache; pelvic pressure; change in vaginal

10. List the predisposing factors to preterm labor.

- Urinary tract infection; over distention of uterus; diabetes; PIH; cardiac disease; placenta previa,
psychosocial factors, i.e., stress

11. When is preterm labor able to be arrested?

- Cervix is <4cm dilated, <50% effacement, and membranes intact and not bulging out of the
cervical os.

12. What is the major side effect of beta-adrenergic (Terbutaline, Ritodrine) tocolytic drugs?
- Tachycardia

13. What special actions should the nurse take in the intrapartum period if preterm labor is
unable to be arrested?
- Monitor the FHR continuously and limit drugs, which cross placental barriers to prevent fetal
depression or further compromise.

14. A prolonged latent phase for a multipara is ____ and for a nullipara is ____. Multiparas
average cervical dilatation is ____cm/hr in the active phase and nulliparas average cervical
dilatation is ____cm/hr in the active phase.
- >14 hours, >20 hours, 1.5 cm/her; 1.2 cm/hr.

15. What are the major goals of nursing care related to pregnancy-induced hypertension with
- Maintenance of uteroplacental perfusion; prevention of seizures; prevention of complications such
as HELLP syndrome, DIC and abruption.

16. Magnesium sulfate is used to treat PIH. A) What is the purpose for administration of
magnesium sulfate? B) What is the main action of magnesium sulfate? C) The antidote for
magnesium sulfate? D) List the 3 main assessment findings indicating toxic effects of
magnesium sulfate.
- A) Prevent seizures by decreasing CNS irritability B) Central nervous system depression (seizure
prevention) C) Calcium Gluconate D) Reduced urinary output, reduced respiratory rate, and
decreased reflexes.

17. What are the major symptoms of pregnancy induced hypertension (preeclampsia)?
- Increase in BP of 30mmHg systolic and 15 mmHg diastolic over previous baseline; hyperflexia;
proteinuria (albuminuria); CNS disturbances; headache, and visual disturbances; epigastric pain.

18. What is the priority nursing action after spontaneous or artificial rupture of membranes?
- Assessment of the fetal heart rate.
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19. What is the most common complication of oxytocin augmentation or induction of labor?
List 3 actions the nurse should take if such a complication occurs.
- Tetany. Turn off Pitocin. Turn pregnant woman to side. Administer O2 by face mask.

20. List the symptoms of water intoxification from the antidiuretic hormone (ADH) effect of
Pitocin (oxytocin).
- Nausea and vomiting, headache, and hypotension.

21. State 3 nursing interventions during FORCEPS delivery.

- Ensure empty bladder. Auscultate FHR before application, during, and between traction periods.
Observe for maternal lacerations and newborn cerebral/facial trauma.

22. What is the cause of pregnancy induced hypertension?

- The person who determines the exact cause will be our next NOBEL prize winner! However, the
underlying pathophysiology appears to be generalized vasospasm with increased peripheral
resistance and vascular damage. This decreased perfusion results in damage to numerous

23. What interventions should the nurse implement to prevent further CNS irritability in the PIH
- Darken room, limit visitors, maintain close 1:1 nurse/client ratio, place in private room, plan
nursing interventions all together so client is disturbed as little as possible.

24. A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this
medication in pregnancy. How should the nurse respond?
- No, oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.

25. Name 3 maternal & 3 fetal complications of gestational diabetes.

- Maternal: hypoglycemia, herperglycemia, ketoacidosis; Fetal: macrosomia, hypoglycemia at birth,
fetal anomalies

26. When should the nurse hold the dose of magnesium sulfate and call the physician?
- When the client’s respirations are <12/minute, DTRs are absent, or urinary output is <100cc/4

27. State 3 priority nursing actions in the postdelivery period for the client with PIH.
- Monitor for signs of blood loss. Continue to assess BP and DTRs q4 hours. Monitor for uterine

28. When are the 2 most difficult times for control for the pregnant diabetic?
- Late in the 3rd trimester and in the postpartum period when insulin needs to drop sharply (the
diabetogenic effects of pregnancy drop precipitously).

29. Why is regular insulin used in labor?

- It is short-acting, predictable, can be infused intravenously and discontinued quickly if necessary.

30. List 3 conditions clients with diabetes mellitus are more prone to develop.
- PIH, hydramnios; infection

31. When is cardiac disease in pregnancy most dangerous?

- At peak plasma volume increase, 28-32 weeks gestation and during Stage II labor.

32. Does insulin cross the placental/breast barrier?

- No, therefore insulin-dependent women may breastfeed.

33. The goal for diabetic management during labor is euglycemia. How is it defined?
- 60-100 mg/dl.

34. What contraceptive technique is recommended for diabetic women?

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- Diaphragm with spermicide. Avoid birth control pills that contain estrogen and IUDs, which are an
infection risk.
35. List the symptoms of cardiac decompensation in the laboring client with cardiac disease.
- Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea.

36. What interventions can the nurse implement to maintain cardiac perfusion in a laboring
cardiac client?
- Position client in a semi or high-Fowler’s position. Prevent Valsalva’s maneuvers. Position client
in a supine or R/T for regional anesthesia. Avoid stirrups because of possible popliteal vein
compression and decreased venous return.

37. Gentle counterpressure against the perineum during an emergency delivery prevents ____
and ____.
- Maternal lacerations, fetal cerebral trauma.

38. When may a vaginal birth after Cesarean (VBAC) be considered by a woman with a
previous c-section?
- If a low uterine transverse incision was performed and can be documented AND if the original
complication does not recur, i.e., CPD.

39. Prior to anesthesia for C-section delivery, the mother may be given an antacid or a gastric
antisecretory drug (histamine receptor antagonist). State the reasons why these drugs are
- Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues.
An antisecretory drug reduces gastric acid, reducing the risk of gastric aspiration.

40. Clients who have had a C-section are prone to what post-op complications?
- Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired maternal
infant bonding.


1. May women with a positive HIV antibody test breastfeed?

- No, HIV has been found in breast milk.

2. What are the common side effects of antibiotics used to treat puerperal infection?
- GI adverse reactions: nausea, vomiting, diarrhea, and cramping. Hypersensitivity reactions:
rashes, urticaria, and hives

3. How does the nurse differentiate symptomatology of cystitis from pylonephritis?

- Pyelonephritis has the same symptoms as cystitis (dysuria, frequency, and urgency) with the
addition of flank pain, fever, and pain at costovertebral angle.

4. What are the signs of endometritis?

- Subinvolution (boggy, high uterus), lochia returns to rubra with possible foul smell, temperature
100.4F or higher, unusual fundal tenderness.

5. What are the nursing actions for endometritis and parametritis?

- Measures to promote lochial drainage; antipyretic measures (acetaminophen, cool baths);
administration of analgesics and antibiotics as ordered; increase fluids with attention to high
protein/high vitamin C diet.

6. State 4 risk factors or predisposing factors t opostpartum infection.

- Operative delivery, intrauterine manipulation , anemia or poor physical health, traumatic delivery,
and hemorrhage.

7. State 4 risk factors or predisposing factors to postpartum hemorrhage.

- Dystocia or prolonged labor, over distention of the uterus, abruptio placentae, and infection
Super Condensed Portable HESI Study Guide 74

8. What immediate nursing actions should be taken when a postpartum hemorrhage is

- Fundal massage. Notify MD if massage does NOT firm fundus. Count pads to estimate blood
loss. Assess/record vital signs. Increase IV fluids and administer oxytocin infusion as ordered.

9. Must women diagnosed with mastitis stop breastfeeding?

- No, women who abruptly stop breastfeeding may make the situation worse by increasing
congestion/engorgement and providing further media for bacterial growth. Client may HAVE to
discontinue breastfeeding if pus is present or if antibiotics are contraindicated for neonate.


1. List the major CNS danger signals, which occur in the neonate.
- Lethargy, high-pitched cry, jitteriness, seizures, and bulging fontanels.

2. A baby is delivered blue, limp, and with a heart rate <100. The nurse dries the infant,
suctions the oropharynx and gently stimulates the infant while blowing O2 over the face.
The infant still does not respond. What is the next nursing action?
- Begin oxygenation by bag and mask at 30-50 breaths/minute. Assist physician in setting up for
intubation procedure.

3. What does the Silverman-Anderson index measure?

- Respiratory difficulty

4. What are the two major complications of O2 toxicity?

- Retrolental fibroplasias and bronchopulmonary dysplasia.
5. Necrotizing enterocolitis results from ____ and is manifested by ____. Ischemia/hypoxia
results in ____.
- Ischemis hypoxia; abdominal distention, sepsis and a lack of absorption from intestines. Injury to
the intestinal mucosa.

6. Intraventricular hemorrhage is more common in ____ and results in symptoms of ____.

- Premature neonates and VLBW babies.

7. What conditions make oxygenation of the newborn more difficult?

- Respiratory distress syndrome; alveolar prematurity/lack of surfactant, anemia and polycythemia.

8. In order to prevent problems with oxygenating the newborn, what parameters can the nurse
- PO2 50-90, SVO2 60-80 mmHg.

9. What are the cardinal symptoms of sepsis in a newborn?

- Lethargy, temperature instability, difficulty feeding, subtle color changes, subtle behavioral
changes and hyperbilirubinemia.

10. A premature baby is born and develops hypothermia. State the major nursing
interventions to treat hypothermia.
- Place under radiant warmer or in incubator with temperature skin probe over liver. Warm all items
touching the newborn. Place plastic wrap over neonate.

11. Nurses often weigh diapers in order to determine exact urine output in the high-risk
neonate. Explain this procedure.
- Diaper is weighed in grams before applying. Weigh diaper after wetting. Calculate and record
each gram or added weight as one cc of urine.

12. What factors does the nurse look for in determining the newborn’s ability to take in
nourishment by nipple/mouth?
- Good suck, coordinated suck-swallow, takes less than 20 minutes to feed, gaining 20-30 gm/day.
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13. What complications are associated with total parenteral nutrition (TPN)?
- Hyperglycemia, electrolyte imbalance, dehydration, and infection.

14. In order to prevent rickets in the preterm newborn, what supplement is given?
- Calcium and vitamin D.

15. List 4 nursing interventions to enhance family/parent adjustment to a high-risk newborn.

- Initiate early visitation at ICU. Provide daily information to family. Encourage participation in
support group for parents. Encourage all attempts at care-giving (enhances bonding).

16. List risk factors for hyperbilirubinemia.

- Rh incompatibility, ABO incompatibility, prematurity, sepsis, perinatal asphyxia.

17. List symptoms of hyperbilirubinemia in the neonate.

- Bilirubin levels rising 5mg/day, jaundice, dark urine, anemia, high reticulocyte (RBC) count, and
dark stools.

18. Write one nursing diagnosis generated from the data pertinent to hyperbilirubinemia.
- Potential for injury related to predisposition of bilirubin for fat cells in brain.

19. List 3 nursing interventions for the neonate undergoing phototherapy.

- Apply opaque mask over eyes. Leave diaper loose so stools/urine can be monitored. Turn every
2 hours. Watch for dehydration.

20. List the symptoms of neonatal narcotic withdrawal.

- Irritability, hyperactivity, high-pitched cry, frantic sucking, coarse flapping tremors, and poor

21. Neonates who are “sick” are prone to receive too much stimulation in the form of invasive
procedures and handling too little developmentally-appropriate stimulation and affection.
How might such an infant respond?
- Failure to thrive, lack of crying.

22. How should the nurse determine the length of a tube needed for oral gavage feeding of a
- From the bridge of the nose, to the earlobe, to a point halfway between the xiphoid and the

23. What are the 2 best ways to test for correct placement of the gavage tube in the infant’s
- Aspiration of stomach contents with pH testing, and auscultation of air bubble injected into

24. What characteristics would the nurse expect to see in a neonate with fetal alcohol
- Microcephaly, growth retardation, short palpebral fissures, and maxillary hypophysia.



 ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no

previous pulmonary problems. The mortality rate is high (50%)
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 In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very
responsive to high concentrations of oxygen.

 Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure
is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them
from collapsing each time the client exhales. The amount of pressure can be set with the
ventilator and is usually around 5 to 10 cm of water.

 Suction only when secretions are present.

 Before drawing arterial blood gases from the radial artery, perform the Allen test to assess
collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar
pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is
good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can
be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also
negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the
hand if thrombosis of the radial artery should follow the puncture.

 If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death
will occur. However, they must be removed from any source of imminent danger, such as a fire.

 PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.

 A child in severe distress should be on 100% O2.

 Early signs of shock are agitation and restlessness resulting from cerebral hypoxia.

 If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position
client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous
return further to the left ventricle.

 Severe shock leads to widespread cellular injury and impairs the integrity of the capillary
membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All
organs are damaged, and if perfusion problems exist, the damage can be permanent.

 All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do
not change infusion rates simultaneously.

 A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is
the first priority? Maintaining an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without constricting clothing; keep legs
elevated (not Trendelenburg because the weight of the lower organs restricts breathing).

 Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild

 Epinephrine: 1:10,000, or 5ml IV for severe

 Volume expanding fluids are usually given to clients in shock. However, if the shock is
cardiogenic, pulmonary edema may result.

 Drugs of choice for shock

- Digitalis preparations: Increase the contractility of the heart muscle
- Vasoconstrictors (Levophed, Dopamine): Generalized vasonconstriction to provide more available
blood to the heart to help maintain cardiac output.

 A common volume-expanding substance is plasma and possibly whole blood.

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 You are caring for a woman who was in severe automobile accident several days ago. She has
several fractures and internal injuries. The exploratory laparotomy was successful in controlling
the bleeding. However, today you find that this client is bleeding from her incision, short of breath,
has a weak thready pulse, has cold and clammy skin, and hematuria.
- What do you think is wrong with the client, and what would you expect to do about it?
- These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the
formation of thrombin (Coumadin does not do this). However, the client described is already past
the coagulation phase and into the hemorrhagic phase. Her management would be administration
of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is

 NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are
required for each of the following situations?
- A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic.
- A 36-year old first time pregnant woman who arrests during labor.
- A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to
catch fire.
- A 40-year old businessman who arrests two days after a cervical laminectomy.


- The American Heart Association recommends that those with known angina pectoris seek
emergency medical care if chest pain is NOT relieved by three nitroglycerin tablets 5 minutes
apart over a 150minute period.
- A person with previously unrecognized coronary disease experiencing chest pain persisting for 2
minutes or longer should seek emergency medical treatment.

 It is important for the nurse to stay current with the American Heart Association’s guidelines for
Basic Life Support (BLS) by being certified every two years as required.

 If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4
cycles, then reassess for breathing and pulse. If two rescuers are performing CPR, a 15:2 ratio is
now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min
compression rate. When trading off, start with compressions.

 Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support
(ACLS) guidelines.

 When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will
correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing
CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless
hyperkalemia and/or preexisting acidosis is documented.

 Infants/prematures may have problems with the following that can predispose to arrest: Beware of
the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory
acidosis), hypercoagulability (if polycythemia exists).

 Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is
almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many
particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are
almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser
concentration to the area of greater concentration.

 Dextrose 10% is a hypertonic solution and should be administered IV.

 Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV
flush lines with intermittent IV medication.
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 Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift
fluid into intracellular or extracellular spaces.

 Potassium imbalances are potentially life-threatening, must be corrected immediately. A low

magnesium often accompanies a low K+, especially with the use of diuretics.

 Fluid Volume Deficit: Dehydration

- Elevated BUN: The BUN measures the amount of urea nitrogen in the blood. Urea is formed in
the liver as the end product of protein metabolism. The BUN is directly related to the metabolic
function of the liver and the excretory function of the kidneys.
- Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to
renal excretory function. However, unlike BUN, the creatinine level is affected very little by
dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on
muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the
BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a
1:20 ratio.
- Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the
same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the
blood can be considered “more concentrated.”
- Urine osmolality and specific gravity increase.

 Check the IV tubing container to determine the drip factor because drip factors vary. The most
common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per

 Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold
in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent
complications such as infiltration, emboli and infection.

 A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE.

 The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal.

 Review the order of blood flow to the heart:

- Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to
the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for
oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the
left ventricle (largest, strongest chamber) and out the aorta.
- Review the three structures that control the one-way flow of blood through the heart:
1. Valves Atrioventricular valves  Tricuspid (right side)  Mitral (left side)
Semilunar valves  Pulmonary (in pulmonary artery)  Aortic (in aorta)
2. Cordae Tendinae
3. Papillary muscles

 Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat.
This action represents a resting and regrouping stage so that the next heartbeat can occur. If
defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia.

 Observe the client for tolerance of the current rhythm. This information is the most important data
the nurse can collect on the client with an arrythmia.

 REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe
dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess
to determine if the leads are attached properly.

 Marking the operative site is required for procedures involving right/left distinctions, multiple
structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the
involvement of the client.
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 Wound dehiscence is separation of the wound edges and is more likely to occur with vertical
incisions. It usually occurs after the early postoperative period, when the client’s own granulation
tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the
wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients
who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus.

 NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process.
Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have her gallbladder
removed in a same-day surgery using a scope instead of an incision. What nursing needs will
dominate each phase of her short hospital stay?
- Preparation phase: Education about postoperative care, NPO, assist with meeting family needs.
- Operative phase: Assessment, management of the operative suite.
- Post-anesthesia phase: Pain management, post-anesthesia precautions.
- Post-operative phase: Prevent and assess for complications, pain management, dietary
restrictions, activity.

 HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-
pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.).

- Wash hands, even if gloves have been worn to give care
- Wear gloves (latex) for touching blood or body fluids, or any non-intact body surface.
- Wear gowns during any procedure that might generate splashes (changing clients with diarrhea).
- Use masks and eye protection during activity which might disperse droplets (suctioning).
- Do not recap needles, dispose of in puncture-resistant containers.
- Use mouth piece for resuscitation efforts.
- Refrain from giving care if you have open skin lesions.

 Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV).

 Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis.

 The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and
management of complications associated with HIV.

 For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3
minutes as needed, until 1.0mg is achieved.

 Use non-invasive methods for pain management when possible:

- Relaxation techniques
- Distraction
- Imagery
- Biofeedback
- Interpersonal skills
- Physical care: altering positions, touch, hot and cold applications.

 Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor
sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory

 Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of
narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional
narcotics cannot be given until the Narcan effects have passed.

 Do not take away the coping style used in a crisis state…DENIAL. It is a useful and needed tool
at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment –
endangering the patient.
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 Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature
also increases metabolism and the demand for oxygen.

 High risk for pneumonia:

- Any person, who has altered level of consciousness, has depressed or absent gag reflex and
cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized
individuals, those with brain injury, drug overdose, or stroke victims).
- When feeding, raise the head of the bed and position the client on side – not on back.

 Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are
easily transmitted over consolidated tissue.

 Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating
expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of
fluid are lost daily by the lungs through evaporation.

 Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough
oxygen to the brain.

 Pneumonia preventatives:
- Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants
(dust, smoke, and aerosols); do not smoke.
- Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate
intake, balance of rest and activity.
- Comatose and immobile persons: elevate head of bed to feed; turn frequently.

 Compensation occurs over time in clients with chronic lung disease, and arterial blood gases
(ABGs) are altered. It is imperative that baseline data are obtained on the client.

 Productive cough and comfort can be facilitated by Semi-Fowler’s or high Fowler’s positions,
which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a
priority in these clients because it elevates the diaphragm and inhibits lung expansion.

 Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to
breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in
adequate to oxygenate the tissues.

 Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized
cyanosis and often right-sided heart failure.
 Cells of the body depend on oxygen to carry out their functions. Inadequate arterial oxygenation
is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the
fingernails, and a late sign is clubbing of the fingers.

 Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia
(hypoxic drive) not the usual hypercapnia, the stimulus to breathe for healthy persons. Therefore,
if too much oxygen is given, the client may stop breathing!

 Health Promotion:
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- Eating consumes energy needed for breathng. Offer mechanically soft diets, which do not require
as much chewing and digestion. Assist with feeding if needed.
- Prevent secondary infections – avoid crowds, contact with persons who have infectious diseases,
and respiratory irritants (tobacco smoke).
- Teach client to report any change in characteristics of sputum.
- Encourage client to hydrate well and to obtain immunizations needed (flu and pneumonia).

 When asked to prioritize nursing actions, use the ABC rule:

- Airway first
- Then breathing
- Then circulation

 Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate
oxygenation is not occurring.

 The key to respiratory status assessment of breath sounds as well as visualization of the client.
Breath sounds are better “described,” not named, e.g., sounds should be described as “crackles,”
“wheeze,” “hihg-pitched whistling sound,” rather than “rales,” “rhonchi,” etc., which may not mean
the same thing to each clinical professional.

 Watch for NCLEX-RN questions that deal with oxygen delivery. In adults, O2 must bubble through
some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the
trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx
provide adequate humidification.

 With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black,
and may appear patchy.

 Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing.

 Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying
pathway is gone for the client who has had a laryngectomy. If the air is not humidified before
entering the lungs, secretions tend to thicken and become crusty.
 A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the
client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks
(first 24 hours).

 Fear of choking is very real for laryngectomy clients. They cannot cough as before because the
glottis is gone. Teach the “glottal stop” technique to remove secretions (take a deep breath,
momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from
the tube).

 TB SKIN TEST: a positive TB skin test is exhibited by an induration 10mm or greater in diameter
48 hours after skin test. Anyone who has received a BCG vaccine will have a positive skin test
and must be evaluated using a chest x-ray.

 Teaching is very important with the TB client. Drug therapy is usually long term (9 months or
longer). It is essential that the client take the medications as prescribed for the entire time.
Skipping doses or prematurely terminating the drug therapy can result in a public health hazard.

- Rifampin: Reduces effectiveness of oral contaceptives; should use other birth control methods
during treatment; gives body fluids orange tinge; stains soft contacts.
- Isoniazid (INH): Increases Dilantin levels.
- Ethambutal: Vision check before starting therapy and monthly; may have to take 1 to 2 years
- Teach rationale for combination drug therapy to increase compliance. Resistance develops more
slowly if several anti-TB drugs given, instead of just one drug at a time.
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 Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are
left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal
cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the
remaining chest organs to fill the empty space.

 If the chest tube remains disconnected, do not clamp! Immediately place the end of the tube in a
container of sterile saline or water until a new drainage system can be connected.

 If the chest tube is accidentally removed from the client, the nurse should apply pressure
immediately with an occlusive dressing and notify the healthcare provider.

 Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external
suction. These fluctuating movements are a good indicator that the system is intact and should
move upward with each inspiration and downward with each expiration. If fluctuations cease,
check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s
position, since expanding lung tissue may be occluding the tube opening. Remember, when
external suction is applied the fluctuations cease. Most hospitals DO NOT MILK chest tubes as a
means of clearing or preventing clots – it is too easy to remove chest tubes. Mediastinal tubes
may have orders to be stripped because of location, compared to larger thoracic cavity tubes.

 Various pathophysiological conditions can be related to the nursing diagnosis “Ineffective

Breathing Patterns.”
1. Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis)
2. Obstruction of the air passages (carcinoma, asthma, chronic bronchitis)
3. Accumulation of fluid in the air sacs (pneumonia)
4. Respiratory muscle fatigue (COPD, pneumonia)


 Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about
1 to 2 liters in a 24-hour period.

 Electrolytes are profoundly affected by kidney problems. There must be a balance between
extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions
or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are
the primary extracellular ions. Potassium and phosphate are the primary intracellular ions.

 In some cases, persons in ARF may not experience the oliguric phase but may progress directly to
diuretic phase during which the urine output may be as much as 10 liters per day.

 Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all
clients with renal failure – done on the same scale at the same time every day.

 Fluid Volume Alterations Fluid

 Excess symptoms:
- Dyspnea
- Tachycardia
- Jugular vein distention
- Peripheral edema
- Pulmonary edema
 Fluid deficit symptoms:
- Decreased urine output
- Reduction in body weight
- Decreased body turgor
- Dry mucous membranes
- Hypotension
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- Tachycardia

 Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps,
diarrhea, and nausea.

 Potassium has a critical safe range (3.5 to 5.0 mEg/L) because it affects the heart, and any
imbalance must be corrected by medications or dietary modification. Limit high potassium foods
(bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium.

 Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and
serum levels may appear near normal. With excessive water retention, the sodium levels appear
decreased dilution). Limit fluid and sodium intake in ARF clients.

 During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal,
aRF is determined to be resolved.

 Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein
must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen
balance occurs causing muscle wasting. The glomerular filtration rate (GFR) is most often used
as an indicator of level of protein consumption.


- All persons in the United States are eligible for Medicare as of their first day of dialysis under
special End Stage Renal Disease funding.
- Medicare card will indicate ESRD.
- Transplantation is covered by Medicare procedure; coverage terminates six months postoperative
if dialysis is no longer required.

 Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea,
creatinine. Ensure high calorie intake so protein is spared for its own work: give hard candy, jelly
beans, flavored carbohydrate powders.

 As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity
since digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea,
vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse
<60 beats per minute (bradycardia).

 The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of
glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate
is left in the peritoneal cavity too long, hyperglycemia may occur.

 The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant.
It is important to tell the client to take the antibiotics round-the-clock and not skip doses so that a
consistent blood level can be maintained for optimal effectiveness.

 Location of the pain can help determine location of the stone.

- Flank pain usually means the stone is in the kidney or upper ureter. If it radiates in the abdomen
or scrotum, the stone is likely to be in the ureter or bladder.
- Excruciating, spastic-type pain is called colic.
- During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled
intervals rather than PRN to prevent spasm and optimize comfort.

 Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the
kidney. The stone may be dissolved by percutaneous irrigation with a liquid which will dissolve the
stone, or ultrasonic sound waves (lithotripsy) can be directed through the needle/catheter to break
up the stone which then can be eliminated through the urinary tract.
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 Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized
balloon on the catheter (30 to 45 cc inflate) will cause a continuous feeling of needing to void. The
client should not try to avoid around the catheter since this can precipitate bladder spasms.
Medications to reduce or prevent spasms should be given.

 Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid.
Use only sterile saline for bladder irrigation after TURP since the irrigation must be isotonic to
prevent fluid and electrolyte imbalance.

 Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of
blood or frank bright bleeding should be reported. However, it is normal for the client to pass small
amounts of blood during the healing process as well as small clots. He should rest quietly and
continue drinking large amounts of fluid.


 What is the relationship of the kidneys to the cardiovascular system?

- The kidneys filter about a liter of blood per minute
- If cardiac output is decreased, the amount of blood going through the kidneys is decreased;
urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac
- When the kidneys produce and excrete 0.5 ml of urine per kg of body weight or average 30 ml/hr
output, the blood supply is considered to be minimally adequate to perfuse the vital organs.

 Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for
acute angina?
- Digoxin – Not appropriate – Increases the strength and contractility of the heart muscle; the
problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help.
- Nitroglycerin – Appropriate – Causes dilation of the coronary arteries, allowing more oxygen to get
to the heart muscle.
- Atropine – Not appropriate – Increases heart rate by blocking vagal stimulation, which suppresses
the heart rate. Does not address the lack of O2 to the heart muscle.
- Propanolol (Inderal) – Not appropriate – for acute angina attack; however, is appropriate for long-
term management of stable angina because it acts as a beta-blocker to control vasoconstriction.

 Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and
the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output
or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation,
weight control, and stress management can control many factors that influence the resistance
blood meets as it flows from the heart.

 Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt
intake, obesity, and use of oral contraceptives.

 The number one cause of CVA with hypertensive clients is non-compliance with medication
regime. Hypertension is often symptomless, and antihypertensive medications are expensive and
have side effects. Studies have shown that the more clients know about their antihypertensive
medications, the more likely they are to take them – teaching is important.

 Decreased blood flow results in diminished sensation in the lower extremities. Any heat source
can cause severe burns before the client actually realizes the damage is being done.

 A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in
his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse
obtain in the first few hours?
- Vital signs q1 hour
- Neurological vital signs
Super Condensed Portable HESI Study Guide 85

- Respiratory status
- Urinary output
- Peripheral pulses

 During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney
damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and
normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems.

 A positive Homen’s sign is considered an early indication of thrombophlebitis. However, it may

also indicate muscle inflammation. If a deep vein thrombosis has been confirmed, a Homan’s sign
should not be elicited because of the increased risk of embolization.

 Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting
clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may
lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in
the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites.

- Antagonist: Protamine Sulfate
- LAB: PTT or APTT determines efficacy
- Keep 1.5 to 2.5 times normal control

- Antagonist: Vitamin K
- LAB: PT determines efficacy
- Keep 1.5 to 2.5 times normal control

 INR: Desirable therapeutic level usually 2 to 3 seconds (reflects how long it takes a blood sample
to clot).

 A holter monitor offers continuous observation of the client’s heart rate. To make assessment of
the rhythm strips, most meaningful, teach the client to keep a record of:
- Medication times and doses
- Chest pain episodes – type and duration
- Valsalva maneuver (straining at stool, sneezing, coughing)
- Sexual activity
- Exercise

 Cardioversion is the delivery of synchornized electrical shock to the myocardium.

 Differentiate in synchronous and asynchronous pacemakers:

- Synchronous or demand pacemaker fires only when the client’s heart rate falls below a rate set on
the generator.
- Asynchronous or fixed pacemaker fires at a constant rate.

 Restricting sodium reduces salt and water retention, thereby reducing vascular volume and

- Side effects of digitalis are increased when the client is hypokalemic.
- Has a negative chronotropic effect, i.e., it shows the heart rate. Hold the digitalis if the pulse rate
is <60, >120, or has markedly changed rhythm.
- Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include
nausea, vomiting, and headache in adults.
- If withheld, consult with physician.

 Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on
valve leaflets. These lesions pose a risk of embolization; erosion/perforation of the valve leaflets;
Super Condensed Portable HESI Study Guide 86

or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency),

most commonly of the mitral valve, can occur depending upon the type of damage inflicted by the
lesions, leading to symptoms of left – or right-sided heart failure.

 Acute and Subacute Infective Endocarditis - There are 2 types of infective endocarditis:
- Acute, which often affects individuals with previously normal hearts and healthy valves, and
carries a high mortality rate
- Subacute, which typically affects individuals with preexisting conditions, such as rheumatic heart
disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk for
both acute and subacute bacterial endocarditis. When this population develops Subacute
Infective Endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are
typically affected due to the introduction of common pathogens which colonize on the skin (S.
epidermis and Candida) into the venous system.

 Pericarditis – presence of a friction rub is an indication of pericarditis (inflammation of the lining of

the heart). ST segment elevation and T wave inversion are also signs of pericarditis.

 With mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In
early period, there may be no symptoms; but, as the disease progresses, the client will exhibit
excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema.
There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.


 A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount of regurgitation as well as

preventing the encroachment of the stomach tissue upward through the opening in the diaphragm.

 Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those
with a family history of ulcers to obtain medical surveillance for ulcer formation.


- Pallor: conjuctival, mucous membranes, nail beds
- Dark, tarry stools
- Bright red or coffee-ground emesis
- Abdominal mass or bruit
- Decreased BP, rapid pulse, cool extremities (shock).

 The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8
liters per day. Large fluid losses can occur if vomiting and/or diarrhea exists.

 Opiate drugs tend to depress gastric motility. However, they should be given with care, and those
receiving them should be closely monitored because a distended intestinal wall accompanied by
decreased muscle tone may lead to intestinal perforation.

 Diverticulosis is the presence of pouches in the wall of the intestine. There is usually do
discomfort, and the problem goes unnoticed unless seen on radiological examination (usually
prompted by some other condition).

 Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the

 A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is
diagnosed with diverticulitis. What are the nutritional needs of this client throughout recovery?
- Acute phase – NPO graduating to liquids.
- Recovery phase – no fiber or foods that irritate the bowel.
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- Maintenance phase – high-fiber diet, with bulk-forming laxatives to prevent pooling of foods in the
pouches where they can become inflamed. Avoid small, poorly digested foods such as popcorn,
nuts, seeds, etc.

 Bowel obstructions:
- Mechanical: due to disorders outside the bowel (hernia, adhesions), due to disorders within the
bowel (tumors, diverticulitis), or due to blockage of the lumen in the intestine (intussusception, gall
- Non-mechanical: paralytic ileus, which does not involve any actual physical obstruction, but results
from inability of the bowel itself to function.

 Blood gas analysis will show alkalotic state if the bowel obstruction is high in the small intestine
where gastric acid is secreted. If the obstruction is in the lower bowel where base solutions are
secreted, the blood will be acidic.

 A client admitted with complaints of constipation, thready stools and rectal bleeding over the past
few months is diagnose with a rectal mass. What are the nursing priorities for this client?
- NG tube (possibly an intestinal tube such as a Miller-Abbott)
- IV fluids
- Surgical preparations of bowel (if obstruction is complete)
- Teaching (preoperative, nutrition, etc.)

 Diet recommended by the American Cancer Society to prevent bowel cancer:

- Eat more cruciferous vegetables (from the cabbage family such as broccoli, cauliflower, Brussels
sprouts, cabbage, and kale).
- Increase fiber intake.
- Maintain average body weight
- Eat less animal fat.

 AMERICAN CANCER SOCIETY RECOMMENDATIONS for early detection of Colon Cancer:

- A digital rectal examination every year after 40.
- A stool blood test every year after 50.
- A sigmoidoscopy examination every 3 to 5 years after the age of 50, based on the advice of a

 Cancer of the colon is the most common cancer in the US when considering men and women
together. An early sign is the rectal bleeding. Encourage patients 50 years of age or older, or
those with increased risk factors, to be screened yearly with fecal occult blood testing. Routine
colonoscopy at 50 is also recommended.


- Yellow skin, sclera, and/or mucous membranes (bilirubin in skin)
- Dark-colored urine (bilirubin in urine)
- Chalky or clay-colored stools (absence of bilirubin in stools)

 Fetor hepaticus is a distinctive breath odor of chronic liver disease. It is characterized by a fruity
or musty odor which results from the damaged liver’s inability to metabolize and detoxify
mercaptan which is produced by the bacterial degradation of metionine, a sulfurous amino acid.

 For treatment of ascities, paracentesis and peritoneovenous shunts (LaVeen and Denver shunts)
may be indicated.

 Esophageal varices may rupture and cause hemorrhage. Immediate management includes
insertion of an esophagogastric balloon tamponade – a Blakemore-Sengstaken or Minnesota
tube. Other therapies include vasopressors, vitamin K, coagulation factors, and blood
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 Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level

 PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING for clients who are anorexic and/or
- Remove strong odors immediately; they can be offensive and increase nausea.
- Encourage client to sit up for meals; this can decrease the propensity to vomit.
- Serve small, frequent meals.

 Liver tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration
of liver tissue being destroyed by the disease. Since many drugs are metabolized in the liver, drug
therapy must be scrutinized carefully. Caution the client that recovery takes many months, and
previously taken medications should not be resumed without the healthcare provider’s directions.

 Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the
peritoneum to stretch tightly. Therefore, sitting up or leaning forward will reduce the pain.

 Following an endoscopic retrogade cholangiopancreatography (ERCP), the client may feel sick.
The scope is placed in the gallbladder and the stones are crushed and left to pass on their own.
These clients may be prone to pancreatitis.

 Non-surgical management of the client with cholecystitis includes:

- Low-fat diet
- Medications for pain and clotting if required
- Decompression of the stomach via NG tube


 Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to
Grave’s disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension.
- Primary nursing interventions include maintaining an airway and adequate aeration.
- Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm.
Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation.

 Post-operative thyroidectomy: be prepared for the possibility of laryngeal edema. Put a

tracheostomy set at bedside along with oxygen and a suction machine; Ca++ gluconate easily

 Normal serum calcium is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a
decrease in the client’s calcium compared to the preoperative value.

 If two or more parathyroid glands have been removed, the chance of tetany increases
- Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal range)
- Check for tingling of toes, fingers, and around the mouth.
- Check for Chvostek’s sign (tap over the parotid gland and which for twitching of lip = positive)
- Check Trousseau’s sign (carpopedal spasm after inflating BP cuff above systolic pressure =

 Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication,

anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and
carbondioxide narcosis). The airway must be kept patent, and ventilator support as indicated.

 Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the
need to teach clients the importance of precisely following the prescribed regimen. They should
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be cautioned against suddenly stopping the medications and be informed that it is necessary to
taper off taking steroids.

 ADDISON”S CRISIS IS A MEDICAL EMERGENCY: Brought on by sudden withdrawal of steroids

or a stressful event (trauma, severe infection)
- Vascular Collpase: Hypotension and tachycardia occur; administer IV fluids at rapid rate until
- Hypoglycemia: Administer IV glucose
- ADMINISTER PARENTERAL HYDROCORTISONE: Essential for reversing the crisis.
- ALDOSTERONE REPLACEMENT: Administer fludrocortisone acetate(Florinef) PO (only available
as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a
sodium deficit.

 Teach clients to take steroids with meals to prevent gastric irritation. They should never skip
doses. If they have nausea or vomiting for more than 12 to 24 hours, they should contact the

 Why do diabetics have trouble with wound healing? High blood glucose contributes to damage of
the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which
inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary
elasticity and promotes problems such as diabetic retinopathy, poor healing or breaks in the skin,
cardiovascular abnormalities, etc.

 Glycosylated Hgb (Hgb A1C)

- Indicates glucose control over previous 120 days (life of RBC)
- Valuable measurement of diabetes control.

 The body’s response to illness/stress is to produce glucose. Therefore, any illness results in

 If in doubt whether the client is hyperglycemic or hypoglycemic, treat for hypoglycemia.


- Provides tight glucose control thereby decreasing the potential for long-term complications
- Technique is specific to each meter if meter is used.
- Monitor before meals, at bedtime, and any time symptoms occur.
- Record results and report to healthcare provider at time of visit.


 A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both
hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the
nurse use and which methods would the nurse not use?
- Use inspection, palpation, and strength testing.
- Do not use range of motion (this activity promotes pain because ROM is limited).

 In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins.
Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and
muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting,
immobilization, and rest for joint deformity; and NSAIDS for the pain.

 Synovial tissues line the bone of the joints. Inflammation of this lining causes destruction of tissue
and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint
destruction. Often the disease will go into remission. Decreasing the amount of bone and joint
destruction will reduce the amount of disability.
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 What activity recommendations should the nurse provide a client with rheumatoid arthritis?
- Do not exercise painful, swollen joints.
- Do not exercise any joint to the point of pain.
- Perform exercises slowly and smoothly; avoid jerky movements.

 NCLEX-RN questions often focus on the fact that avoiding sunlight is key in management of lupus
erythematosus – this is what differentiates it from other connective tissue diseases.

 Degenerative joint disease (DJD) and osteoarthritis are often described as the same disease, and
indeed they both result in hypertrophic changes in the joints. However, they differ in that
osteoarthritis is an inflammatory disease and DJD is characterized by non-inflammatory
degeneration of the joints.

 Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis.
Encourage exercise, a diet high in calcium, and supplemental calcium. While TUMS is an
excellent source of calcium, it is also high in sodium and hypertensive or edematous individuals
should seek another source for supplemental calcium.
 The main cause of fractures in the elderly, especially women, is osteoporosis. The main fracture
sites seem to be hip, vertebral bodies, and Colles’ fracture of forearm.

 NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very
risky. When using a non-wheeled walker, the client should lift and move the walker forward, then
take a step into it. The client should avoid scooting the walker or shuffling forward into it which
takes more energy and is less stable than a single movement.

 What type of fracture is more difficult to heal, an extra capsular fracture (below the neck of the
femur) or an intracapsular fracture (in the neck of the femur)?
- The blood supply enters the femur below the neck of the femur. Therefore, an intra-capsular
fracture is much more harder to heal and has a greater likelihood of necrosis since it is cut off from
the blood supply.

 The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and
combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more
common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The
initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2).
Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is
suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with
endotracheal intubation.

 In clients with hip fractures, thromboembolism is the most common complication. Prevention
includes passive range of motion exercises, elastic stocking use, elevation of the foot of the bed
25 degrees to increase venous return, and low-dose hepatin therapy.

 Clients with fractures, casts, or edema to the extremities need frequent neurovascular assessment
distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain and pulses
should be assessed.
 Assess the “5 Ps” of neurovascular functioning: pain, paresthesia, pulse, pallor and paralysis.

 Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device
usually accompanies the client to the postoperative floor. Check drainage often.

 A big problem after joint replacement is infection.

 Fractures of bone predispose the client to anemia, especially if long bones are involved. Check
hemtocrit every 3 to 4 days to monitor erythropoiesis.

 Instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting.
This upward motion can pop the prosthesis out of the socket.
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 Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi
(may limit milk intake), and venous thrombosis (may be on prophylactic anticoagulants).

 The residual limb should be elevated on one pillow. If the residual limb (stump) is elevated too
high, the elevation can cause contracture.


 Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye

 Eye drops are used to cause pupil constriction since movement of the muscles to constrict the
pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye.
Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after
administration of pilocarpine and adaptation to dark environments is difficult because of pupillary
constriction (desired effect of the drug).

 There is an increased incidence of glaucoma in the elderly population. Older clients are prone to
problems associated with constipation. Therefore, the nurse should assess these clients for
constipation and postoperative complications associated with constipation, and implement a plan
of care directed at prevention, and, if necessary, treatment for constipation.

 The lens of the eye is responsible for projecting light, which enters onto the retina so that images
can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered
and vision is blurred.

 When the cataract is removed, the lens is gone, making prevention of falls important. If the lens is
replaced with an implant, vision is better than if a contact lens is used (some visual distortion) or if
glasses are used (greater visual distortion – everything has a curved shape).

 The ear consists of three parts: the external ear, middle ear, and the inner ear. Inner ear
disorders, or disorders of the sensory fibers going to the CNS., often are neurogenic in nature and
may not be helped with a hearing aid. External and middle ear problems (conductive) may result
from infection, trauma or wax buildup. These types of disorders are treated more successfully with
hearing aids.

 NCLEX-RN questions often focus on communicating with older adults who are hearing impaired.
- Speak in a low-pitched voice, slowly, and distinctly.
- Stand in front of the person with the light source behind the client.
- Use visual aids if available.


 Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such
as lethargic, stuporous, or obtunded.

 Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired
persons require total care.

 Clients with an altered state of consciousness are fed by enteral routes since the likelihood of
aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in
the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying
and the feeding should be held.

 Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression.
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 Any client on bedrest/immobilized must have range of motion exercises often and very frequent
position changes. Do not leave the client in any one position for longer than 2 hours. Any position
that decreases venous return is dangerous, i.e., sitting with dependent extremities for long

 If temperature elevates, take quick measures to decrease it since fever increases cerebral
metabolism and can increase cerebral edema.

 Safety measures for immobilized clients:

- Prevent skin breakdown with frequent turning.
- Maintain adequate nutrition.
- Prevent aspiration with slow, small feedings or NG feedings.
- Monitor neurological signs to detect the first signs that intracranial pressure may be increasing.
- Provide range of motion exercises to prevent deformities.
- Prevent respiratory complications – frequent turning and positioning for optimal drainage.

 Restlessness may indicate a return to consciousness but can also indicate anoxia, distended
bladder, covert bleeding, or increasing cerebral anoxia. Do not over-sedate, and report any
symptoms of restlessness.

 The forces of impact influence the type of head injury. They include acceleration injury, which is
caused by the head in motion, and deceleration injury, which occurs when the head stops
suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists.

 Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate
increased ICP.
 CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of
CSF leakage, the usual signs of increased ICP may not occur.

 Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level
of responsiveness.

 Physical assessment should concentrate on respiratory status, especially in clients with injury at
C-3 to C-5, as cervical plexus innervates diaphragm.

 It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a
spinal cord is compressed for 12 to 24 hours.

 A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in
alkaline media, so keeping urine diluted ad acidic is prophylactic against infection. Also, keeping
the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder.

 Benign tumors continue to grow and take up space in the confined area of the cranium causing
neural and vascular compromise for the brain, increased intracranial pressure, and necrosis of
brain tissue – even benign tumors must be treated as they may have malignant effects.

 Craniotomy post-operative medications:

- Corticosteroids to reduce swelling
- Agents and osmotic diuretics to reduce secretions (atropine, robinul)
- Agents to reduce seizures (phenytoin)
- Prophylactic antibiotics

 Symptoms involving motor function usually begin in the upper extremities with weakness
progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of the cases. MS
is more common in women. Progression is not “orderly.”

 Drug therapy for MS clients: ACTH, cortisone, Cytoxan, and other immunosuppressive drugs.
Nursing implications for administration of these drugs should focus on prevention of infection.
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 In clients with Myasthenia Gravis, be alert for changes in respiratory status – the most severe
involvement may result in respiratory failure.

 Bedrest often relieves symptoms. Bladder and respiratory infections are often a recurring
problem. Need for health promotion teaching.

 Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic
crisis is associated with a negative test.

 NCLEX-RN questions often focus on the features of Parkinson’s disease – tremors (a coarse
tremor of fingers and thumb on one hand which disappears during sleep and purposeful activity –
also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: SAFETY!

 An important aspect of Parkinson’s treatment is drug therapy. Since the pathophysiology involves
an imbalance between acetylcholines and dopamine, symptoms can be controlled by
administering dopamine precursor (Levodopa).

 CNS involvement related to cause of CVA:

- Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue – often related to
- Embolytic: caused by a clot, which has broken away from some vessel and has lodged in one of
the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may
happen again).

 Atrial flutter/fibrillation has a high incidence of thrombus formation following arrythmias due to
turbulence of blood flow through all valves/heart chambers.

 A woman who had a stroke two days ago has left-sided paralysis. She has begun to regain some
movement in her left side. What can the nurse tell the family about the client’s recovery period?
- The quicker movement is recovered, the better the prognosis is for more or full recovery. She will
need patience and understanding from her family as she tries to cope with the stroke. Mood
swings can be expected during the recovery period, and bouts of depression and tearfulness are

 Words that describe losses from CVA:

- Apraxia: inability to perform purposeful movements in the absence of motor problems.
- Dysarthria: difficulty articulating
- Dysphasia: impairment of speech and verbal comprehension
- Aphasia: loss of the ability to speak
- Agraphia: loss of the ability to write
- Alexia: loss of the ability to read
- Dysphagia: dysfunctional swallowing

 Steroids are administered after a stroke to decrease cerebral edema and retard permanent
disability. H2 inhibitors are administered to prevent peptic ulcers.

 Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a
deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels
drop below 7g/dl.
 ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood
products. TWO registered nurses should simultaneously check the physician’s prescription,
client’s identity, and blood bag label.
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 A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities.
She is diagnosed with acute myeologenous leukemia. What are the expected laboratory findings
for this client and what is the expected treatment?
- Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high).
- Treatment: Prevention of infection; prevention and/or control of bleeding; high protein, high calorie
diet; assistance with ADL; drug therapy.

 Infection in the immunosuppressed person may not be manifested with an elevated temperature.
It is imperative, therefore, that the nurse performs a total and thorough assessment of the client

 Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital!

Advise client to stay away from persons with known infections such as colds. In the hospital,
maintain an environment as sterile and as clean as possible. These persons should not eat raw
vegetables or fruits – only cooked to destroy any bacteria.

 Hodgkin’s is one of the most curable of all adult malignancies. Emotional support is vital. Career
development is often interrupted for treatment. Chemotherapy renders many male clients sterile.
May bank sperm prior to treatment, if desired.

 Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to
benign uterine tumors. Assess for signs of anemia.

 What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it
impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can
protrude through the vaginal wall.

 Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and
localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic
exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagina,
rectum, and bladder are removed in an attempt to stop metastasis). Chemotherapy is not useful
with this type of cancer.

 Pap smears should begin within 3 years of having intercourse or no later than age 21, whichever
comes first. Should be done annually until age 30 and then may be done every 2 to 3 years if a
woman has 3 consecutive normal results. After age 70 may stop if woman has 3 consecutive
normal and no abnormal pap smears in last 10 years. Women at high risk should have annual

 Ovarian cancer is the leading cause of death from gynecologic cancers in the US. Growth is
insidious, so it is not recognized until it is at an advanced stage.

 The major emphasis in nursing management of cancers of the reproductive tract is early detection.

 The importance of teaching female clients how to do self-breast examination cannot be

overemphasized. Early detection is related to positive outcomes.

 The presence or absence of hormone receptors is paramount in selecting clients for adjuvant

 Men whose testes have not descended into the scrotum or whose testes descended after age 6
are at high risk for developing testicular cancer. The most common symptom is the appearance of
a small, hard lump about the size of a pea on the front or side of the testicle. Manual testicular
examination should be done after a shower by gently palpating the testes and cord to look for a
small lump. Swelling may also be a sign of testicular cancer.
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 STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is
legally responsible to report cases of child abuse. Chlamydia is the most reported communicable
disease in the United States.

 Pelvic inflammatory disease (PID) involves one more of the pelvic structures. The infection can
cause adhesions and eventually result in sterility. Manage the pain associated with PID with
analgesics and warm sitz baths. Bedrest in a semi-Fowler’s position may increase comfort and
promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain.

 A client comes to the clinic with a chancre on his penis. What is the usualy treatment?
- IM dose of penicillin (such as Benzathine penicillin G 2.4 million units).
- Obtain sexual history, including the names of his sex partners, so that they can receive treatment.

 Massive volumes of IV fluids are given. It is not uncommon to give over 1,000 cc/hr during various
phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is
supported with fluids but is not overloaded.

 Infection is a life-threatening risk for those with burns. Dressing changes are VERY PAINFUL!
Medicate client prior to procedure.

 Pre-existing conditions that might influence burn recovery are age, chronic illness, diabetes,
cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug and/or
alcohol abuse.



8. When does birth length double? = by 4 years

9. When does the child sit unsupported? = 8 months

10. When does a child achieve 50% of adult height? = 2 years

11. When does a child throw a ball overhand? = 18 months

12. When does a child speak 2-3 word sentences? = 2 years

13. When does a child use scissors? = 4 years

14. When does a child tie his/her shoes? = 5 years

 Be aware that a girl’s growth spurt during adolescence begins earlier than boys (as early as 10
years old).

 Temper tantrums are common in the toddler, i.e., considered “normal,” or average behavior.

 Be aware that adolescence is a time when the child forms his/her identity and that rebellion
against family values is common for this age group.

 Normal growth and development knowledge is used to evaluate interventions and therapy. For
example, “What behavior would indicate that thyroid hormone therapy for a 4-month-old is
effective?” You must know what milestones are accomplished by a 4-month-old. One correct
answer would be “has steady head control” which is an expected milestone for a 4-month-old and
indicates that replacement therapy is adequate for growth.
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 Use facts and principles related to growth and development in planning teaching interventions.
For example: “What task could a 5-year-old diabetic boy be expected to accomplish by himself?”
One correct answer would be to pick the injection sites. This is possible for a preschooler to do
and gives the child some sense of control.

 School-age children are in Erikson’s stage of industry, meaning they like to do and accomplish
things. Peers are also becoming important for this age child.

 Age groups concepts of bodily injury:

- Infants: After 6 months, their cognitive development allows them to remember pain.
- Toddlers: Fear intrusive procedures.
- Preschoolers: Fear body mutilation.
- School Age: Fear loss of control of their body.
- Adolescent: Major concern is change in body image.


 Subcutaneous injection, rather than intradermal, invalidates the Mantoux test.

 The common cold is not a contraindication for immunization.

 Following immunization, what teaching should the nurse provide to the parents?
- Irritability, fever (<102F), redness and soreness at injection site for 2 to 3 days are normal side
effects of DPT and IPV administration.
- Call health care provider if seizures, high fever, or high-pitched crying occur.
- A warm washcloth on the thing injection site and “bicycling” the legs with each diaper change will
decrease soreness.
- Acetaminophen (Tylenol) is administered orally 4 to 6 hours (10 to 15 mg/Kg).

 Children with German measles pose a serious threat to their unborn siblings. The nurse should
counsel all expectant mothers, especially those with young children, to be aware of the serious
consequences of exposure to German measles during pregnancy.

 Common childhood problems are encountered by nurses caring for children in the community or
hospital settings. The child’s age directly influences the severity and management of these

 Teach proper cooking and storage to preserve potency, i.e., cook vegetables in small amount of
liquid. Store milk in opaque container.

 Add potassium to IV fluids ONLY with adequate urine output.

 Urinary output for infants and children should be 1 to 2 ml/kg/hr.

 Use of syrup of ipecac is no longer recommended by the American Academy of Pediatrics. Teach
parents that it is NOT recommended to induce vomiting in any way as it may cause more damage.


 Child needs 150% of the usual calorie intake for normal growth and development.

 Do not examine the throat of a child with epiglottis due to the risk of completely obstructing the
airway, i.e., do not put a tongue blade or any object in the throat.

 In planning and providing nursing care, a patent airway is always a priority of care, regardless of
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 Respiratory disorders are the primary reason most children and their families seek medical care.
Therefore, these disorders are frequently tested on the NCLEX-RN. Knowing the normal
parameters for respiratory rates and the key signs of respiratory distress in children is essential!

 The nurse should be sure a PT and PTT have been determined prior to a tonsillectomy. More
importantly, the nurse should ask if there has been a history of bleeding, prolonged/excessive, or if
there is a history of any bleeding disorders in the family.

 When calculating a pediatric dosage, the nurse must often change the child’s weight from pounds
to kilograms.

 HINT: weight expressed in kilograms should always be a smaller number than weight expressed in


 Polycythemia is common in children with cyanotic defects.

 The heart rate of a child will increase with crying or fever.

 Infants may require tube feeding to conserve energy.

 Basic difference between cyanotic and acyanotic defects:

- Acyanotic: Has abnormal circulation, however, all blood entering the systemic ciruclation is
- Cyanotic: Has abnormal circulation with unoxygenated blood entering systemic circulation.

 Congestive heart failure is more often associated with acyanotic defects.

 CHF is a common complication of congenital heart disease. It reflects the increased workload of
the heart resulting from shunts or obstructions. The two objectives in treating CHF are to reduce
the workload of the heart and increase cardiac output.
 When frequent weighings are required, weigh client on the same scale at same time of day so that
accurate comparisons can be made.


 The nursing goal in caring for children with Down syndrome is to help the child reach his/her
OPTIMAL level of functioning.

 Feed infant or child with cerebral palsy using nursing interventions aimed at preventing aspiration.
Position child upright and support the lower jaw.

 The signs of ICP are the opposite of those of shock.

- Shock: Increased pulse, Decreased blood pressure.
- Increased ICP: Decreased pulse, Increased blood pressure.

 Baseline data on the child’s USUAL behavior and level of development is essential so changes
associated with increased ICP can be detected EARLY.

 Do not pump shunt unless specifically prescribed. The shunt is made up of delicate valves, and
pumping changes pressures within the ventricles.

 Medication noncompliance is the most common cause of increased seizure activity.

 Do NOT use tongue blade, padded or not, during a seizure. It can cause traumatic damage to
mouth/oral cavity.
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 Monitor hydration status and IV therapy carefully. With meningitis, there may be inappropriate
ADH secretions causing fluid retention (cerebral edema) and dilutional hyponatremia.

 Headache upon awakening is the most presenting symptom of brain tumors.

 Most postoperative clients with infratentorial tumors are prescribed to lie flat and turn to either
side. A large tumor may require that the child NOT be turned to the operative side.

 Suctioning, coughing, straining, and/or causes increased ICP.


 Decreased urinary output is FIRST sign of renal failure.

 Surgical correction for hypospadias is usually done before preschool years due to achieving
sexual identity, castration anxiety and toilet training.


 Typical parent/family reaction to a child with an obvious malformation such as cleft lip/palate are
quilt, disappointment, grief, sense of loss, and anger.

 Children with cleft lip/palate and those with pyloric stenosis both have a nursing diagnosis
“alteration in nutrition; less than body requirements.”
- Cleft lip/palate is related to decreased ability to suck.
- Pyloric stenosis is related to frequent vomiting.

 Nutritional needs and fluid and electrolyte balance are key problems for children with GI disorders.
The younger the child, the more vulnerable they are to fluid and electrolyte imbalances and
greater is the need for caloric intake required for growth.

 Take axillary temperature on children with congenital megacolon.


 Remember the Hgb norms:

- Newborn: 14 to 24 g/dl
- Infant: 10 to 15 g/dl
- Child: 11 to 16 g/dl

 Teach family about administration of oral iron:

- Give on empty stomach (as tolerated for better absorption)
- Give with citrus juices (vitamin C) for increased absorption
- Use dropper or straw to avoid discoloring teeth
- Stools will become tarry
- Iron can be fatal in severe overdose; keep away from children. Do not give with dairy products.

 Inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge
of genetic transmission patterns. Remember:
- Autosomal recessive: Both parents must be heterozygous, or carriers of the recessive trait, for the
disease to be expressed in their offspring. With each pregnancy, there is a 1:4 chance of the
infant having the disease. However, all children of such patterns CAN get the disease – NOT 25%
of them. This is the transmission for sickle cell anemia, cystic fibrosis, and phenylketonuria (PKU).
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- X-linked recessive trait: The trait is carried on the X chromosome, therefore, usually affects male
offspring, e.g., hemophilia. With each pregnancy of a woman who is a carrier there is a 25%
chance of having a child with hemophilia. If the child is male, he has a 50% chance of having
hemophilia. If the child is female, she has a 50% chance of being a carrier.

 Hydration is very important in treatment of sickle cell disease because it promotes hemodilution
and circulation of red cells through the blood vessels.
 Important terms:
- Heterozygous gene (HgbAS) sickle cell trait
- Homozygous gene (HbSS) sickle cell disease
- Abnormal hemoglobin (HGBS) disease and trait

 Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron
deficiency. Folic acid is given only to stimulate RBC synthesis.

 Have epinephrine and oxygen readily available to treat anaphylaxis when administering l-

 Prednisone is frequently used in combination with antineoplastic drugs to reduce the mitosis of
lymphocytes. Allopurinol, a xanthine-oxidase inhibitor, is also administered to prevent renal
damage from uric acid build up during cellular lysis.


 An infant with hypothyroidism is often described as a “good, quiet baby” by the parents.

 Early detection of hypothyroidism and phenylhetonuria is essential in preventing mental

retardation in infants. Knowledge of normal growth and development is important, since a lack of
attaintment can be used to detect the existence of these metabolic/endocrine disorders and
attainment can be used for evaluating the treatment’s effect.

 Nutrasweet (aspartame) contains phenylalanine and should not therefore, be given to a child with

 Diabetes mellitus (DM) in children was typically diagnosed as insulin dependent diabetes (Type I)
until recently. A marked increase in Type II DM has occurred recently in the US, particularly
among Native-American, African-American, and Hispanic children and adolescents. Adolescence
frequently causes difficulty with management since growth is rapid and the need to be like peers
makes compliance difficult. Remember to consider the child’s age, cognitive level of development,
and psychosocial development when answering NCLEX-RN questions.

 When child is in ketoacidosis, administer regular insulin IV as prescribed in normal saline.

 There has been an increase in the number of children diagnosed with Type II diabetes. The
increasing rate of obesity in children is thought to be a contributing factor. Other contributing
factors include lack of physical activity and a family history of Type II diabetes.


 Fractures in older children are common as they fall during play and are involved in motor vehicle

 Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse.
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 Fractures involving the epiphyseal plate (growth plate) can have serious consequences in terms of
growth of the affected limb.

 Skin traction for fracture reduction should not be removed unless prescribed by healthcare

 Pin sites can be sources of infection. Monitor signs of infection. Cleanse and dress pin sites as

 Skeletal disorders affect the infant’s or child’s physical mobility, and typical NCLEX-RN questions
focus on appropriate toys or activities for the child who is on bedrest and/or immobilized.

 Children do not like injections and will deny pain to avoid “shots.”

 A brace does not correct the curve of a child with scoliosis, it only stops or slows the progression.

 Corticosteroids are used short term in low doses during exacerbations. Long-term use is avoided
due to side effects and their adverse effect on growth.



 The menstrual phase varies in length for most women.

 From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other
words, ovulation occurs 14 days before the next menstrual period.

 Sperm lives approximately 3 days and eggs live about 24 hours. A couple must avoid unprotected
intercourse for several days before the anticipated ovulation and for 3 days after ovulation in order
to prevent pregnancy.

 Because some women experience implantation bleeding or spotting, they do not know they are

 Look for signs of maternal-fetal bonding during pregnancy. For example: talking to fetus in utero,
massaging abdomen, nicknaming fetus are all healthy psychosocial activities.

 For many women, BATTERING (emotional or physical abuse) begins during pregnancy. Women
should be assessed for abuse in private, away from the male partner, by a nurse who knows local
resources and how to determine the safety of the client.

 Practice determining gravidity and parity: A woman who is 6 weeks pregnant has the following
maternal history:
- Has a 2 yr. old healthy daughter.
- Had a miscarriage at 10 weeks, 3 years ago.
- Had an elective abortion at 6 weeks, 5 years ago. With this pregnancy, she is a gravida 4, para 1
(only 1 delivery after 20 weeks gestation).

 Practice calculating EDB (estimated date of birth). If the first day of a women’s last normal
menstrual period was October 17, what is her EDB using Nagele’s rule? July 24. Count back 3
months and add 7 days (always give February 28 days).

 At approximately 28 to 32 weeks gestation, the maximum plasma volume increase of 25 to 40%

occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 to 42%. High Hct
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values may look “good,” but in reality represent pregnancy-induced hypertension and a depleted
vascular space.

 Hgb/Hct data can be used to evaluate nutritional status. Example: a 22-year old primigravida at
12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31%. She has gained 3 pounds during
the first trimester. A weight gain of3.5 to 5 pounds during the first trimester is recommended and
this client is anemic. Supplemental iron and a diet higher in iron are needed.
 Foods high in iron: fish and red meats; cereal and yellow vegetables; green leafy vegetables and
citrus fruits; egg yolks and dried fruits.

 As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta). Teach
the woman that a side-lying position increases perfusion to uterus, placenta, and fetus. Recent
research indicates that the knee-chest position is best for increasing perfusion and that the side-
lying position (either left or right side-lying) is the second most desirable position to increase
perfusion. Prior to this research, the left side-lying position was usually encouraged.

 Fetal well-being is determined by assessing fundal height, fetal heart tones/rate, fetal movement
and uterine activity (contractions). Changes in fetal heart rate are the first and most important
indicator of compromised blood flow to the fetus, and these changes require action! Remember,
the normal FHR is 110 to 160 bpm.

 Danger signs during pregnancy. Teach clients to immediately report any of the following danger
signs. Early intervention can optimize maternal and fetal outcome.

 Possible indications of preeclampsia/eclampsia:

- Visual disturbances
- Swelling of face, fingers or sacrum
- Severe, continuous headache
- Persistent vomiting

 Signs of infection:
- Chills
- Dysuria
- Temperature over 100.4 F
- Pain in abdomen
- Fluid discharge from vagina (anything other than normal leukorrhea)
- Change in fetal movement and/or increased FHR

 Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of
vitamins. However, only the healthcare provider can prescribe prenatal vitamins. It is the nurse’s
responsibility to teach about proper diet and taking prescribed vitamins, if prescribed by the
healthcare provider.

 It is recommended that pregnant women drink one quart of milk/day. This will ensure that the daily
calcium needs are met an help to alleviate the occurrence of leg cramps.


 In some states, the screening for neural tube defects through either maternal serum AFP levels or
amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with
both false positives and false negatives.
 When an amniocentesis is done in early pregnancy, the bladder must be full to help support the
uterus and to help push the uterus up in the abdomen for easy access. When an amniocentesis is
done in late pregnancy, the bladder must be empty to avoid puncturing the bladder.

 Early decelerations, caused by head compression and fetal descent, usually occur between 4 and
7 cm and in the 2nd stage. Check for labor progress if early decelerations are noted.
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 If cord prolapse is detected, the examiner should position the mother to relieve pressure on the
cord (i.e., knee-chest position) or push the presenting part off the cord until IMMEDIATE Cesarean
delivery can be accomplished.

 Late decelerations indicate uteroplacental insufficiency and are associated with conditions such as
postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae.

 When deceleration patterns (late or variable) are associated with decreased or absent variability
and tachycardia, the situation is OMINOUS (potentially disastrous) and requires immediate
intervention and fetal assessment.

 A decrease in uteroplacental perfusion results in late decelerations; cord compression results in a

pattern of variable decelerations. Nursing interventions should include changing maternal
position, discontinuing Pitocin infusion, administering oxygen and notifying the healthcare provider.

 The danger of nipple stimulation lies in controlling the “dose” of oxytocin stimulated from the
posterior pituitary. The chance of hyper-stimulation or tetany (contractions over 90 seconds or
contractions with less than 30 seconds in between) is increased.

 Percutaneous umbilical blood sampling (PUBS) can be done during pregnancy under ultrasound
for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis, and some
genetic testing can be done using this method.

 The most important determinant of fetal maturity for extra-uterine survival is the L/S ratio (2:1 or


 Be able to differentiate true labor from false labor.

 True labor:
- Pain in lower back that radiates to abdomen
- Accompanied by regular, rhythmic contractions
- Contractions that intensify with ambulation
- Progressive cervical dilation and effacement

 False labor:
- Discomfort is localized in abdomen
- No lower back pain
- Contractions decrease in intensity and/or frequency with ambulation

 Know normal findings for clients in labor:

- Normal FHR in labor: 110 to 160 bpm
- Normal maternal BP: <140/90
- Normal maternal pulse: <100 bpm
- Normal maternal temperature: <100.4 F

 Slight elevation is often due to dehydration and the work of labor. Anything higher indicates
infection and must be reported immediately.

 Admission procedures:
- vulvar/perineal shave (may not be done)
- enema: may be refused by woman due to pre-labor diarrhea or recent, large bowel movement. An
enema should not be administered to a client in active labor. If head is floating, watch for cord
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 Meconium-stained fluid is yellow-green and may indicate fetal stress.

 Breathing techniques such as deep chest, accelerated, and cued are not prescribed by the stage
and phase of labor, but by the discomfort level of the laboring woman. If coping is decreasing,
switch to a new technique.

 Hyperventilation results in respiratory alkalosis due to blowing off too much CO2. Symptoms
- Dizziness
- Tingling of fingers
- Stiff mouth
- Have woman breathe into her cupped hands or a paper bag in order to rebreathe CO2.

 Determine cervical dilation before allowing client to push. Cervix should be completely dilated (10
cm) before the client begins pushing. If pushing starts too early, the cervix can become
edematous and never fully dilate.

 Give the oxytocin after the placenta is delivered because the drug will cause the uterus to
contract. If the oxytocic drug is administered before the placenta is delivered, it may result in a
retained placenta, which predisposes the client to hemorrhage and infection.

 Application of perineal pads after delivery:

- Place two on perineum
- Do NOT touch inside of pad
- DO apply from front to back, being careful not to drag pad across the anus.

 Methergine is NOT given to clients with hypertension due to its vasoconstrictive action. Pitocin is
given with caution to those with hypertension.

 FULL BLADDER is one of the most common reasons for uterine atony and/or hemorrhage in the
first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to
the right of the umbilicus, what action should be taken first? First, perform fundal massage; then
have the client empty her bladder. Recheck fundus q15 minutes X 4 (1 hour); q30 minutes X 2

 If narcotic analgesics (codeine, meperidine) are given, raise side rails and place call light within
reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about
drowsiness as a side effect.

 A 1st degree tear involves only the epidermis. A 2 nd degree tear involves dermis, muscle, and
fascia. A 3rd degree tear extends into the anal sphincter, and a 4 th degree extends up the rectal
mucosa. Tears cause pain and swelling. Avoid rectal manipulations.

 If it was documented that the fetus passed meconium in utero or the nurse noted LATE passage of
meconium in delivery room, the neonate MUST be attended by a pediatrician, neonatologist,
and/or nurse practitioner to determine, through endotracheal tube observation and suction, the
presence of meconium below the cords. It can result in pneumonitis/meconium aspiration
syndrome, which will necessitate a sepsis workup including a chest x-ray early in the transitional
newborn period.

 Do not wait until a 1 minute Apgar is assigned to begin resuscitation of the compromised neonate.

 Apgar scores of 6 or < at 5 minutes require an additional Apgar assessment at 10 minutes.

 IV administration of analgesics is preferred to IM for the client in labor because the onset and peak
occurs more quickly and duration of the drug is shorter.

 IV administration:
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- Predictable onset: 5 minutes

- Peak: 30 minutes
- Duration: 1 hour

 IM administration:
- Onset: within 30 minutes
- Peak: 1 to 3 hours after injection
- Duration: 4 to 6 hours

 Tranquilizers (ataractics and/or phenothiazines) Phenergan, Vistaril, are used in labor as

analgesic-potentiating drugs to decrease maternal anxiety.

 Agonist narcotic drugs (Demerol, morphine) produce narcosis and have a higher risk for
maternal/fetal respiratory depression. Antagonist drugs (Stadol, Nubain) have less respiratory
depression but MUST be used with caution in a mother with preexisting narcotic dependency
since withdrawal symptoms occur immediately.

 Pudendal block and subarachnoid (saddle block) are used only for second stage of labor.
Peri/epidural may be used for all stages of labor.

 The first sign of block effectiveness is usually warmth and tingling of ball/big toe of foot.

 Discontinue continuous infusion at end of Stage I or during transition to increase pushing


 Regional block anesthesia and fetal presentation

- Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia resulting in
persistent occiput posterior position of fetus.
- Monitor for fetal position. REMEMBER, mother cannot tell you she has back pain, which is the
cardinal sign of persistent posterior fetal position.
- Regional blocks, especially epidural and caudal, often result in assisted (forceps or vacuum)
delivery due to the inability to push effectively in 2nd stage.

 Nerve block anesthesia (spinal or epidural) during labor blocks motor as well as nerve fibers.
Vasodilation below the level of the block results in blood pooling in the lower extemities and
maternal hypotension. Approximately 20 minutes prior to nerve block anesthesia, the client should
be hydrated with 500 to 1000 cc of lactated ringers IV. Monitor maternal vital signs and FHR q5 to
15 minutes. If hypotension occurs – turn the client to her side, administer O2 at 10 L/min by
facemask, and increase IV rate.


 Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. The first 10 to 12 days post-
delivery, values of 25,000 mm3 are common. Elevated WBC and the normal elevated ESR may
confuse interpretation of acute postpartal infections. For example, if the nurse assesses a client’s
temperature to be 101 F on the client’s second postpartum day, what assessments should be
made before notifying the physician? Assess fundal height and firmness, perineal integrity, check
for a positive Homan’s sign and other symptoms, i.e., burning on urination, pain in leg, excessive
tenderness of uterus.

 Client/family teaching is a common area for NCLEX-RN questions. Remember, when teaching the
first step is to assess the client’s (parent’s) level of knowledge and identify their readiness to learn.
Client teaching regarding lochia changes, perineal care, breastfeeding, sore nipples are commonly
tested content.

 After the 1st PP day, the most common cause of uterine atony is retained placental fragments. The
nurse must check for presence of fragments in lochial tissue.
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 Women can tolerate blood loss, even slightly excessive blood loss, in the postpartal period due to
the 40% increase in plasma volume during pregnancy. In postpartal period can void up to 3,000
cc/day to reduce this volume increase that occurred during pregnancy.

 Client should void within 4 hours of delivery. Monitor closely for urine retention. Suspect retention
if voiding is frequent and <100 cc per voiding.

 Women often have a syncopal spell (faint) on the first ambulation after delivery (usually related t
ovasomotor changes, orthostatic hypotension). The astute nurse will check for client’s Hgb and
Hct for anemia and the blood pressure, sitting and lying for orthostatic hypotension.

 Kegel exercises: increase integrity of introitus and improve urine retention. Teach client to
alternate contraction and relaxation of the pubococcygeal muscles.

 Assess for thromboembolism: Examine legs of PP client daily for pain, warmth, and tenderness or
a swollen vein which is tender to touch. Client may or may not exhibit a positive Homan’s sign
(dorsiflexion of foot causes compression of tibial veins and pain if thrombus is present).

 “Postpartum blues” are usually normal, especially 5 to 7 days after delivery (unexplained
tearfulness, feeling “down,” and a decreased appetite). Encourage use of support persons to help
with housework for first two postpartum weeks. Refer to community resources.

 Remember RhoGAM is given to a Rh-negative mother who delivers a Rh-positive fetus and has a
negative direct Coombs. If the mother has a positive Coombs, there is no need to give RhoGAM
since the mother is already sensitized.

 Because Rh Immune Globulins suppress the immune system, the client who receives both
RhoGAM and the Rubella vaccine should be tested for rubella immunity at 3 months.


 PHYSICAL ASSESSMENT: A detailed physical assessment is performed by the nurse or

physician. Regardless of who performs the physical assessment, the nurse must know normal
versus abnormal variations of the newborn. Observations must be recorded and the physician
and the physician notified regarding abnormalities.
 It is difficult to differentiate between caput succedaneum (edema under the scalp) and
cephalhematoma (blood under the periosteum). The caput crosses suture lines and is usually
present at birth, while the cephalhematoma does NOT cross suture lines and manifests a few
hours after birth. The danger of cephalhematoma is increased by hyperbilirubinemia due to
excess RBC breakdown.

 These neurological reflexes are transient, and, as such, disappear usually within the first year of
life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects.
Anticipate NCLEX-RN questions regarding normal newborn reflexes. Physical assessment
questions focus on normal characteristics of the newborn and the differentiation of conditions such
as caput succedaneum and cephalhematoma.

 The umbilical cord should always be checked at birth. It should contain 3 vessels, 1 vein which
carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the
placenta. This is the opposite of normal circulation in the adult. Cord abnormalities usually
indicate cardiovascular or renal anomalies.

 Postnatally, the fetal structures of foramen ovale, ductus arteriosus and ductus venosus should
close. If they do not, cardiac and pulmonary compromise will develop.
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 Suctioning the mouth first and then the nose. Stimulating the nares can initiate inspiration which
could cause aspiration of mucus in oral pharynx.

 Circumcision has become controversial since there is no real medical indication for the procedure
and it does not cause trauma and pain to the newborn. It was once thought to decrease the
incidence of penile and cervical cancer, but some researchers say this is unfounded.

 HYPOTHERMIA (heat loss) leads to depletion of glucose and, therefore, the use of brown fat
(special fat deposits fetus puts on in last trimester which are important to thermoregulation) for
energy, resulting in ketoacidosis and possible shock. Prevent by keeping neonate warm!

 Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC
destruction) occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it
becomes pathologic. Typically, NCLEX-RN questions ask about normal problem of physiologic
jaundice which occurs 2 to 3 days after birth due to the liver’s inability to keep up with RBC
destruction and bind bilirubin. Remember, unconjugated bilirubin is the culprit.

 Do not feed a newborn when the respiratory rate is over 60. Inform the physician and anticipate
gavage feedings in order to prevent further energy utilization and possible aspiration.
 A 7 lb. 8 oz. baby would need 50 calories X 7 lbs = 350 calories plus 25 calories (1/2 lb. or 8 oz.) =
375 calories per day. Most infant formulas contain 20 calories/ounce. Dividing 375 by 20 = 18.75
ounces of formula needed per day.

 Teach parents to take infant’s temperature BOTH axillary and rectally. While axillary is
recommended, some pediatricians will request a rectal temperature (core).
- AXILLARY: Place thermometer under arm and hold thermometer in place 5 minutes.
- RECTALLY: Use thermometer with BLUNT end. Insert thermometer ¼ to ½ inch and hold in place
for 5 minutes. Hold feet and legs firmly.


 Clients with prior traumatic delivery, history of D&C, multiple abortions (spontaneous or induced),
or daughters of DES mothers may experience miscarriage or preterm labor related to
INCOMPETENT CERVIX. The cervix may be surgically repaired prior to pregnancy, or DURING
gestation. A CERCLAGE (McDonald’s suture) is placed around the cervix to constrict the internal
os. The cerclage may be removed prior to labor if labor is planned or left in place if cesarean birth
is planned.

 Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency
room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed with

 A client who is 32 weeks gestation calls the healthcare provider because she is experiencing dark,
red vaginal bleeding. She is admitted to the emergency room where the nurse determines the
FHR to be 100 bpm. The client’s abdomen is rigid and boardlike, and she is complaining of
severe pain. What action should the nurse take first? First, the nurse must use knowledge base
to differentiate between abruptio placentae (this client) from placenta previa (painless bright red
bleeding occurring in the third trimester). The nurse should immediately notify the healthcare
provider and no abdominal or vaginal manipulation or exams should be done. Administer O2 per
face mask. Monitor for bleeding at IV sites and gums due to the increased risk of DIC.
Emergency Cesarean section is required since uteroplacental perfusion to the fetus is being
compromised by early separation of the placenta from the uterus.

 Clients with abruptio placentae or placenta previa (actual or suspected) should have NO
abdominal or vaginal manipulation. NO Leopold’s maneuvers. NO vaginal exams. NO rectal
exams, enemas, or suppositories. NO internal monitoring.
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 Disseminated intravascular coagulation (DIC) is a syndrome of abnormal clotting that is systematic

and pathologic. Large amounts of clotting factors, especially fibrinogen, are depleted causing
widespread external and/or internal bleeding. DIC is related to fetal demise, infection/sepsis,
pregnancy-induced hypertension (Preeclampsia) and abruptio palcentae.

 Podophyllin, which is usually used to treat HPV, is contraindicated in pregnancy because it is

associated with fetal death, preterm labor, and cervical carcinoma.

 Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found),
or eating raw meat.

 Rubella is teratogenic to the fetus during the FIRST trimester, causing congenital heart disease
and/or congenital cataracts. All women should have their titers checked during pregnancy. If a
women’s titer’s are low, she should receive the vaccine AFTER delivery and be instructed not to
get pregnant within 3 months. Breastfeeding mothers may take the vaccine.

 Although Metronidazole (Flagyl) is the treatment of choice for some vaginal infections, its use is
contraindicated in the first trimester of pregnancy, and its use during the second trimester is
controversial. Medications usually recommended for the non-pregnant client with STDs may be
CONTRAINDICATED for the pregnant client due to effect on the fetus.

 The outcome of adolescent pregnancy depends on prenatal care. NUTRITION is a key factor
since the adolescent’s physiological needs for growth are already increased, plus the additional
stress of pregnancy.

 Although the toxic side effects of magnesium sulfate are well known and watched for, it is just as
important to get serum blood levels of magnesium sulfate above 4 mg/dl in order to prevent
convulsions and reach therapeutic range.

 Hold next dose of magnesium sulfate and notify healthcare provider if any toxic symptoms occur
(<12 respirations/minute, urine output <100 cc/4 hours, absent DTRs, Magnesium sulfate > 8

 When administering magnesium sulfate. ALWAYS have antidote available (calcium gluconate, 20
ml vial of 10% solution).

 Tachycardia is the major side-effect of tocolytic drugs, which are bete adrenergic agents such as
terbutaline (Brethine) or ritodrine (Yutopar) used to stop preterm labor. Teach the client to take her
pulse prior to administration and withhold medication if pulse is not within the prescribed
parameters (usually whitheld if pulse >120 to 140). If administration is via a continuous pump,
teach client to monitor pulse periodically.

 In 1978, the FDA banned the use of oxytocin for ELECTIVE inductions. The healthcare provider
must provide, for the record, the medical reason for oxytocin use.

 Dystocia frequently requires the use of oxytocin for augmentation or induction of labor. Uterine
tetany is a harmful complication and careful monitoring is required. The desired effect is
contractions q2 to 3 minutes, with duration of contractions no longer than 90 seconds.
Continuously monitor FHR and uterine resting tone. If tetany occurs, turn off Pitocin, turn client to
a side-lying position, and administer O2 by facemask. Check output (should be at least 100 cc/4
hours). Oxytocin’s most important side effects is its antidiuretic (ADH) effect, which can cause
water intoxification. Using IV fluids containing electrolytes decreases the risk of water

 The uterus is most sensitive to becoming tetanic at the beginning of infusion. The client must
ALWAYS be attended and contractions monitored. Contractions should last NO longer than 90
seconds to prevent fetal hypoxia.
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 Women with previous uterine scars are prone to uterine rupture especially if oxytocin or forceps
are used. If a woman complains of a sharp pain accompanied by the abrupt cessation of
contractions, suspect uterine rupture, a MEDICAL EMERGENCY. Immediate surgical delivery is
indicated to save the fetus and the mother.

 Rarely are antihypertensive drugs used in the preeclamptic client. They are given only in the
event of diastolic blood pressure over 110 mmHg. (CVA danger). Drug of choice is Hydralazine
HCL (Apresoline).

 Altough delivery is often described as the “cure” for preeclampsia, the client can convulse up to 48
hours after delivery.

 The major goal of nursing care for a client with preeclampsia is to maintain uteroplacental
perfusion and prevent seizures. This requires the administration of magnesium sulfate. Withhold
administration of magnesium sulfate if signs of toxicity exist: respirations <12/minute, absence of
DTRs, and urine output <30 ml/hour.

 Nursing care during labor and delivery for the client with cardiac disease is focused on prevention
of cardiac embarrassment, maintenance of uterine perfusion, and alleviation of anxiety.

 Should these clients experience preterm labor, the use of beta-adrenergic agents such as
terbutaline (Brethine) and ritodrine HCL (Yutopar) are contraindicated due to the chance of
myocardial ischemia.

 Normal diuresis, which occurs in the postpartum period, can pose serious problems to the new
mother with cardiac disease because of the increased cardiac output.

 Coumadin may NOT be taken during pregnancy due to its ability to cross the placenta and affect
the fetus. HEPARIN is the drug of choice; it does NOT cross the placental membrane.

 Recent research has found that Helicobacter pylori, (the bacterium that causes stomach ulcers)
infection is another possible causative factor in hyperemesis. Other pregnancy and non-
pregnancy risk factors for hyperemesis gravidarum include first pregnancy, multiple fetuses, age
under 24, history of this condition in other pregnancies, obesity, and high fat diets.

 In severe cases of hyperemesis gravidarum, the healthcare provider may prescribe

antihistamines, vitamin B6, or phenothiazines to relieve nausea. The provider also prescribe
metoclopramide (Reglan) to increase the rate the stomach moves food into the intestines, or
antacids to absorb stomach acid and help prevent acid reflux.

 Women who suffer from hyperemesis gravidarum are often deficient in thiamin, riboflavin, vitamin
B6, vitamin A, and retinol-binding proteins.

 GLUCOSE SCREEN: Client does NOT have to fast for this test. 50 gm of glucose is given and
blood is drawn after one hour. If the blood glucose is greater than 135 mg/dl, the na three-hour
glucose tolerance test (GTT) is done.

 High incidence of fetal anomalies occurs in pregnant diabetic women. Therefore, fetal surveillance
is very important. Ultrasound exam. Alpha-fetoprotein (to determine neural tube anomalies).
Non-stress and contraction stress tests.

 Oral hypoglycemics are not taken in pregnancy due to potential teratogenic effects on fetus.
Insulin is used for therapeutic management.

 When a woman is admitted in labor with diagnosis of diabetes mellitus. She is more prone to
preeclampsia, hemorrhage and infection. Delivery is often scheduled between 37 to 38 weeks
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gestation to avoid the end of the 3 rd trimester of pregnancy because this is a VERY difficult time to
maintain diabetic control.

 It is useful to discontinue long-acting insulin administration on the day before the delivery is
planned since insulin requirements are less in labor and drop precipitously after delivery.

 Estrogen-containing birth control pills affect glucose metabolism by increasing resistance to

insulin. The intrauterine device may be associated with an increased risk of infection in these
already vulnerable women.

 If a woman is medicated, the responsible adult accompanying her must sign the necessary
consent forms. State laws differ as to the acceptability of a friend signing the consent form rather
than a relative.

 Babies delivered abdominally miss out on the vaginal squeeze and are born with more fluid in the
lungs, predisposing the newborn to transient tachypnea (TTN) and respiratory distress.

 The preferable low-transverse uterine incision usually results in less postoperative pain, less
bleeding, and less incidents of ruptured uterus. The classical, vertical incision on the uterus may
involve part of the fundus, resulting in more postoperative pain, bleeding, and an increased
chance of uterine rupture.

 Due to the exploration and cleansing of the uterus just after delivery of the placenta, the amount of
lochia may be scant in the recovery room. However, pooling in the vagina and uterus while on
bedrest may result in blood running down the client’s leg when she first ambulates. Cesarean
birth clients have the same lochial changes, placental site healing, and aseptic needs as do
vaginal birth clients.

 A laparotomy of any kind, including cesarean birth, predisposes the client to postoperative
paralytic ileus. When the bowel is manipulated in surgery, it ceases preistalsis, which may persist.
Symptoms include: absent bowel sounds, abdominal distention, tympany on percussion, nausea
and vomiting, and of course, obstipation (intractible constipation). Early ambulation is an effective
nursing intervention.


 Nurse must be especially supportive of postpartum client with infection because it usually implies
isolation from newborn until organism is identified and treatment begun. Arrange phone calls to
nursery and window viewing. Involve family, spouse, significant others in teaching, and encourage
other family members to continue neonatal attachment activities.

 Most common iatrogenic cause of UTI is urinary catheterization. Encourage clients to void
frequently and not ignore the urge. IV antibiotic are usually administered to clients with

 Remember, the risk of postpartum infections increases for clients who experienced problems
during pregnancy (e.g., anemia, diabetes) or experienced trauma during labor and delivery.

 Clients taking anticoagulants can usually expect to have heavy menstrual periods.

 In most cases, a mother who is on antibiotic therapy can continue to breastfeed unless the
healthcare provider thinks the neonate is at risk for sepsis by maternal contact. Sulfa drugs are
used cautiously in lactating mothers because they can be transferred to the infant in breast milk.

 Many times mastitis can be confused with a blocked milk sinus, which is treated by nursing closer
to the lump and by rotating the baby on the breast. Breastfeeding is not contraindicated for
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women with mastitis, unless pus is in the breast milk, or the antibiotic of choice is harmful to the
infant. If either of these occurs, milk production can still be fostered by manual expression.

 During medical emergencies such as bleeding episodes, clients need calm, direct explanations
and assurance that all is being done that can be done. If possible, allow support person at
bedside. Risk-management principles state that the suit-prone client is one who feels things are
being hidden from her or that adequate attention is NOT being give to HER problem.

 Risk factors for hemorrhage include: dystocia, prolonged labor, over distended uterus, abruptio
placentae, and infection.

 What immediate nursing actions should be taken when a postpartum hemorrhage is detected?
- Perform fundal massage
- Notify the healthcare provider if the fundus does not become firm with massage
- Count pads to estimate blood loss
- Assess and record vital signs
- Increase IV fluids (additional IV line may be indicated)
- Administer oxytocin infusion as prescribed


 “Jitteriness” is a clinical manifestation of hypoglycemia and hypocalcemia. Laboratory analysis is

indicated to differentiate between two etiologies.

 To avoid metabolic problems brought on by cold stress, the first step and number one priority, in
management of the newborn is to prevent loss of body heat, followed by ABCs. Neonates
produce heat by non-shivering thermogenesis, by burning brown fat. The neonate is easily
stressed by hypothermia and develops acidosis from hypoxia. Prevent chilling (keep under
radiant warmer or in isolette). If cold, the first signs exhibited are prolonged acrocyanosis, skin
mottling, tachycardia, and tachypnea. If cold stressed, warm slowly over 2 to 4 hours since rapid
warming may produce apnea. The neonate needs glucose, he/she has little glycogen storage and
needs to be fed.

 The lower the score on the Silverman-Anderson index of Respiratory Distress, the better the
respiratory status of the neonate. A score of 10 indicates that a newborn is in severe respiratory
distress. This is the exact opposite of the method used for Apgar scoring.

 WATCH the newborn Hct; it is difficult to oxygenate either an anemic newborn (lack of oxygen-
carrying capacity) or a newborn with polycythemia (Hct >80%, thich, sluggish circulation).

 The PO2 should be maintained between 50 to 90 mmHg. PO2 <50 signifies hypoxia, PO2 > 90
signifies oxygen toxicity problems.

 Antibiotic dosage is based on the neonate’s weight in kilograms. Peak and trough drug levels are
drawn to evaluate if therapeutic drug levels have been achieved. Closely monitor the neonate for
adverse effects of ALL drugs.
 Sepsis can be indicated by both a temperature increase and a temperature decrease.

 Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. Close monitoring of
therapeutic levels and observation for side effects are required.

 Renal immaturity in the preterm infant makes the monitoring of IV fluid administration and drug
therapy crucial. Closely monitor BUN and creatinine levels when administering the “mycin”
antibiotics to treat infections in the neonate.

 If tube passes into trachea, newborn can make NO noise, i.e., no crying. Newborn may gag,
cough, or become cyanotic.
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 To assess for skin jaundice, apply with thumb over bony prominences to blanch skin. After
removing thumb, area will look yellow before normal skin color reappears. The best areas for
assessment are the nose, forehead, and sternum. In dark-skinned infants, observe conjunctival
sac and oral mucosa.

 Lab tests measure total and direct (conjugated, excretable, non-fat soluble) bilirubin levels. The
dangerous bilirubin is the unconjugated, indirect (fat-soluble), which is measured by subtracting
the direct from the total bilirubin.

 Maintenance of hydration is crucial for all infants. The preterm infant is already at risk for fluid and
electrolyte imbalances due to increased body surface area from extended body positioning and
larger body area in related to body weight. Phototherapy treatment for hyperbilirubinemia (level >
12 mg/dl) increases the risk for dehydration.



 The purpose of therapeutic interaction with clients is to allow them the autonomy to make choices
when appropriate. Keep statements value free, advice free, and reassurance free. Remember,

 What action should the nurse take in a “psychiatric situation” when the client describes a physical
problem? Assess, assess, assess! If the client with paranoid schizophrenia on the psychiatric unit
complains of chest pain, take his/her blood pressure. If the OB client who has delivered a dead
fetus complains of perineal pain – look at the perineal area (she may have a hematoma). Just
because the focus of the client’s situation is on his/her psychological needs, it does not mean that
the nurse can ignore physiological needs.

 Remember, nurses are “nice” people, but they are also therapeutic.

 Basic communication principles can be applied to all clients:

- Establish trust.
- Demonstrate a non-judgmental attitude
- Offer self; be emphathetic, NOT sympathetic
- Use active listening
- Accept and support client’s feelings
- Clarify and validate client’s statement
- Use matter-of-fact approach

 Remember, a nurse’s nonverbal communication may be more important that his/her verbal

 A question concerning nurse-client confidentiality often appears on the NCLEX-RN. For the nurse
to tell a client she/he will not tell anyone about their discussion, puts the nurse in a difficult
position. Some information MUST be shared with other team members for the client’s safety (e.g.,
suicide plan) and optimal therapy.

 Nausea is a common complaint after ECT. Vomiting by the unconscious client can lead to
aspiration. Because post-ECT clients are unconscious, the nurse must observe closely for the
possibility of aspiration, i.e., MAINTAIN A PATENT AIRWAY!

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 Common physiological responses to anxiety include increased heart rate and blood pressure;
rapid, shallow respirations; dry mouth, tight feeling in throat; tremors, muscle tension; anorexia;
urinary frequency; palmar sweating.

 Anxiety is very contagious and is easily transferred from client to nurse AND from nurse to client.
FIRST, the nurse must assess his/her own level of anxiety and remain calm. A calm nurse assists
the client to gain control, decrease anxiety, and increase feelings of anxiety.

 When a client described a phobia or expresses an unreasonable fear, the nurse should
acknowledge the feeling (fear) and refrain from exposing the client to the identified fear. After trust
is established, a desensitization process may be prescribed. Desensitization is the nursing
intervention for phobia disorders. The nurse should:
- Assist client to recognize factors associated with feared stimuli that precipitate a phobic response.
- Teach and practice with client alternative adaptive coping strategies such as the use of thought
substitution (replacing a fearful thought with a pleasant thought), and relaxation techniques. Role-
playing is useful when the client is in a calm state.
- Expose client progressively to feared stimuli, offering support with the nurse’s presence.
- Provide positive reinforcement whenever a decrease in phobic reaction occurs.
- NOTE: In all likelihood, the desensitization process will be overseen by a mental health
practitioner (NP psych CNS, or psychologist).

 The nurse should place an anxious client where there are reduced environmental stimuli – a quiet
area of the unit, away from the nurse’s station.

 The best time for interaction with a client is at the completion of the performed ritual. The client’s
anxiety is lowest at this time; therefore, it is an optimal time for learning.

 Compulsive acts are used in response to anxiety, which may or may not be related to the
obsession. It is the nurse’s responsibility to help alleviate anxiety. Interfering will increase anxiety.
These acts should be allowed as long as the client’s acts are free of violence. The nurse should:
- Actively listen to the client’s obsessive themes
- Acknowledge effects that ritualistic acts have on the client
- Demonstrate empathy
- Avoid being judgmental

 For clients with postraumatic stress disorder, the nurse should:

- Actively listen to client’s stories of experiences surrounding the traumatic event
- Assess suicide risk
- Assist client to develop objectivity about the event and problem solve regarding possible means of
controlling anxiety related to the event
- Encourage group therapy with other clients who have experienced the same or related traumatic


 Be aware of your own feelings when dealing with this type of client. It is a challenge to be non-
judgmental. The pain is real to the person experiencing it. These disorders cannot be explained
medically: they result from internal conflict. The nurse should:
- Acknowledge the symptom or complaint
- Reaffirm that diagnostic test results reveal no organic pathology
- Determine the secondary gains acquired by the client


 The nurse should be aware that ALL behavior has meaning.

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 Avoid giving clients with dissociative disorders too much information about past events at one
time. The various types of amnesia, which accompany dissociative disorders, provide protection
from pain. Too much, too soon, may cause decompensation.


 Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety
and cause difficulty in relating and working with other individuals. NCLEX-RN questions test
personality disorder content by describing management situations.

 Persons with a personality disorder are usually comfortable with their disorder and believe that
they are right and the world is wrong. These individuals usually have very little motivation to
change. Think of them as a CHALLENGE.


 People with Anorexia gain pleasure from providing others with food and watching them eat. These
behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare
food for unit-based activities.

 People with Bulimia often use syrup of ipecac to induce vomiting which may cause cardiovascular
problems such as congestive heart failure (CHF). Because CHF is not usually seen in young
people, it is often overlooked. Assess for edema and listen to breath sounds.

 Physical assessment and nutritional support are a priority; the physiological implications are great.
Nursing interventions should increase self-esteem and develop a positive body image. Behavior
modification is useful and effective. Family therapy is most effective since issues of control are
common in these disorders. (Therapy is usually long term).


 Depressed clients have difficulty hearing and accepting compliments because of their lowered
self-concept. Comment on signs of improvement by noting the behavior, e.g., “I noticed you
cobed your hair today” NOT, “You look nice today.”

 The most important signs and symptoms of depression are a depressed mood with a loss of
interest or pleasure in life. The client has sustained a loss. Other symptoms include:
- Significant change in appetite often accompanied by a change in weight – either weight loss or
- Insomnia or hyperinsomnia (usually sleeping during the day – often because the client is not
sleeping at night due to anxiety).
- Fatigue or a lack of energy
- Feelings of hopelessness, worthlessness, guilt, or over-responsibility
- Loss of ability to concentrate or think clearly
- Preoccupation with death or suicide

 The nurse knows depressed clients are improving when they begin to take an interest in their
appearance or begin to perform self-care activities, which were previously of little or no interest.

 The nurse should suspect an imminent suicide attempt if a depressed client becomes “better,”
e.g., happy or even elated. Be aware – a happy affect may signify that the client feels relieved
that a plan has been made and he/she is ready for the suicide attempt.
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 When dealing with a depressed client, the nurse should assist with personal hygiene tasks and
encourage the client to initiate grooming activities even when he/she does not feel like doing so.
This helps promote self-esteem and a sense of control.

 An important intervention for the depressed client is to sit quietly with the client. When answering
NCLEX-RN questions, remember that you are working at Utopia General and there is plenty of
time and staff to provide ideal nursing care. Do not let realities of clinical situations deter you from
choosing the best nursing intervention. The best intervention is to sit quietly with the client,
offering support with your presence.

 There are always drug questions on the NCLEX-RN. Here are some tips: Know common side
effects for drug groups. For example:
- Anti-anxiety drugs = sedation, drowsiness
- Antidepressant drugs = anticholinergic effects, postural hypotension
- MAO inhibitors = hypertensive crisis

 Know specific problems or concerns for drug therapy. For example:

- Lithium requires renal function assessment and monitoring
- Phenothiazines cause extrapyramidal effects (EPS); tardive dyskinesia can be permanent if client
is not assessed regularly for signs of tardive dyskinesia!

 Know specific client teaching for drug therapy. For example:

- Phenothiazines = photosensitivity, need to wear protective clothing, sunglasses
- MAO inhibitors = dietary restrictions to prevent hypertensive crisis

 Monitor serum lithium levels carefully. The therapeutic range is between 0.5 and 1.5 mEq/L. the
therapeutic and toxic levels are very close in reading. Signs of toxicity are evident when lithium
levels are more than 1.5 mEq/L. Blood levels should be drawn 12 hours after LAST dose.

 Manic clients can be very caustic toward authority figures. Be prepared for personal “put downs.”
Avoid arguing or becoming defensive.

 What activities are appropriate for a manic client? = Noncompetitive physical activities, which
require the use of large muscle groups.

 Where should a manic client be placed on the unit? = Make every attempt to reduce stimuli in the
environment. Place the client in a quiet part of the unit.

 What interventions should the nurse use if a client becomes abusive?

- Redirect negative behavior or verbal abuse in a calm, firm, non-judgmental, non-defensive manner
- Suggest a walk or physical activity
- Set limits on intrusive behavior. For example, “When you interrupt, I cannot explain the procedure
to the others; please wait your turn.”
- If necessary, seclude or administer medication if client becomes totally out of control. Always
remember to use compassion because nurses are “nice” people.

 Two atypical antipsychotic drugs are also indicated for mania (risperidone and olanzapine).


 There are five types of schizophrenia specified under the DSM-IV-TR. The DSM-IV-TR is a
diagnostic manual prepared by the American Psychiatric Association that provides diagnostic
criteria for all psychiatric disorders.

 Observe for increased motor activity and/or erratic response to staff and other clients. The client
may be experiencing an increase in command hallucinations. When this occurs, there is an
increased potential for aggressive behavior. THINK PRN!
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 When evaluating client behaviors, consider the medications the client is receiving. Exhibited
behaviors may be manifestations of schizophrenia or a drug reaction.

 Use Bleuler’s four As to help remember the important characteristics of schizophrenia:

- Autism (preoccupied with self)
- Affect (flat)
- Association (loose)
- Ambivalence (difficulty making decisions)

 Do not argue with a client about their delusions. Logic does NOT work, it only increases the
client’s anxiety. Be matter-of-fact and divert delusional thought to reality. Trust is the basis for all
interactions with these clients. Be supportive and non-judgmental. Stress increases anxiety and
the need for delusions and hallucinations. Do not agree you hear voices (you should be the
client’s contact to reality), but acknowledge your observation of the client, for example, “You look
like you’re listening to something.”

 Know the side effects of drugs commonly used to treat schizophrenia since client behavioral
changes may be due to drug reactions instead of schizophrenia.


 Know what defense mechanisms are used by chemically dependent clients. Denial and
rationalization are the two most common coping styles used – their use must be confronted so
accountability for the client’s own behavior can be developed.

 What basic needs have priority when working with chemically dependent clients? Nutrition is a
priority. Alcohol and drug intake has superseded the intake of food for these clients.

 What behaviors are expected during withdrawal? In the alcoholic, delirium tremens (DT) occurs 12
to 36 hours after the last intake of alcohol. Know the symptoms (tachycardia, tachypnea,
diaphoresis, marked tremors, hallucinations, paranoia). In drug abuse, withdrawal symptoms are
specific to the type of drug.

 What medications can the nurse expect to administer to chemically dependent clients? In treating
alcohol withdrawal, Librium or Ativan are commonly used. Antabuse is often used as s deterrent
to drinking alcohol. Client teaching should include the effects of consuming any alcohol while on
Antabuse. Encourage client to read all labels of over-the-counter medications and food products,
which may contain small amounts of alcohol.

 What type of therapy is used with chemically dependent clients? Group therapy is effective as
well as support groups such as Alcoholics Anonymous, Narcotics Anonymous, etc.
 Harm reduction is a community health strategy designed to reduce the harm of substance abuse
to families, individuals, community, and society.
- More compassionate drug treatment options including abstinence and drug substitution models.
- HIV related interventions such as needle exchanges
- Directed drug use management should the client wish to continue use
- Changes in laws concerning possession of paraphernalia


 Select only one nurse to care for an abused child. Abused children have difficulty establishing
trust. The child will be less anxious with one consistent caregiver.
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 Women who are abused may rationalize the spouse’s behavior and unnecessarily accept the
blame for his actions. The woman may or may not choose to press charges. Be sure to give her
the number of a shelter for “help line” for future occurrences, as well as develop a safety plan.

 It is difficult for an elderly person to admit abuse for fear being placed in a nursing home or being
abandoned. Therefore, it is imperative to establish a trusting relationship with the elderly client.

 Rape victims are at high risk for Post Traumatic Stress Disorder (PTSD). Immediate intervention
to diminish distress is vital. The nurse should also assess for and intervene for sequellae such as
unwanted pregnancy, sexually transmitted diseases, and HIV risk.

 Questions on the NCLEX-RN regarding physical/sexual abuse usually focus on three aspects:
- Physical manifestations of abuse
- Client safety
- Legal responsibilities of the nurse – In children, the nurse is legally responsible to report all
suspected cases of abuse. In intimate partner abuse, it is the adult’s decision; the nurse should
be supportive of their decision. Remember to document objective factual assessment data and
the client’s exact words in cases of sexual abuse/rape.


 Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to
dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a history.
Such changes are usually due to a specific stressor, and treatment for the causative stressor will
usually result in correcting the confusion.

 Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego.

 Nursing interventions for the confused elderly should focus on:

- Maintaining the client’s health and safety
- Encouraging self care
- Reinforcing reality orientation (e.g., “Today is Monday,” and call the client by name).
- Providing a consistent, safe environment – engage client in simple tasks, activities to build self-

 Providing consistent caregiver is a priority in planning nursing care for the confused older client.
Change increases anxiety and confusion.

 May also use atypical antipsychotics such as resperidine, quetiapine, olanzapine, Clozaril is not a
front-line agent due to side-effects. May also give mood stabilizers and antianxiety medications as

 The basic difference between delirium and dementia is that delirium is acute, and reversible,
whereas dementia is gradual and permanent.


 Children also experience depression, which often presents as headaches, stomachaches, and
other somatic complaints. Be sure to assess suicidal risks, especially in the adolescent.

 The client’s lack of remorse or guilt about their antisocial behavior represents a malfunction of the
superego or conscience. The id functions on the basic instinct level and strives to meet immediate
needs. The ego is in touch with external reality and is the part of the personality that makes
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 Important points to remember when answering NCLEX-RN questions:

- These children may be involved in self-fulfilling prophecy (e.g., “Mom says that he/she is a trouble-
maker, therefore, he/she must live up to Mom’s expectations”).
- Confront the client with his/her behavior, e.g., lying. This gives the client a sense of security.
- Provide consistent interventions – helps to prevent manipulation. Inconsistency does not help the
client develop self-control.


 Changes in the heart and lungs result in less efficient utilization of O2, which reduces an
individual’s capacity to maintain physical activity for long periods of time. Physical training for
older persons can significantly reduce blood pressure and increase aerobic capacity. NCLEX-RN
questions ask about teaching and designing rehab programs for the elderly – they should contain
something about exercise and nutrition.

 Older persons often complain that they cannot get to sleep at night and do not sleep soundly even
after they fall asleep. This is because they have shorter stages of sleep, particularly shorter cycles
from stages 1 to 4 and REM sleep (stage 4 is deep sleep). They are easily awakened by
environmental stimuli. They often compensate by napping during the day, which leads to further
disruptions of night sleep. A common response is use of prescription sleeping pills which can
create still further problems of disorientation, etc.

 Both systolic and diastolic blood pressure tend to increase with normal aging, but the elevation of
the systolic is greater. REMEMBER the physiologic of blood pressure, which is expressed as a
ratio of systolic to diastolic pressure. Systolic refers to the level of blood pressure during the
contraction phase whereas diastolic refers to the stage when the chambers of the heart are filling
with blood.

 Dysrhythmias in the elderly are particularly serious since older persons cannot tolerate decreased
cardiac output, which can result in syncope, falls, and transient ischemic attacks (TIAs). Pulse
may be rapid, slow, or irregular.

 Angina symptoms may be absent in the elderly or they may be confused with GI symptoms.
 With aging, the muscles that operate the lings lose elasticity so that respiratory efficiency is
reduced. Vital capacity (the amount of air brought into the lungs at one time) decreases.
Breathing may become more difficult after strenuous exercise or after climbing up several flights of
stairs. The rate of decline has been found to be slower in more active persons. The nurse should
encourage older persons to remain physically active for as long as possible. Declining muscle
strength may impair cough efficiency. This fact makes older persons more susceptible to chronic
bronchitis, emphysema, and pneumonia.

 COPD is the major cause of respiratory disability in the elderly.

 Aging changes that contribute to chronic constipation:

- The number of enzymes in the small intestine is reduced and simple sugars are absorbed more
slowly, resulting in decreased efficiency of the digestive process.
- The smooth muscle content and muscle tone of the wall of the colon decrease. Anatomical
changes in the large intestine result in decreased intestinal motility.
- Psychological factors, as well as abuse of over-the-counter laxatives
- Decreases in fluid intake and mobility contribute to constipation

 Tooth loss is NOT a normal aging process. Good dental hygiene, good nutrition, and dental care
can prevent tooth loss.

 Older persons appear to eat small quantities of food at mealtimes. This is because the digestive
system of older persons features a decrease in contraction time of the muscles and more time is
needed for the cardiac sphincter to open. Therefore, it takes more time for the food to be
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transmitted to the stomach. Thus, the sensation of fullness may occur before the entire meal is

 Older persons have a higher risk of developing renal failure because normal age-related changes
result in compromised renal functioning. The nurse should pay careful attention to urinary output
in older clients because it is the first sign of loss of renal integrity.

 Kegel exercises consist of tightening and relaxing the vaginal and urinary meatus muscles. These
exercises have been very successful in reducing the incidence of incontinence. They must be
done consistently, and they can be done unobtrusively at home.

 The elderly with incontinence may seek isolation, thereby predisposing themselves to loneliness.

 15 to 30% of community-based elderly and almost 50% of elderly living in nursing homes suffer
from difficulties with bladder control. Older persons may be more sensitive to alcohol and caffeine
since these substances inhibit the production of antidiuretic hormone (ADH). An assessment of
sensitivity to bladder problems is essential when planning nursing care.

- As one ages, the total number of functioning glomeruli decreases until function has been reduced
by nearly 50%. This decrease in the filtration efficiency of the kidneys has grave implications for
persons who are taking medication. Of particular importance are penicillin, tetracycline, and
digoxin, which are primarily cleared from the blood stream by the kidneys. These drugs remain
active longer in an older person’s system. Therefore, they may be more potent, indicating a need
to adjust the dosage frequency of administration.

 Alzheimer’s disease is the most common irreversible dementia of old age. It is characterized by
deficits in attention, learning, memory, and language skills. Discuss the problems family members
have in dealing with Alzheimer’s clients in relation to the following disease manifestations:
- Depression
- Night wandering
- Aggressive or passiveness
- Failure to recognize family members

 Strokes from cerebral thrombosis are more common in older persons than are strokes from
cerebral hemorrhage. Clots tend to develop when patient is awake or just arousing.

 Normal loss of brain cells is compounded by alcohol, smoking, and breathing polluted air. In
relation to such losses, the nurse should teach to shop at uncrowded times in stores that are
familiar to them, slow down well in advance of traffic signals, stay in the slower lane of the
freeway, avoid freeways during rush hours, and leave for appointments well ahead of time.

 The most common endocrine disorders in the older adult are thyroid dysfunctions and diabetes.

 Impaired mobility, impaired skin integrity, decreased peripheral circulation, and a lack of physical
activity place the elderly at risk for developing decubitus ulders.

 Ways to help prevent/decrease the occurrence of falls:

- Adequate lighting
- Pain the edges of stairs a bright color
- Place a bell on the elderly person’s cat (since cats move quickly and get underfoot)
- Wear proper footwear that supports the foot and contributes to balance (made of non-slippery

 Peripheral circulation decreases as one ages. Regular assessment of the feet is very important
because it increases the opportunity to discover and treat skin care problems early. These
problems could become more serious because of decreased circulation.
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 Older persons have a dry, wrinkled skin because they lose subcutaneous fat and the second layer
of skin, the dermis, becomes less elastic.

 Diminished eyesight results in:

- A loss of independence (ADL and driving)
- A lack of stimulation
- The inability to read
- A fear of blindness

 Lower the tone of your voice when talking to an older person who is hearing-impaired. High-
pitched tones (i.e., women’s voices) are the first hearing to go, therefore, lowering the pitch of your
voice increases the likelihood that an older person with a hearing loss will be able to hear you

 Presbycusis (age-related hearing loss) can result in decreased socialization, avoidance of friends
and family, decreased sensory stimulation, and hazardous conditions when driving.

 Use frequent touch to decrease the sense of isolation and to compensate for visual and sensory

 Older persons undergo a great many changes, which are usually associated with LOSS (loss of
spouse, friends, career, home, health, etc.). therefore, older persons are extremely vulnerable to
emotional and mental stress.

 INTEGRITY VS. DESPAIR is Erikson’s final stage of growth and development. Reminiscing is a
means of setting one’s life in order (accepting life and self), which is the task of this stage of
Erikson’s development theory. The goal of this stage is to feel a sense of meaning in one’s life,
rather than to feel despair or bitterness that life was wasted. The major task of old age is to
redefine self in relation to a changed role. Those persons who had been in charge of situations
most of their lives may now fund themselves in dependent positions. The role adjustment is a
major task of old age.

 Think about the following situations and discuss the nursing care for each.
- A nursing supervisor who has had a stroke and is sent to a long term facility for rehabilitation.
- An oil company executive retires after 42 years with the company to travel in his recreational
vehicle wit his wife and dog.
- Shortly after their 53rd wedding anniversary, a woman who has never worked outside the home
loses her husband to brain cancer.

 There are many conditions that can imitate dementia in the older adult. A key role for the nurse is
to complete assessment to rule out other possible causes.

Important HESI/NCLEX Terms/Glossary:

abruptio placentae
Premature separation of a normally positioned placenta in a pregnancy of at least 20 weeks' gestation either
before labor or during labor but before delivery. This serious complication of pregnancy, occurring in one of
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every 200 births and often resulting in hemorrhage, may lead to the death of the mother, the fetus, or both.
Also called ablatio placentae, accidental hemorrhage.

1. Behavior toward another that is offensive, harmful, or injurious. 2. Misuse or particularly excessive use of
a substance, service, or equipment; commonly refers to improper use of a drug or similar substance.

1. The act or process of adapting to changes in the physiologic or psychological environment to maintain
homeostasis. 2. In ophthalmology: adjustment of the lens of the eye for various distances. 3. In sociology:
the use of compromise, arbitration, or negotiation to resolve conflicts between persons or groups that arise
from differences in customs or cultural norms. Also called adjustment.

acquired immunodeficiency syndrome (AIDS)

A disorder of the immune system characterized by an inability to mount a successful defense against
infection such as by organisms that usually aren't pathogenic (opportunistic infections). The syndrome is
caused by infection with the human immunodeficiency virus, which causes a marked depletion in the
number of helper T cells. AIDS is currently incurable and fatal. However, recently developed drug treatments
and regimens seem to be effective in prolonging the lives of clients with AIDS.

active immunity
Acquired immunity caused by the production of antibodies, either after infection or as a result of vaccination.

acute lymphocytic leukemia (ALL)

A form of leukemia, most commonly occurring in children, marked by large numbers of immature leukocytes
in the blood and blood-forming tissues (including the bone marrow, spleen, liver, and lymph nodes). The
disease has a sudden onset and rapid clinical course. Signs and symptoms include fever, pallor, fatigue,
loss of appetite, anemia, bleeding, bone pain, spleen enlargement and, because the immune function is
disturbed, frequent infection. Also called acute lymphoblastic leukemia.

acute nephritis
Acute inflammation of the kidney, possibly involving the glomerulus, tubules, and interstitial tissues.

Addison's disease
A life-threatening condition characterized by fatigue, hypotension, loss of appetite and weight, nausea or
vomiting, and increased hyperpigmentation of the skin and mucous membranes. It results from partial or
complete loss of glucocorticoid, mineralocorticoid, and androgenic function of the adrenal glands caused by
tuberculosis, an autoimmune process, or other disease. Also called Addisonism, Addison's syndrome,
chronic adrenocortical insufficiency.

Addisonian crisis
An emergency situation occurring with adrenal hypofunction and exposure to trauma, surgery, or other
severe physiologic stress that exhausts the body's stores of glucocorticoids.

1. Activated or transmitted by epinephrine, norepinephrine, or a similar substance. 2. Also called a
sympathomimetic, a drug that stimulates alpha or beta receptors (thus mimicking the effects of epinephrine
or norepinephrine) or acts primarily on receptors in the sympathetic nervous system that are stimulated by
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advance directive
Documented written or verbal instructions by the client about his wishes for life-sustaining medical care in
the event he becomes incapacitated (for example, living wills, durable powers of attorney for health care, or
any document that states the client's wishes).

1. In anatomy: any muscle in a state of contraction whose action is opposed by another muscle with which
it’s paired (called the antagonist). 2. In pharmacology: a drug that has an affinity for and stimulates
physiologic activity at cell receptors.

An intense, irrational fear of being in open spaces or of venturing out from the home or other familiar setting.
The anxiety may be generalized to any setting beyond the home or may be specific for certain types of
situations and environments, such as open spaces or crowded places.

1. Loss of the ability to move voluntarily. 2. The rest period after systole in the normal heart rhythm. 3. In
psychiatry: a neurotic condition characterized by symptoms of paralysis.

Allen's test
A test designed to evaluate a client's collateral circulation in the arm before an invasive arterial procedure
such as arterial blood gas analysis. While the client's radial and ulnar arteries are occluded, he clenches his
fist, causing the hand to blanch. The client then unclenches his fist while the pressure on the ulnar artery is
released (but the radial artery remains occluded). The hand should become pink, indicating a patent ulnar

Decreased visual acuity in one eye in the absence of detectable structural or pathologic changes.

The absence or cessation of menstruation. Except in preadolescents and in pregnant and postmenopausal
women, amenorrhea may reflect dysfunction of the hypothalamus, pituitary gland, ovary, or uterus;
congenital absence or surgical removal of both ovaries or the uterus; or an adverse effect of medication.

Withdrawal of a sample of amniotic fluid by transabdominal puncture and needle aspiration, usually
performed during the fifth month of pregnancy to detect such genetic disorders as Down syndrome, neural
tube defects, and Tay-Sachs disease; if the clinician suspects sex-linked genetic defects, the procedure may
be done to determine fetal gender.

Artificial rupture of the membranes.

1. Having the ability to relieve pain. 2. A medication that relieves pain.

A systemic reaction to a previously encountered antigen.
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A surgical procedure in which two blood vessels, ducts, or other tubelike structures are joined to allow the
flow of substances between them. Types of anastomoses are end-to-end and side-to-side.

angina pectoris
Severe chest pain characterized by sensations of spasm, constriction, and crushing weight, classically
radiating from the area over the heart to the left shoulder and arm and possibly accompanied by a feeling of
choking or suffocation. Angina usually results from myocardial oxygen deprivation secondary to
atherosclerosis of the coronary arteries.

Loss of appetite.

anorexia nervosa
An eating disorder, most common among adolescent girls, that is characterized by an aversion to eating, a
morbid fear of becoming obese despite significant weight loss, a disturbed body image that results in a
feeling of being fat even when extremely thin, and amenorrhea (in females).

1. In pharmacology: a drug that nullifies the action of another drug. 2. In anatomy: a muscle whose effects
counteract the effects of another muscle. 3. In dentistry, a tooth that meets another in the opposite jaw
during chewing or clenching of the teeth.

Direction referring from front to back and side to side.

1. Of or relating to blockade of the impulses of parasympathetic or other cholinergic nerve fibers. 2. Any
agent with anticholinergic properties.

anticipatory guidance
Information about a disorder or about the normal growth and development expectations of a specific age-
group given at an appropriate time before an event in order to provide the client with support and strategies
for dealing with potential problems before they occur.

antiembolism stockings
Elasticized stockings prescribed for some postoperative or bedridden clients to enhance venous blood flow
from the lower extremities and thus prevent thromboembolism resulting from pooling of blood in the veins
and dilation of veins.

antisocial personality disorder

A disorder that manifests after age 15 as a pervasive disregard for and violation of the rights of others.

Absence of urine production.

aortic stenosis
An abnormal narrowing of the orifice of the aortic valve, which prevents normal flow of blood from the left
ventricle into the aorta. The constriction may result from a congenital malformation or pathologic fusion of
the valve cusps. Aortic stenosis causes decreased cardiac output and pulmonary vascular congestion.
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Apgar score
A numerical evaluation of a neonate's condition in which a rating of 0, 1, or 2 is assigned to each of five
criteria: heart rate, respiratory effort, muscle tone, reflex responses, and skin color. The five scores are then
combined: A score of 7 to 10 is considered normal, 4 to 7 indicates moderate distress, and 3 or less
indicates acute distress. The Apgar score is usually obtained at 1 minute and 5 minutes after birth.

Loss or impairment of the ability to communicate through speech, written language, or signs, resulting from
brain disease or trauma.

aphthous stomatitis
A recurring disease of unknown cause marked by the eruption of ulcers on the mucous membranes of the
mouth. Also called canker sore.

Inflammation of the vermiform appendix. When acute, appendicitis commonly necessitates an
appendectomy to prevent perforation of the appendix and subsequent peritonitis.

Complete or partial inability to perform purposeful movements in the absence of sensory or motor

The absence of living, disease-producing organisms. Medical asepsis refers to the removal or destruction of
disease organisms or infected material. Surgical asepsis refers to protection against infection before, during,
or after surgery by means of sterile technique.

A respiratory disorder characterized by recurrent attacks of paroxysmal dyspnea, bronchospasm, wheezing
on expiration, and coughing. Conditions that may trigger an asthma attack include inhalation of allergens or
pollutants, vigorous exercise, emotional stress, and infection.

Impairment of the ability to coordinate voluntary muscle movement.

atopic dermatitis
A skin inflammation occurring in individuals with a genetic predisposition to allergies, characterized by
intense itching, maculopapular lesions, and excoriation (rash pattern varies with age but usually occurs on
the face).

Evaluation of hearing using an audiometer. Various audiometric tests identify the lowest intensity of sound at
which a client can perceive an auditory stimulus, hear different frequencies, and differentiate speech
sounds. Pure tone audiometry evaluates the ability to hear frequencies, usually ranging from 125 to 8,000
Hz, and can determine whether a hearing loss results from a problem in the middle ear, inner ear, or
auditory nerve.

auditory hallucinations
Perceptual experiences occurring in the absence of actual external sensory stimuli (for example, hearing
voices telling one to do something).
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auscultatory gap
Absence of Korotkoff sounds between phases I (onset of faint, clear tapping sound that gradually intensifies)
and II (onset of swishing-like sound) while obtaining a blood pressure reading.

Austin Flint murmur

A mid-diastolic aortic regurgitation murmur usually heard best using the bell of the stethoscope over the
mitral area. It’s a low-pitched, rumbling murmur.

The surgical transfer of tissue (commonly skin) from one location of the body to another location in the same

autoimmune disorder
A disorder resulting from an inappropriate immune response that is directed against the self. Antigens
normally found in the internal cells stimulate the development of antibodies; these antibodies can’t
distinguish antigens of the internal cells from external antigens and act against the internal cells to cause
various reactions.

A condition in which the immune system mounts an attack against the individual's own body tissues. One
theory proposes that autoimmunity reflects an inability of the immune system to distinguish between
autoantigens and foreign substances, caused by some change in the cellular components of the immune
system. Autoimmunity may lead to hypersensitivity and autoimmune disease.

autonomic dysreflexia
Reaction that may occur in clients with spinal cord injury above T6. Dysreflexia results in profuse
diaphoresis, pounding headache, blurred vision, and dramatically elevated blood pressure. This life-
threatening reaction may occur even from seemingly minor stimuli, such as lying on a wrinkled sheet or
having a full bladder.

autosomal recessive disorder

Genetic disorder involving two expressed abnormal autosomal genes (not expressed in the parents) in
which the individual affected receives one copy of the altered gene from each parent; thus the individual is
homozygous for that trait.

bacterial meningitis
Inflammation of the meninges of the brain and spinal cord caused by bacteria such as Neisseria
meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli.

Battle's sign
Discoloration of the skin behind the ear after the fracture of a bone in the lower skull.

bipolar disorder
A mood disorder characterized by major depression and full manic episodes.

body surface area

Means for calculating the amount of drug to be given to a client (typically a child) using a nomogram or for
estimating the extent of a burn
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borderline personality disorder

A disorder characterized by unstable relationships, potentially self-damaging impulsiveness, difficulty in
controlling anger, recurrent suicidal threats, and chronic feelings of boredom and emptiness.

Irregularity in heart rate or rhythm characterized by slowness.

A slow but steady heartbeat at a rate of less than 60 beats per minute. Bradycardia is normal during sleep
and in well-conditioned athletes. In other circumstances, it may indicate an abnormal condition, such as
brain tumor or digitalis toxicity.

Braxton Hicks contraction

Light, painless, irregular uterine tightening during pregnancy, arising during the first trimester and increasing
in frequency, duration, and intensity by the third trimester. Also called false labor. Strong Braxton Hicks
contractions occurring near term may be mistaken for true labor.

breast engorgement
Distention of the milk ducts and surrounding tissue as breast milk is formed, causing the breasts to become
fuller, larger, and firmer.

A lung inflammation that usually begins in the terminal bronchioles, occurring mainly in infants and
debilitated persons. Also called bronchopneumonia. Commonly, bronchiolitis results from upper respiratory
infection, specific infectious fevers, and other debilitating diseases.

Visual examination of the tracheobronchial tree using a bronchoscope.

Broviac catheter
Single-lumen silicone central venous catheter used for long-term venous access.

Brudzinski's sign
Flexion of the hips and knees in response to passive flexion of the neck; signals meningeal irritation.

An abnormal vascular "swishing" sound heard on auscultation as a result of turbulent blood flow through
dilated, irregular, torturous, or stenotic vessels.

Of or relating to the inside of the cheek; may also refer to a tooth surface or the gum next to the cheek.

An eating disorder characterized by episodes of binge eating that may end in self-induced vomiting,
alternating with periods of normal eating or fasting. Depression and awareness of the abnormal behavior are
part of this illness.
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cardiac catheterization
A diagnostic procedure in which a cardiac catheter is inserted into a large vein (usually of an arm or leg) and
then threaded through the vein to the client's heart.

cardiac output
The volume of blood ejected by the heart per minute (normally ranging from 4 to 8 L). Cardiac output equals
the stroke volume (the difference between end-diastolic volume and end-systolic volume) multiplied by the
heart rate.

cardiogenic shock
A condition of low cardiac output that results from heart pump failure, such as in acute myocardial infarction,
heart failure, or severe cardiomyopathy.

Primary noninflammatory disease of the myocardium.

A stuporous or unresponsive state commonly characterized by an inability to move or talk.

Any of a group of compounds having a sympathomimetic action and composed of a catechol molecule and
the aliphatic portion of an amine. Some catecholamines are produced by the body and function as key
neurologic chemicals. Others are synthesized as drugs for use in the treatment of such disorders as
asthma, shock, and heart failure.

cauda equina
The aggregation of spinal roots, resembling the tail of a horse, that descend from the first lumbar vertebrae
and occupy the vertebral canal below the cord.

celiac disease
A chronic disease in which an individual can’t tolerate foods containing gluten or wheat protein. Signs and
symptoms include abdominal distention, vomiting, diarrhea, muscle wasting, and extreme lethargy.

An infection of deep subcutaneous tissue and sometimes muscle that may be associated with infection of an
operative or traumatic wound. Cellulitis is characterized by local heat, pain, redness, and swelling.

cerebral aneurysm
A saclike dilation of the wall of a cerebral artery, typically resulting from weakness of the wall. A cerebral, or
berry, aneurysm usually occurs in the circle of Willis and is prone to rupture.

cerebral contusion
A bruising of the brain tissue as a result of a severe blow to the head. A contusion disrupts normal nerve
function in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.

cerebral palsy
A permanent disorder of motor function resulting from nonprogressive brain damage or a brain lesion.
Cerebral palsy usually appears before age 3.
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chelation therapy
Administration of agents that bind to metals; administered to aid in the removal of excess metals, such as
lead or iron in the body.

Treatment of a disease using chemicals that exert a toxic effect on the pathogen or abnormal cell growth.

chest physiotherapy
An array of physical techniques, including postural drainage, chest percussion and vibration, and coughing
and deep-breathing maneuvers. Chest physiotherapy is used to loosen and help eliminate lung secretions,
reexpand lung tissue, and promote optimal use of respiratory muscles.

The presence or formation of gallstones in the gallbladder.

1. Of or relating to nerve fibers that are stimulated to free acetylcholine at a synapse. 2. An agent that frees

chronic bronchitis
A persistent respiratory disease marked by increased production of mucus by the glands of the trachea and
bronchi. This common disease is characterized by a cough (with expectoration) at least 3 months of the year
for more than 2 consecutive years.

Chvostek's sign
A spasm of the facial muscles elicited by light taps on the facial nerve. This spasm signals tetany and is
seen in clients with hypocalcemia.

Involving the removal of the foreskin of the penis.

Area encircling or concerning the periphery of an object or body part.

A chronic, degenerative liver disease in which the lobes are covered with fibrous tissue, the liver
parenchyma degenerates, and the lobules are infiltrated with fat.

Communication technique used to help the client identify inconsistencies in his statements.

clinical depression
Syndrome characterized by persistent sadness and dysphoria accompanied by disturbances in sleep and
appetite, lethargy, and an inability to experience pleasure.

A congenital foot deformity in which the foot is twisted out of shape or position.
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cognitive development
Ability to learn from experience, gain and maintain knowledge, respond to new situations, and solve

Examination of the colon using a flexible endoscope to visualize internal body areas or to remove tissue
samples or small growths.

communicable disease
A disease that may be transmitted directly or indirectly from one person to another.

compartment syndrome
A neurovascular complication commonly associated with fractures of the limb; constricting or occlusive
dressings, sutures, or casts; poor positioning; and any injury causing ischemia, swelling, or bleeding into the
tissues that ultimately can lead to permanent dysfunction and deformity. It’s characterized by increasing limb
pain unrelieved by analgesics, pallid or dusky skin color changes, absent pulse or edema distal to the injury
site, decreased active and passive muscle movement distal to the injury site, pain with passive muscle
stretching, and sensory changes.

1. Adherence to a therapeutic regimen. 2. A tissue's or organ's ability to yield to pressure without disruption,
commonly used to describe the distensibility of an air- or fluid-filled organ.

A ritualistic, repetitive, and involuntary defensive behavior.

A violent shock or jarring, such as from an explosion or a blow. Concussion of the brain is characterized by
loss of consciousness. Severe concussion may also cause impairment of brain stem functions.

congenital hip dislocation

Improper formation and function of the hip socket, commonly involving subluxation (where the femoral head
is high in the acetabulum) or dislocation (where the femoral head is above the acetabulum).

Solidification of the lungs that occurs with pneumonia.

Abnormal flexion and fixation of a joint, possibly permanent, which is typically caused by muscle wasting
and atrophy or by loss of normal skin elasticity such as from extensive scar tissue.

controlled substance
Any substance that is strictly regulated or outlawed because of its potential for abuse or addiction.

conversion disorder
A disorder in which the client attempts to resolve a psychological conflict through the loss of a specific
physical function -- for example, by paralysis, blindness, or inability to swallow.
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Corrigan's pulse
Short, forceful, bounding pulse typically associated with aortic insufficiency.

The experience of physical symptoms associated with pregnancy, such as nausea, vomiting, and backache,
by the husband of a pregnant woman; the response often results from stress, anxiety, and empathy for the
pregnant woman.

Short, explosive or popping sounds usually heard during inspiration. They may be coarse (loud and low in
pitch) or fine (less intense and high in pitch) and resemble the sounds heard when rolling hair between the
fingers near the ear.

Crohn's disease
A chronic inflammatory bowel disease of unknown cause, usually involving the terminal ileum, with scarring
and thickening of the bowel wall. Signs and symptoms include frequent episodes of diarrhea, severe
abdominal pain, nausea, fever, chills, anorexia, and weight loss.

An acute viral infection of the respiratory tract that causes acute upper airway obstruction. Characterized by
stridor, a barking cough, and hoarseness, it primarily affects infants and young children ages 3 months to 3
years and follows an upper respiratory tract infection.

Appearance of the presenting part of the fetus at the perineum and seen when the vulva are separated.

crystalloid fluid
Clear solutions (usually in reference to I.V. solutions) containing electrolytes and water.

Cushing's syndrome
A metabolic disorder caused by chronic, excessive production of adrenocortical hormones or by prolonged
high-dose glucocorticoid therapy. It’s characterized by such signs and symptoms as hypertension, diabetes
mellitus, dusky complexion with purple striae, muscle wasting, weakness, and sudden development of fat
around the face, neck, and trunk.

Bluish discoloration of the skin and mucous membranes resulting from an excessive amount of
deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule such as in

Referring to the bluish or bluish black discoloration of the skin and mucous membranes that results from
excessive concentration of unoxygenated hemoglobin in the blood.

cystic fibrosis
An inherited disorder of the exocrine glands that affects multiple organ systems, causing such conditions as
chronic pulmonary disease, pancreatic deficiency, sweat gland dysfunction, malabsorption, and liver
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Direct visualization of the urinary tract by inserting a cystoscope in the urethra.

Removal of dead or damaged tissue or foreign material from a wound to prevent the growth of
microorganisms and further damage and to promote healing.

A drop in baseline fetal heart rate as indicated by the fetal monitor. Early deceleration is a drop in fetal heart
rate that coincides with uterine contraction. Variable deceleration is a drop in fetal heart rate that doesn't
occur at a consistent point during contractions. Prolonged deceleration is a drop in fetal heart rate that
occurs for an extended period of time.

deep vein thrombosis

A condition involving the development of a blood clot in the deep veins of the pelvis, groin, or legs that
disrupts venous blood flow and leads to swelling and edema.

The partial or complete separation of a wound's edges.

Having insufficient water in the body or tissues.

False ideas or beliefs accepted as real by the client.

delusions of grandeur
Distorted or false idea or belief that one has exceptional powers, wealth, skill, influence, or destiny.

Denver Developmental Screening Test

An assessment tool used to evaluate the development of a child in four categories: personal social, fine
motor-adaptive, language, and gross motor skills.

dependent personality disorder

A disorder that begins in early adulthood and is characterized by an excessive need to be taken care of that
leads to submissive and clinging behavior and fear of separation.

Neutralization of electrical polarity; reversal of the resting potential in excitable cell membranes when
stimulated. An example is the reduction of the ion differential of sodium and potassium across the nerve
cells at the neuromuscular junction.

diabetes insipidus
A metabolic disorder marked by extreme polyuria and polydipsia and resulting from deficient secretion or
production of antidiuretic hormone (ADH) or inability of the renal tubules to respond to ADH. (Rarely,
excessive water intake causes signs and symptoms.) The condition may be acquired (secondary to disease
or drug therapy), inherited, idiopathic, or nephrogenic.
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diabetes mellitus
A chronic disorder of carbohydrate metabolism characterized by hyperglycemia and glycosuria resulting
from inadequate production or utilization of insulin.

diabetic ketoacidosis
An acute, life-threatening form of metabolic acidosis that may arise as a complication of uncontrolled
diabetes mellitus. Accumulation of ketone bodies leads to urinary loss of water, potassium, ammonium, and
sodium, resulting in hypovolemia, electrolyte imbalances, an extremely high blood glucose level and,
commonly, coma. Signs and symptoms include flushed, hot, dry skin; confusion; nausea; diaphoresis;
restlessness; and fruity breath odor.

Displacement of any body part, primarily a bone from its normal position in a joint.

disseminated intravascular coagulation (DIC)

A life-threatening disorder of excessive clot formation caused by overstimulation of the body's clotting and
anticlotting processes in response to disease or injury. Such overstimulation is followed by a deficiency in
clotting factors with hypocoagulability and hemorrhaging.

1. Tending to increase the formation and excretion of urine. 2. An agent that promotes the formation and
excretion of urine.

Inflammation of one or more diverticula, or saclike herniations, in the muscular layer of the colon.

The presence of saclike herniations through the muscular layer of the colon without accompanying
inflammation. Most clients with this condition have few signs or symptoms except for occasional rectal

drip factor
An indication of the number of drops needed to obtain one milliliter of solution delivered by a manufacturer's
I.V. tubing based on the drop size.

dumping syndrome
A condition of nausea, weakness, profuse sweating, and dizziness occurring in clients who have had a
subtotal gastrectomy. Signs and symptoms arise soon after eating when the contents of the stomach empty
too rapidly into the duodenum. Also called postgastrectomy syndrome. Eating small, frequent, high-
protein, high-calorie meals may help prevent discomfort and ensure adequate nutrition.

Difficulty swallowing, commonly resulting from obstructive or motor disorders of the esophagus. Obstructive
disorders, such as an esophageal tumor or lower esophageal ring, interfere with the ability to swallow solids;
motor disturbances such as achalasia impair swallowing of solids and liquids.

Shortness of breath, difficulty breathing, or labored breathing resulting from certain heart conditions, anxiety,
or strenuous exercise.
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dystonic reaction
Severe tonic contractions of the muscles in the neck, mouth, and tongue; dystonic reaction is a common
adverse reaction to antipsychotic drugs.

Painful or difficult urination, which is usually caused by a bacterial infection or an obstruction in the urinary

Parrotlike and inappropriate repetition of another's words.

ectopic pregnancy
Implantation of the fertilized ovum outside the uterine cavity. Types of ectopic pregnancy are abdominal
pregnancy, interstitial pregnancy, and tubal pregnancy.

Shortening of the vaginal portion of the cervix and thinning of its walls during labor due to stretching and
dilation caused by the fetus. Full effacement obliterates the constrictive neck of the uterus. The extent of
effacement is expressed as a percentage of full effacement.

elbow restraints
Type of restrictive device attached to the client's body at the elbow to restrict movement or access to
another body part; may be applied after cleft palate repair to reduce the risk of injury to the suture line.

electrocardiogram interpretation
Analysis of the waveforms seen on an electrocardiogram

electroconvulsive therapy (ECT)

The induction of a brief seizure and loss of consciousness by applying a low-voltage alternating current to
the brain through scalp electrodes. ECT is used in the treatment of affective disorders (primarily acute
depression), especially in clients resistant to psychoactive drugs. On awakening, the client has no memory
of the shock.

electromyogram (EMG)
A record of the electrical activity of skeletal muscles, obtained by surface electrodes or needle electrodes
and devices that amplify, transmit, and record the signals. The technique is helpful in diagnosing
neuromuscular disorders, pinpointing motor nerve lesions, and measuring electrical potentials induced by
voluntary muscle contraction.

Diagnostic test that records the electrical activity of selected skeletal muscle groups at rest and during
voluntary contraction. It involves percutaneous insertion of a needle electrode into a muscle with
measurement of the muscle's electrical discharge through an oscilloscope.

An abnormal condition of the endocardium and heart valves marked by vegetations on the valves and
endocardium. It may occur as a primary disorder or arise in association with another disease.

endotracheal intubation
Passage of a wide-bore tube through the mouth or nose into the trachea. It may be used to maintain a
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patent airway, administer anesthesia, aspirate secretions, prevent aspiration of foreign material into the
tracheobronchial tree of an unconscious or paralyzed person, or administer positive pressure ventilation that
can’t be given effectively by a mask.

Referring to administration by mouth, rectum, or directly into the intestinal system.

enteral feedings
Delivery of nutrients directly into the GI tract through a feeding tube.

enteric precautions
A category-specific type of infection precautions established by the Centers for Disease Control and
Prevention involving infections transmitted by intestinal secretions. These have since been replaced with
standard precautions and transmission-based precautions.

Involuntary passage or release of urine after the age when bladder control would have been normally

The lidlike, cartilaginous structure that overhangs the larynx and prevents food from entering the larynx and
trachea during swallowing.

Inflammation of the epiglottis. Acute epiglottitis, a severe form of the condition that primarily affects children,
causes stridor, fever, sore throat, croupy cough, and a reddened, swollen epiglottis.

A group of neurologic disorders marked by uncontrolled electrical discharge from the cerebral cortex and
typically manifested by seizures with clouding of consciousness. Epilepsy is most commonly of unknown
cause (idiopathic) but is sometimes associated with head trauma, intracranial infection, brain tumor,
vascular disturbances, intoxication, or chemical imbalance.

Surgical incision into the perineum to enlarge the vaginal opening for delivery. It’s performed to prevent
traumatic tearing of the perineum, to hasten or promote delivery, or to prevent stretching of perineal muscles
and connective tissue.

Psychosocial development theorist who described eight developmental stages across the life span, each of
which is characterized by a conflict between two opposing forces.

erythroblastosis fetalis
Hemolytic anemia of the neonate caused by placental transmission of maternally formed antibodies against
the incompatible antigens of fetal blood. It results from maternal-fetal blood group incompatibility, specifically
involving the rhesus (Rh) factor and the ABO blood groups, and is characterized by accelerated destruction
of red blood cells and resulting jaundice. In Rh factor incompatibility, the hemolytic reaction appears only
when the mother is Rh-negative and the infant is Rh-positive. Isoimmunization rarely occurs with the first
pregnancy, but the risk increases with each succeeding pregnancy.
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A thick scab or dry crust that appears after a thermal or chemical burn.

esophageal atresia
A congenital anomaly involving closure of the esophagus at some point, often ending in a blind pouch.

The change of a liquid to a vapor at a temperature below the boiling point of the liquid. Evaporation occurs
at the surface of the liquid, hastened by an increase in temperature and a decrease in atmospheric

1. Pushing out or removal of the viscera, especially through a surgical incision. 2. In ophthalmology:
excision of the contents of the eyeball (except the sclera).

An increase in the seriousness of a disease or disorder or in its signs and symptoms.

1. Describing the tissues and structures of the brain located outside the pyramidal tract and not running
through the medullary pyramid -- excluding the motor neurons, motor cortex, and corticospinal and
corticobulbar tracts. 2. Of or relating to the function of these tissues and structures.

Escape, usually of blood, lymph, or I.V. solution, from a vessel into surrounding tissues.

failure to thrive
Condition in which an infant's height and weight fall below the third percentile on a standard growth chart;
also called reactive attachment disorder.

fantasy play
Type of play involving imaginary playmates typically associated with preschoolers.

febrile seizure
Typically, a tonic-clonic seizure of relatively short duration (usually less than 1 minute) occurring with an
acute illness and fever.

fifth disease
A contagious, relatively benign disease caused by the Parvovirus B19; most commonly occurs in children
ages 2 to 12 and is characterized by a red rash on the cheeks. Also called erythema infectiosum.

A soft spot, such as the spaces covered by tough membranes remaining between the bones of an infant's

Pregnancy that has continued for a period of 38 to 42 weeks.
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The base of an organ; the portion of a hollow organ farthest from its mouth, such as the fundus of the

Inflammation of the stomach and stomach lining.

Inflammation of the lining of the stomach and intestines that accompanies numerous GI disorders;
characterized by anorexia, weakness, abdominal pain, nausea, and diarrhea.

Opening created into the stomach.

gestational diabetes
The development of diabetes during pregnancy, usually during the second trimester.

gestational trophoblastic disease

Failure of an embryo to develop beyond a primitive state due to proliferation and degeneration of the
trophoblastic villi becoming filled with fluid and appearing as grape-sized vesicles Also called a
hydatidiform mole, molar pregnancy.

A group of eye diseases characterized by abnormally elevated pressure within the eye due to obstruction of
the outflow of aqueous humor.

glomerular filtration rate

Rate at which the glomeruli in the kidneys filter blood (normally, 125 ml/minute).

Inflammation of the glomeruli in the kidneys.

A group of disorders associated with inborn errors of metabolism that affect purine and pyrimidine use;
results in increased production of uric acid or interferes with its excretion. Manifested by hyperuricemia,
recurrent acute inflammatory arthritis, deposition of urate crystals in the joints of the extremities, and uric
acid urolithiasis.

Graham Steell's murmur

A pulmonary regurgitation murmur resulting from pulmonary hypertension; usually loud with a blowing
quality and variable in duration, it’s heard best along the left sternal border over the third and fourth
intercostal spaces.

granulation tissue
Tissue that develops during collagen production; capillaries form as budlike structures from nearby vessels,
penetrating the wound, growing into loops, and providing a nutritional source for the newly generated tissue;
the loops give the tissue a "granular" appearance.
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Graves' disease
A disorder of the thyroid gland characterized by pronounced thyrotoxicosis usually associated with an
enlarged thyroid gland, exophthalmos, or pretibial myxedema.

A pregnant woman.

Enlargement and development of the mammary glands in men, usually temporary and benign.

Sensory perceptions that don't result from external stimuli and that occur during wakefulness.

health care power of attorney

A legal document in which an individual designates another person, called an "attorney-in-fact," to act on the
individual's behalf if the principal person becomes disabled or incapacitated. The document becomes void
when the principal person dies or recovers.

heart failure
Inability of the heart to pump an adequate amount of blood to the tissues.

Bleeding into a joint cavity.

The presence of blood in the urine.

Surgical removal of one-half of the colon.

Paralysis on one side of the body or a part of it that indicates an injury to the motor area of the brain.

Paralysis of one side of the body.

Written recording of the blood count differential.

hemolytic reaction
Type of blood transfusion reaction occurring when the donor's blood is incompatible with the recipient's
blood; the most serious type of transfusion reaction.

A bleeding disorder characterized by a failure of the blood clotting mechanism. It’s an inherited condition
occurring almost exclusively in males.
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The coughing or spitting up of blood caused by hemorrhage in the lungs or bronchi. Minor amounts of blood
may appear in the sputum of individuals with bronchitis or upper respiratory tract infections.

hepatic encephalopathy
A serious complication of liver failure affecting a client's neurologic status; believed to result from the
accumulation of toxins, such as ammonia, in the blood.

hepatojugular reflux
Distention of the neck veins when manual pressure is applied over the right upper quadrant of the abdomen;
it suggests heart failure.

Enlargement of the liver.

Having two different genes at corresponding loci on homologous chromosomes.

hiatal hernia
Protrusion of part of the stomach through the esophageal opening in the diaphragm.

homonymous hemianopia
Blindness or visual deficit in one-half of the field of vision of both eyes. Either the right halves or the left
halves of each eye are affected.

State of severe despair associated with feelings of inadequacy and isolation, an inability to act on one's
behalf, and a belief that the situation is highly unlikely to improve.

A system of family-centered care using a multidisciplinary approach designed to assist the chronically ill
person to maintain a satisfactory lifestyle through the terminal phases of dying.

human immunodeficiency virus (HIV)

A retrovirus identified as the primary cause of acquired immunodeficiency syndrome (AIDS).

hydatidiform mole
A usually benign neoplasm that occurs at the end of a degenerating pregnancy and arises from enlarged
chorionic villi and the proliferation of trophoblastic tissue.

Presence of an excess volume of amniotic fluid during pregnancy.

Treatment involving the use of water, such as tub or shower baths and whirlpools.

hyperemesis gravidarum
Severe and prolonged vomiting during pregnancy to such a degree that weight loss and an imbalance of
fluids and electrolytes occur.
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Elevated serum level of phosphorus above 2.6 mEq/L or 4.5 mg/dl.

Excessive sleepiness.

A severe elevation in body temperature.

Disorder involving overproduction of thyroid hormone, leading to a metabolic imbalance.

1. A solution that has greater osmotic pressure compared to another solution; a fluid in which cells shrink. 2.
In reference to muscles or arteries, having a greater than normal degree of tension.

hypertrophic cardiomyopathy
Primary disease of the cardiac muscle characterized by disproportionate, asymmetrical thickening of the
interventricular septum, particularly in the anterior-superior region. Also called idiopathic hypertrophic
subaortic stenosis.

To increase the rate or depth of one's inspirations or expirations, or both; may occur with anxiety.

Preoccupation with the fear that one has a serious illness despite medical reassurance to the contrary; fear
interferes with psychosocial functioning.

Low serum glucose levels.

A congenital abnormality in males in which the urethral opening is on the underside, rather than at the tip, of
the penis; in females, the defect is manifested by a urethral opening into the vagina.

1. A solution that has a decreased osmotic pressure compared to another solution; a fluid in which cells
swell. 2. In reference to muscles or arteries, having a less than normal degree of tension.

A decreased level of oxygen in inspired air.

Introduced inadvertently by a medical practitioner or resulting from a diagnostic procedure or treatment.

A contagious, inflammatory skin infection that usually occurs on the face. Characterized by the appearance
of small, itchy blisters that rupture and form a crusty scab; usually caused by streptococcal or
staphylococcal bacteria or a combination of both types of organisms.
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incentive spirometer
A device that requires the client to deep breathe, hold the breath for approximately 3 seconds, and then
exhale in an effort to expand the lungs.

Unsuitability for combination, often due to antagonistic action.

Area of hardened tissue.

The invasion and multiplication of pathogenic organisms within the body.

informed consent
Permission obtained from a client to perform a specific test or procedure after the client has been fully
informed about the test or procedure.

intelligence quotient (IQ)

Measurement of a person's ability to comprehend relationships, think, problem solve, and adjust to new
situations; usually expressed as a score and based on standardized intelligence tests.

intermittent claudication
Pain that occurs with activity or exercise but that is relieved with rest. This pain results from the body's
inability to supply arterial blood (blood rich in nutrients) to the tissues that experience an increase in demand
during exercise or activity.

The deep analysis of the meaning and significance of what a client is saying and doing in an effort to gain
insight into his behavior.

Dermatitis that occurs at moist, warm sites where skin surfaces rub together, such as the armpits, the inner
surfaces of the thighs, and between the buttocks; caused by an overgrowth of normal flora.

intra-aortic balloon pump

A device consisting of a balloon attached to a catheter that is introduced into the descending thoracic aorta
through the femoral artery. Alternating inflation (during diastole) and deflation (during systole) of the balloon
alters resistance to aortic blood flow and both decrease the heart's workload and increase the supply of
blood to the coronary arteries.

intracranial pressure
Pressure exerted by the brain tissue, cerebrospinal fluid, and blood.

intradermal injection
Injection of any substance into the skin between the dermis and epidermis. The technique is typically used
to produce a local drug effect (such as in local anesthesia for procedures such as suturing wounds) or
during allergy testing. Also called intracutaneous injection.
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intraosseous infusion
Administration of fluid, blood, or drugs into the bone marrow cavity of a long bone; typically used in children
for emergency situations when I.V. access is difficult or unavailable.

Telescoping or invagination of a portion of the bowel into an adjacent portion; most commonly seen in

iron deficiency anemia

Anemia characterized by an insufficient amount of iron in the serum, decreased stores of iron in the bone
marrow, and elevated serum iron-binding.

Excitability or excessive responsiveness to a stimulus.

Of or relating to a solution that has the same osmotic pressure as another solution; a solution in which cells
neither swell nor shrink.

juvenile hypothyroidism
A condition involving a deficiency of thyroid hormone secretion in children.

Kawasaki disease
A febrile, multisystem disorder affecting the small to medium-size vessels, primarily of the lymph nodes,
most commonly in children before puberty; usually follows exposure to an infection. Also called
mucocutaneous lymph node syndrome.

Kegel exercises
Exercises involving alternate contraction and relaxation performed to strengthen the perineal muscles.

A neurologic syndrome resulting from deposition of unconjugated bilirubin in the brain cells and
characterized by severe neural symptoms.

Kernig's sign
Elicitation of resistance and hamstring muscle pain when the examiner attempts to extend the knee while
the hip and knee are both flexed 90 degrees.

Kussmaul's respirations
Abnormally deep, gasping type of respirations resulting from air hunger; associated with severe diabetic
acidosis and coma.

Surgical removal of the bony arches of one or more vertebrae; performed to relieve spinal cord compression
or to remove a displaced intervertebral disk.

lead poisoning
Poisoning caused by the ingestion or absorption of lead or one of its salts. Signs and symptoms include loss
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of appetite and weight, anemia, constipation, insomnia, headache, dizziness, irritability, a blue line at the
margin of the gums, and peripheral neuropathy.

A feeling or condition of sluggishness, apathy, or inactivity.

Any disturbance in fat metabolism.

living will
A witnessed document indicating a client's desire to be allowed to die a natural death rather than be kept
alive by heroic, life-sustaining measures. The will applies to decisions that will be made after a terminally ill
client is incompetent and has no reasonable possibility of recovery.

The vaginal discharge present during the first several weeks after delivery.

lochia alba
A creamy white, brown, or colorless discharge consisting mainly of serum and white blood cells; typically
stops flowing at about 6 weeks postpartum.

lochia rubra
Present during the first 3 to 4 postpartal days; it’s bloody and may contain mucus, tissue, debris, and small

lochia serosa
A pink or brownish discharge persisting for 5 to 7 days postpartum.

Logan bar
Apparatus used to protect the surgical incision after cleft lip repair.

Logan bow
A wire U-shaped apparatus taped to both cheeks of an infant or toddler following cleft lip repair to protect the
surgical site.

lumbar puncture
Fluid withdrawal from the subarachnoid space of the lumbar region of the spinal canal, usually between the
third and fourth lumbar vertebrae, for diagnostic or therapeutic purposes. Also called spinal tap.

A diagnostic radiographic evaluation of lymphatic system filling after injection of a contrast medium into a
lymphatic vessel of each foot or hand.

Edema of an arm or leg caused by the buildup of interstitial fluid as a result of lymphatic inflammation or
obstruction or a lymph node disorder.

A radiograph of the breast; used for diagnostic purposes.
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Radiography of the mammary gland to identify benign and malignant neoplastic processes.

The surgical resection of a breast; usually performed to remove a malignant tumor.

Inflammation of the mammary gland; usually caused by streptococcal or staphylococcal infection and
infrequent breast-feeding.

A dark, greenish black material that occurs in the intestines of a fetus that forms the first stools of a neonate.
The fluid is thick and sticky and is composed of intestinal gland secretions, some amniotic fluid, and
intrauterine debris.

megaloblastic anemia
A hematologic disorder that is characterized by the production and peripheral proliferation of megaloblasts.

Ménière's disease
A labyrinthine dysfunction that produces severe vertigo, sensorineural hearing loss, and tinnitus.

metabolic acidosis
A condition resulting from excessive accumulation of acid or depletion of bicarbonate.

metabolic alkalosis
A clinical state marked by decreased amounts of acid or increased amounts of base bicarbonate.

A therapeutic environment, typically used as part of inpatient psychiatric therapy.

mitral stenosis
Obstruction of blood flow from the left atrium to the left ventricle due to thickening and contracting of the
mitral valve leaflets; consequently, left atrial volume and pressure rise and the chamber dilates. Greater
resistance to blood flow causes pulmonary hypertension, right ventricular hypertrophy, and right-sided heart

muscular dystrophy
A group of degenerative genetic diseases characterized by weakness and the progressive atrophy of
skeletal muscles with no evidence of nervous system involvement.

Diffuse muscle pain or tenderness associated with many infectious diseases.

myasthenia gravis
An abnormal muscle weakness and fatigability, especially in the muscles of the face and throat, resulting
from a defect in the conduction of nerve impulses at the myoneural junction.
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mycoplasmal pneumonia
A contagious respiratory disease caused by Mycoplasma pneumoniae, characterized by a sore throat, dry
cough, fever, malaise, and myalgia.

Osteolytic neoplasm consisting of a protrusion of cells typical of the bone marrow.

The protrusion of a hernial sac containing a portion of the spinal cord, its meninges, and cerebrospinal fluid
through a congenital defect in the vertebral column.

A disorder that results from hypofunction of the thyroid. Signs and symptoms include enlarged tongue,
slowed speech, moon face, drowsiness, cold intolerance, hair loss, and anemia.

myxedema coma
A rare, serious form of hypothyroidism that usually results from lack of treatment or mistreatment, severe
stress (from infection, exposure to cold, or trauma), or the use of sedatives or anesthetics in a client being
treated for hypothyroidism.

A device that employs a baffle to produce a fine aerosol spray consisting of particles less than 30
micrometers in diameter.

necrotizing enterocolitis
GI disorder commonly associated with premature infants and characterized by diffuse or patchy intestinal
necrosis and sometimes accompanied by sepsis.

negative nitrogen balance

Increased rate of protein breakdown when compared to protein synthesis; nitrogen excretion that exceeds
nitrogen intake.

A form of abuse involving the failure to protect a person from injury or meet the person's physical, emotional,
or medical needs.

The surgical removal of a kidney, usually done to remove a tumor, drain an abscess, or treat

nephrotic syndrome
A clinical classification including all kidney diseases characterized by marked proteinuria, hypoalbuminemia,
and edema.

Any one of a group of substances that act on a target nerve cell to excite or inhibit transmission of nerve
impulses; substances include norepinephrine, acetylcholine, and dopamine.
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Involuntary, rapid movements of the eyeball that may be horizontal, rotatory, vertical, or mixed.

obsessive-compulsive disorder
A disorder characterized by obsessive thoughts and compulsive behaviors that represent recurring efforts to
control overwhelming anxiety, guilt, or unacceptable impulses that persistently enter the consciousness.

A diminished flow of urine in relation to fluid intake; usually less than 400 ml in 24 hours. Also called

ophthalmia neonatorum
Eye infection occurring at birth or in the first month; most commonly caused by gonorrhea or chlamydia.

Opium-derived or synthetically produced drugs that alter pain perception, induce mental changes, promote
deep sleep, depress respirations, constrict pupils, and decrease GI motility.

orthostatic hypotension
Abnormally low blood pressure that occurs when a person stands up. Also called postural hypotension.

The concentration or osmotic pressure of a solution; expressed in osmoles of solute per kilogram of solvent.

The osmotic pressure of a solution expressed in osmoles of solute per liter of solution.

Delayed or poor mineralization of bone; the adult equivalent of rickets. This condition is associated with
anorexia, fracture, pain, weakness, and weight loss.

Inflammation of bone that results from a local or general infection of bone and bone marrow. The bacterial
infection is caused by trauma or surgery, by direct extension from a nearby infection, or by introduction from
the bloodstream.

A disorder in which bone mass is reduced and fractures occur after minimal trauma. It occurs most
commonly in postmenopausal women, sedentary or immobilized individuals, and persons on long-term
steroid or heparin therapy.

A discharge from the ear, which may be serous, sanguineous, or purulent if the external or middle ear is

Harmful effect on the function of the eighth cranial nerve or hearing organs; most commonly associated with
prescribed drugs.
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Paget's disease
A common bone disease that usually affects middle-aged and elderly people. It’s marked by inflammation of
the bones, softening and thickening of the bones, excessive bone destruction, and unorganized bone repair;
the result is bowing of the long bones. The cause is unknown.

Repetition of words or phrases with increasing rapidity.

Acute or chronic inflammation of the pancreas.

An abnormal condition characterized by the loss or impairment of motor function or the impairment of
sensory function.

paralytic ileus
A decrease in or absence of bowel motility that may occur following abdominal surgery or may be caused by
numerous other conditions, most commonly by peritonitis.

paranoid schizophrenia
Disorder involving disordered thinking with delusional thought content characterized by preoccupation with
delusions or auditory hallucinations, lack of organized speech, disorganized or catatonic behavior, or flat or
inappropriate affect.

An abnormal condition characterized by the loss of sensation and motor function in the lower limbs, which
may result in either complete or incomplete paralysis.

Not in or through the digestive system, but rather by injection through some other route, such as
subcutaneously, I.V., I.M., or intradermally.

Abnormal or heightened touch sensations, such as burning, numbness, prickling, and tingling, that
commonly occur without external stimulus.

Awareness of objects and the ability to differentiate between them.

percutaneous transluminal coronary angioplasty (PTCA)

A technique to open stenosed atherosclerotic arteries. A balloon catheter is inserted through the skin and
into the vessel to the site of narrowing; the balloon is inflated, thus flattening the plaque against the arterial

Inflammation of the pericardium; may be caused by trauma, neoplasm, infection, uremia, myocardial
infarction, or collagen disease.
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1. The pelvic floor and its associated structures; located between the symphysis pubis and the coccyx and
on the sides by the ischial tuberosities. 2. The body area between the thighs; bounded by the anus and
scrotum in males and by the anus and vulva in females.

peristaltic waves
Alternating involuntary contraction and relaxation of the smooth muscle fibers of a structure in a wavelike
fashion to propel the contents forward; commonly associated with the GI tract.

peritoneal dialysis
A procedure performed to remove toxins, drugs, or other wastes normally excreted by the kidney; transfers
these substances across the peritoneum by intermittently introducing and removing a dialysate from the
peritoneal cavity.

An inflammation of the peritoneum; can be produced by bacteria or irritating substances introduced into the
abdominal cavity by a penetrating wound or perforation of an organ.

pernicious anemia
A megaloblastic anemia characterized by decreased gastric production of hydrochloric acid from the parietal
cells of the stomach essential for vitamin B12 absorption; results in vitamin B12 deficiency.

The process by which cells engulf and digest solid substances, such as microorganisms and cell debris.

phenylketonuria (PKU)
An inborn metabolic disorder caused by absence or deficiency of phenylalanine hydroxylase, the enzyme
responsible for the conversion of phenylalanine to tyrosine; results in accumulation of phenylalanine and its
metabolites, causing mental retardation and other neurologic problems, light pigmentation, eczema, and a
distinctive mousy odor.

A chromaffin-cell tumor of the adrenal medulla that secretes an excessive amount of the catecholamines
epinephrine and norepinephrine, which results in severe hypertension, increased metabolism, and

The treatment of disease by the use of light, especially ultraviolet light or other concentrated rays; used to
treat acne, psoriasis, and hyperbilirubinemia.

pituitary dwarfism
A condition characterized by a deficiency in secretion of the growth hormone from the anterior pituitary

placenta accreta
Abnormal adherence of the placenta to the uterine wall.

placenta previa
Implantation of the placenta so that it adjoins or covers the internal os of the uterine cervix. The most
common symptom is painless hemorrhage in the last trimester.
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An acute infection of the lung parenchyma that commonly impairs gas exchange.

A collection of air in the pleural space; may result from an open chest wound that permits the entrance of air
or from the rupture of a vesicle on the surface of the lung. Common types of pneumothorax are open,
closed, and tension.

Chronic, excessive thirst.

The simultaneous inflammation of a number of voluntary muscles.

Degeneration of peripheral nerves primarily supplying the distal muscles of the extremities. It results in
muscle weakness, with sensory loss and atrophy, and decreased or absent deep tendon reflexes.

Voracious or excessive eating before becoming satiated.

The excessive excretion of urine from the kidneys.

postterm neonate
A neonate born after the onset of the 43rd week of pregnancy.

An abnormal condition characterized by the development of hypertension during pregnancy, accompanied
by edema or proteinuria, usually after the 20th week of gestation.

pressure ulcer
Localized area of skin breakdown occurring secondary to prolonged pressure. Necrotic tissue develops
because the vascular supply to the area is diminished.

preterm neonate
A neonate born before the beginning of the 38th week of pregnancy.

A woman who is pregnant for the first time.

Prinzmetal's angina
A variant of angina pectoris, a form of unstable angina, in which the attacks occur during rest. Attacks are
indicated by an ST-segment elevation on an electrocardiogram.

productive cough
A mechanism by which the body clears the airway passages of secretions that normal mucociliary action
doesn't remove; usually sudden, forceful, noisy expulsion of air from the lungs that contains sputum or blood
(or both).
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False attribution of one's unacceptable feelings, impulses, or thoughts onto another.

Itching; an unpleasant sensation that leads to rubbing or scratching the skin in an effort to obtain relief.
Scratching the skin may lead to secondary infection.

The development of a Parkinson-like disorder (neuromuscular disorder involving progressive muscle rigidity,
akinesia, and involuntary tremors) due to psychotropic drug therapy.

1. Of or pertaining to the period from the end of childbirth until involution of the uterus is complete (usually 3
to 6 weeks). 2. Of or pertaining to a woman (puerpera) who has just given birth to an infant.

pulmonary edema
An abnormal condition in which extravascular fluid is accumulated in lung tissues and alveoli.

pulse pressure
The numeric difference between the systolic and diastolic pressures, usually 30 to 40 mm Hg.

Containing or forming pus.

Inflammation of the kidney and its pelvis.

The presence of pus in the urine, commonly a sign of urinary tract infection.

The first notable fetal movement in utero, usually occurring at 16 to 20 weeks' gestation.

radical mastectomy
Surgical removal of an entire breast, pectoral muscles, axillary lymph nodes, and all fat, fascia, and adjacent
tissues; usually used in the treatment of breast cancer.

reaction formation
Substitution of behavior, thoughts, or feelings that are completely opposed to one's own unacceptable
behavior, thoughts, or feelings.

rectal route
Use of the rectum to administer medication

A technique in which the listener interprets the feelings of the client and repeats them back to the client;
encourages the client to clarify his feelings.
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Part of the cardiac conduction cycle in which the cell returns to its resting state, a more negatively charged
state. Calcium ions move into the cell and potassium ions move out, followed by the extrusion of sodium
and calcium ions from the cell and the restoration of potassium ions into the cell by the sodium potassium

respiratory acidosis
Caused by reduced alveolar ventilation; is marked by increased partial pressure of arterial carbon dioxide,
excess carbonic acid, and increased plasma hydrogen-ion concentration. Hypoventilation inhibits the
excretion of carbon dioxide, which consequently produces excessive carbonic acid and thus lowers blood

respiratory alkalosis
Caused by both respiratory and nonrespiratory factors, this condition is marked by decreased partial
pressure of arterial carbon dioxide, decreased hydrogen-ion concentration, and increased blood pH.
Extreme anxiety can precipitate hyperventilation associated with respiratory alkalosis.

A method used to support a client's breathing and circulation until the body can do so on its own or the client
is mechanically supported. It involves maintaining an open airway, providing artificial ventilation through
rescue breathing, and promoting artificial circulation through external cardiac compression.

Reye's syndrome
Acute encephalopathy and fatty infiltration of the internal organs following acute viral infections, such as
influenza B, chickenpox (varicella), the enteroviruses, and the Epstein-Barr virus; has also been associated
in children with administration of aspirin and other salicylates.

Rh incompatibility
In hematology: two blood groups that are antigenically different and, therefore, aren't compatible because
one group lacks the Rh factor.

rheumatic fever
An inflammatory disease sometimes occurring if group A beta-hemolytic streptococcal infection is
inadequately treated.

rheumatoid arthritis
A chronic, systemic collagen disease marked by inflammation, stiffness, and pain in the joints and related
structures that result in crippling deformities.

ritodrine therapy
A prescribed treatment that uses the beta-receptor agonist ritodrine to halt preterm labor.

Romberg’s sign
A swaying (or falling) when a person stands with feet together and eyes closed. It’s an indication that the
person has lost a sense of position. Also called rombergism.

rooting reflex
A response in neonates to the cheek being touched or stroked. The infant turns the head toward the
stimulated side and begins to suck. The reflex usually disappears by 3 to 4 months of age.
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Russell traction
An orthopedic device that combines suspension and traction to align and immobilize the legs; used to treat
diseases of the hip and knee and fractured femurs as well as hip and knee contractures.

A contagious skin disease caused by the itch mite, Sarcoptes scabiei.

schizotypal personality disorder

A disorder characterized by acute discomfort with and reduced capacity for close relationships and by
cognitive or perceptual distortions and eccentricities of behavior, beginning in early adulthood.

An appreciable lateral curvature of the spine resulting from numerous causes, including congenital
malformations of the spine, muscle paralysis, poliomyelitis, sciatica, and unequal leg length.

sensorineural hearing loss

Hearing loss caused by a defect or lesion of the inner ear or the acoustic nerve resulting in a distortion of
sound that makes discrimination difficult.

sensory perceptions
Awareness of one's surroundings through the use of vision, hearing, taste, touch, and smell.

Of a discharge containing both serum and blood.

An abnormal physiologic state characterized by reduced cardiac output, circulatory insufficiency,
tachycardia, hypotension, restlessness, pallor, and diminished urinary output. Shock may be caused by a
variety of conditions, including trauma, infection, hemorrhage, poisoning, myocardial infarction, and

sickle cell anemia

A chronic and incurable hereditary disorder occurring in people homozygous for hemoglobin S (Hb S). The
presence of Hb S results in distortion and fragility of erythrocytes.

sickle cell crisis

Episode of widespread cellular sickling in which the client's red blood cells containing hemoglobin S are
exposed to conditions in which oxygen supply to the cells is decreased. This leads to cellular contraction
and piling within the cell, altering the shape of the red blood cells (sickling). These sickled cells become rigid
and clump together to form clusters, ultimately obstructing capillary blood flow and causing tissue ischemia.

simple fracture
An uncomplicated, closed bone fracture in which the skin isn't broken.

skin turgor
Skin characteristic determined by pinching a small area of skin on the medial arm or anterior chest and
noting how quickly it returns to its position when released.
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somatoform pain
Development of the symptom of pain as a result of psychological stress.

spinal shock
Loss of autonomic reflex, motor, and sensory activity below the level of a lesion. Signs of spinal shock
include flaccid paralysis, loss of deep tendon and perianal reflexes, and loss of motor and sensory function.

standard precautions
Infection control guidelines established by the Centers for Disease Control and Prevention requiring all
health care personnel to use gloves, gowns, and goggles to prevent contact with a client's blood or body
fluids and to adhere to strict safety measures when handling needles, scalpels, and other sharp instruments.

status asthmaticus
A severe and prolonged asthma attack in which bronchospasm fails to respond to oral medication,
sometimes resulting in hypoxia, cyanosis, and unconsciousness.

Stokes-Adams attack
Episode of confusion and light-headedness accompanying syncope with or without seizures due to
inadequate cerebral perfusion secondary to heart block.

1. A minute pore, orifice, or surface opening. 2. An artificial, surgically created opening of an internal organ
on the body surface, such as for a colostomy or tracheostomy. 3. A new opening surgically created between
two structures, such as for a gastroenterostomy or pancreaticogastrostomy.

An inflammation of the mouth that may result from bacterial, viral, or fungal infection; exposure to chemicals
or drugs; vitamin deficiency; or a systemic inflammatory disease.

A high-pitched respiratory sound, usually heard during inspiration, caused by an obstruction of the trachea
or larynx.

A condition of sudden onset in which a cerebral blood vessel is occluded by an embolus or cerebrovascular
hemorrhage. The resulting ischemia of brain tissue that is normally perfused by the affected vessel may lead
to permanent neurologic damage.

subdural hematoma
A condition involving the collection of blood between the dura mater and the brain.

Under the tongue.

sudden infant death syndrome (SIDS)

The sudden, unexpected, and inexplicable death of an infant who appears to be healthy. It occurs during
sleep, typically in infants between the ages of 3 weeks and 5 months. Also called crib death.
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Located above the tentorium of the brain.

A liquid that contains solid particles that aren't dissolved; stirring or shaking the liquid maintains the

Group of drugs that mimic the effects of impulses conveyed by adrenergic postganglionic fibers of the
sympathetic nervous system.

synchronized cardioversion
Delivery of an electrical shock to the client in conjunction with the R wave on his ECG, just as the heart
muscle contracts. Delivery is timed to avoid the T wave because an electrical discharge at this time may
cause ventricular fibrillation.

synergistic effect
Administration of two drugs producing the same qualitative effect together to produce a greater response
than either drug alone.

systemic lupus erythematosus (SLE)

A chronic inflammatory multisystemic disorder of connective tissue, characterized principally by involvement
of the skin, joints, kidneys, and serosal membranes.

A condition characterized by a regular but accelerated action of the heart, usually l00 to 150 beats per

tactile fremitus
Vibration in the chest wall that can be felt when a hand is applied to the thorax while the patient is speaking.
It's most commonly due to consolidation of a lung or a part of a lung but may also be caused by congestion,
inflammation, or infection.

tardive dyskinesia
A neurological syndrome marked by slow, rhythmical, automatic movements that occur as an adverse effect
of extended phenothiazine use.

tension pneumothorax
A condition in which air enters the pleural space through a tear in lung tissue but can't exit through the same
vent, thereby trapping air in the pleural space with each inspiration and producing positive pleural pressure.
This in turn causes the ipsilateral lung to collapse.

An indication of decreased skin turgor, as exhibited by a fold of skin remaining or holding in the pinched
position after being released.

Causing harm to the developing fetus.
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Hyperexcitability of nerves and muscles as a result of a lessened concentration of extracellular ionized
calcium; symptoms include convulsions, muscle twitching and cramps, and sharp flexion of the wrist and
ankle joints.

tetralogy of Fallot
A combination of congenital cardiac defects consisting of pulmonic stenosis, interventricular septal defect,
dextroposition of the aorta so that it overrides the interventricular septum and receives venous as well as
arterial blood, and right ventricular hypertrophy.

A reduction in the number of blood platelets; usually caused by destruction of erythroid tissue in bone
marrow. The condition may be a result of neoplastic disease or an immune response to a drug.

Inflammation of a vein, often involving clot formation. Common causes include chemical irritation, blood
hypercoagulability, immobilization, infection, postoperative venous stasis, prolonged sitting or standing,
trauma to the vessel wall, or a long period of I.V. catheterization.

tonic-clonic seizure
Paroxysmal, uncontrolled discharge of central nervous system neurons extending to the entire brain and
characterized by stiffening (tonic phase) and then rapid synchronous muscle jerking and hyperventilation
(clonic phase). Also called a major or grand mal seizure.

The surgical removal of the palatine tonsils.

total parenteral nutrition (TPN)

The administration of total caloric needs in a nutritionally adequate solution of glucose, protein hydrolysates,
minerals, and vitamins through a catheter inserted into the superior vena cava.

tracheoesophageal fistula
Abnormal opening between the esophagus and trachea that may lead to aspiration.

The surgical creation of an opening through the neck into the trachea; used to relieve upper airway
obstruction and aid breathing.

1. The action of pulling a part of the body along the long axis. 2. In orthopedics: the act of exerting force
through a system of weights and pulleys to align, immobilize, or relieve pressure in a limb, bone, or group of

Method or route of topical drug administration; provides continuous drug delivery through the skin to achieve
a constant, steady blood concentration level.

transsphenoidal adenohypophysectomy
Surgery involving the pituitary gland, most commonly performed to remove a pituitary tumor. The physician
enters from the inner aspect of the upper lip through the sphenoid sinus.
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transsphenoidal hypophysectomy
Microsurgery in which an incision is made at the junction of the gums and upper lip. A surgical microscope is
advanced and a special surgical instrument is used to excise all or part of the pituitary gland.

Trendelenburg's position
Position in which the client's head is lower than the trunk; typically, the body and legs are elevated on an

Trousseau's sign
An assessment technique for evaluating neuromuscular irritability (tetany) associated with hypocalcemia.
When Trousseau's sign is positive, the client develops a carpopedal spasm (adducted thumb, flexed wrist
and metacarpophalangeal joints, and extended interphalangeal joints) after a blood pressure cuff is applied
to the client's upper arm and inflated to a pressure above systolic pressure for approximately 1 to 4 minutes.

An acute or chronic infection from exposure to Mycobacterium tuberculosis or another strain of
mycobacteria characterized by pulmonary infiltrates and formation of granulomas with caseation, fibrosis,
and cavitation.

type 1 diabetes
An endocrine disorder involving disturbances in carbohydrate, protein, and fat metabolism, usually occurring
before age 30 and requiring the use of exogenous insulin and dietary management. Also called insulin-
dependent diabetes mellitus.

type 2 diabetes
An endocrine disorder involving disturbances in carbohydrate, protein, and fat metabolism; characterized by
insulin resistance with varying degrees of insulin secretory defects. May be treated with diet, exercise, and
oral antidiabetic agents. Exogenous insulin is sometimes necessary.

type 2 herpes simplex

A type of herpes simplex virus transmitted primarily through contact with genital secretions and affecting the
genital structures.

ulcerative colitis
A chronic, recurrent ulceration of the colon of unknown cause in which there is abdominal cramping, rectal
bleeding, and diarrhea containing blood, pus, and mucus.

urinary incontinence
Inability to prevent urine discharge.

urinary tract infection (UTI)

A bacterial infection, most commonly caused by Escherichia coli or a species of Klebsiella, Proteus,
Pseudomonas, or Enterobacter, affecting one or more parts of the urinary tract.

A vascular reaction caused by dilation and increased permeability of the capillaries. Symptoms include the
development of transient wheals with pale centers and well-defined erythematous margins.
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Differing rhythmicity or changes in condition; often used to describe fetal heart rate reflected on the fetal
heart rate tracing as a slight irregularity or jitteriness.

vaso-occlusive crisis
The most common type of sickle cell crisis resulting from blood vessel obstruction by rigid, tangled sickle
cells leading to tissue anoxia and possibly necrosis. Also called a painful crisis or infarctive crisis.

vastus lateralis
The largest of the four muscles that make up the quadriceps femoris; located on the outside of the thigh,
extending from the hip joint to the common quadriceps tendon and inserted in the patella; extends the leg.

A radiographic test using a contrast medium to identify thrombi or obstruction in the veins of the lower
extremities or the kidneys.

ventricular septal defect (VSD)

An abnormal opening in the septum separating the ventricles, usually resulting from failure of the fetal
interventricular foramen to close; results in blood flow from the left ventricle to the right ventricle and
recirculation of blood through the pulmonary artery and lungs.

ventricular tachycardia
A life-threatening arrhythmia that occurs when the ventricles produce several premature ventricular
contractions in succession; usually due to a problem with the heart's conduction system and increased
myocardial contractility.

A sensation of movement in which the client feels himself revolving in space (subjective vertigo) or his
surroundings revolving about him (objective vertigo); may result from diseases of the inner ear or from
disturbances of the vestibular pathways in the central nervous system.

1. Any small anatomic sac that contains liquid. 2. A small blister that contains clear fluid.

wet-to-dry dressings
Type of wound covering (dressing) in which gauze moistened with normal saline is applied wet to the wound
and removed once the gauze becomes dry and adheres to the wound bed; used for debridement.

Wilms' tumor
A rapidly growing malignant kidney tumor that occurs most commonly in children younger than age 5,
although it sometimes develops before birth. Rare cases occur later in life. Also called adenomyosarcoma.

X-linked recessive disorders

Genetic disorders in which the abnormal gene exists on the X chromosome; only males exhibit clinical signs
of the disorder because they have no offsetting X chromosome.

An I.M. injection technique in which the client's skin is pulled in such a way that the needle track is sealed off
after the injection. The technique is done to minimize subcutaneous irritation and discoloration.
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Comprehensive HESI Exit and Subject Exam Flashcards

Question Answer Hint

transports nutrients, O2, hormones & enzymes
to tissues, carries CO2 and waste products
away from tissues, helps regulate temp, fluid
Blood functions:
electrolytes & pH, protects body from bacteria
and foreign substances, coagulates to prevent
excess fluid loss
Volume of blood present in the circulatory
What is total blood volume?
system (arteries, veins, capillaries)
Total blood volume is approximately.... 4-5 L in females 5-6 L in males
Normal pH range is... 7.35-7.45 (arterial blood)
the formed elements and plasma (Blood as a
Whole blood refers to...
Connective tissue (Blood consists of cells and
What kind of tissue is blood classified
cell fragments surrounded by a liquid
intercellular matrix)
Cellular elements comprise ____% of
the blood volume?
Plasma comprises ___% of the blood
Approximately 95% of the volume of
red blood cells
the formed elements consists of.....
Cell fragments are called.... platelets
Approximately 5% of the volume of
WBC and platelets
the formed elements consists of....
The formed elements account for ____
% to ___% of the total blood volume 38% to 48%
in females. (AKA Hematocrit)
The formed elements account for ____
% to ___% of the total blood volume 44% to 54%
in males. (AKA Hematocrit)
The % of total blood volume
composed of formed elements in the Hematocrit
blood sample is the...
Red Blood Cells or RBC functions: transport O2 and CO2 throughout body
body's defense against microorganisms and
White Blood cells or WBC functions...
foreign material.
Platelets are essential for... preventing blood loss (hemostasis)
In a healthy person, only _______ mature In persons with disease states, immature
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blood cells are found in blood

and abnormal cells may be present.
Is a viscous (sticky) pale yellow colloidal fluid
What is plasma? accounting for slightly more than half the total
blood volume.
92% water and 8% dissolved or proteins such
as albumin, globulins and fibrinogen, salts,
What is plasma made of?
nutrients, gases, waster products, hormones and
Plasma without the proteins that clot
blood is called....
from digestive tract, interstitial fluids and as a
How does water enter plasma?
by-product of metabolism.
How does water leave plasma? Kidneys, lungs, intestinal tract and skin
Where do the solutes come from in the liver, kidneys, intestines, endocrine glands and
plasma? immune tissues such as the spleen.
What are other terms for circulatory
vascular space or vascular system.
Blood or fluid within the vascular
system is referred to as....
Blood or fluid outside the vascular
system is referred to as....
the space surrounding the cells outside the
What is the interstitial space?
vascular system.
The exchange of nutrients, gases,
hormones, waste products takes place at the capillary level (the walls are one cell
between blood and tissues occurs thick) (microvasculature)
The process by which nutrients and
other substance cross the capillary wall diffusion
is called....
How does the lymphatic system differ
It is not a closed loop system.
from the circulatory system?
1.)picks up fluids and large complex substances
that have left the circulatory system and
What does the lymphatic system do? entered the tissues 2.)returns them to the
vascular system (helps maintain normal blood
What do lymph nodes do? filter lymphatic vessels
the thoracic duct on the left side of body the
What are two large lymph vessels?
right lymphatic duct on the right side
What do the thoracic duct and right empty into veins in the upper chest and return
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lymphatic duct do? fluid to the vascular system.

would develop a balloon-like appearance. Their
What would happen to a person if fluid
blood volume is depleted (fluid lost from their
remains in the interstital space?
Vascular system includes both: peripheral and cardiopulmonary systems
circulatory system but not the cardiopulmonary
Peripheral system refers to...
superior vena cava (receives blood from head
and upper part of body) inferior vena cava
What are the major veins in the body?
(blood from lower part of body) Both vessels
enter the Right atrium of the heart. (RA)
Cardiopulmonary system refers to.... heart and lungs as they function together.
Blood going into right atrium from
both vena cavae is....
From the right atrium, blood is
pumped to the right ventricle through tricuspid
which valve?
From the right ventricle (RV),
pulmonary blood goes to pulmonary arteries to
deoxygenated blood is pumped out
go to lungs
through which valve?
What happens in the aveolar capillary O2 and CO2 are exchanged. (CO2 is the waste
newtwork in the lungs? product of cellular metabolism)
Where does the oxygenated blood go through pulmonary veins to the left atrium
from the lungs? (LA)of the heart.
Where does blood go from left atrium pumped into the left ventricle (LV) through the
(LA)? mitral or biscuspid valve.
Where does blood go from left
ejected through aortic valve to the aorta.
ventricle (LV))?
enzyme produced mainly in liver, bone,
What is Alkaline Phosphatase (ALP)?
intestine, kidney & placenta.
differentiates between liver and bone disorders
What does Alkaline Phosphatase
when other enzyme tests are done (ALP
isoenzymes 1 & 2, GGTP and/or 5'N)
ALP isoenzyme, ALP1 is of what
ALP isoenzyme, ALP2 is of what
hypothyroidism, malnutrition, scurvy,
What could a decreased ALP level
hypophosphatasia, pernicious anemia, placental
mean? alkaline phosphatase
What drugs may decrease alkaline
flouride, oxalate, propranolol (Inderal)
phosphatase (ALP)values?
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obstructive biliary disease (juandice), cancer of

the liver, hepatocellular cirrhosis, hepatitis,
leukemia, cancer of the bone, breast or prostate,
What could an increased ALP level Paget's disease (osteitis deformans) healing fx,
mean? alkaline phosphatase multiple myeloma, osteomalacia, GI ulcerative
dx, late pregnancy, hyperthyroidism,
hyperparathyroidsim, rheumatoid arthritis,
ABX, cochicine, methyldopa(Aldomet),
allopurinol, phenothiazines, indomethacin
What drugs may increase alkaline
(Indocin) procainamide, some oral
phosphatase (ALP)values?
contraceptives, tolbutamine, INH (isoniazid)
and IV albumin
Collect 5-10ml of venous blood in red-top tube.
No food or fluid restrictions are required.
Procedure for ALP test? Withhold drugs that may elevate ALP for 8-24
hrs w/Dr's permission. List client's age & drugs
that may affect results on lab slip.
Know factors that can elevate serum ALP
levels (drugs, IV albumin), age of client, late
pregnancy to 3 weeks postpartum, blood drawn
Nursing implications for ALP test: 2-4 hrs after fatty meal. record info on lab slip.
inform pt that other enzyme tests may be
ordered to verify dx, assess for s/s of liver dx or
bone dx.
20-90 U/L at 30 C, 24-97 U/L at 37 C, 2-4
Normal ALP levels for adult
U/dL, 4-13 U/dL elderly-slightly higher
enzyme that is derived from the pancreas,
What is amylase? salivary gland and liver. increases in acute
Normal ALP levels for child: 0-12 yr = 40-300 U/L 13-18 yr = 30-165 U/L
acute pancreatitis (can be 2X normal at peak at
20-30 hrs and returns to normal in 2-4 days),
What cause increase amylase levels?
abdominal surgery involving gallbladder and
What are the two major types of P-type, occur more frequently in acute
amylase isoenzymes and what do they pancreatitis. elevated S-type can be d/t ovarian
relate to? and bronchogenic tumors.
determines the significance of a normal or
slightly elevated serum amylase, esp when pt
Why is the urine amylase helpful to
has sxs of pancreatitis. Urine amylase can
remain elevated up to 2 wks after acute
What are normal serum levels of adult - 60-160 Somogyi U/dL pregnancy:
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slightly increased child: usually not done

elderly: could be slightly higher than adult
What are normal lvels of serum S (salivary) type 45-70% P (pancreatic) type
amylase isoenzymes? 30-55%
What is normal urine amylase level? adult: 4-37 U/L2h
IV D/W, advanced chronic pancreatitis, acute
What can a decreased level of amylase and subacute necrosis of the liver, chronic
indicate? alcoholism, toxic hepatitis, severe burns, severe
What drugs can decrease amylase
glucose, citrates, flourides, oxalates
acute pancreatitis, chronic pancreatitis (acute
onset), partial gastrectomy, peptic ulcer
What can an elevated level of amylase perforation, obstruction of pancreatic duct,
indicate? acute cholecystitis, CA of pancreas, DKA, DM,
acute alcoholic intoxication, mumps, RF, BPH,
burns, pregnancy
narcotics, ethyl alcohol (large amts) ACTH,
What drugs may increase amylase
guanethidine, thiazide diuretics, salicylates,
is a screening test for diagnosing systemic
lupus erythematosis (SLE) and other collagen
What is the ANA test?
diseases. Scleroderma, RA, cirrhosis, leukemia,
infectious mononucleosis and malignancy.
What is reference value for ANA test? Adult: negative
What is an elevated level of ANA? >1:20
abx, HTN meds, methyldopa (Aldomet)
What drugs may increase ANA value? isoniazide (INH) diuretics, thiazides, phenytoin
(Dilantin) oral contraceptives, antiarrhythmics
to assess disturbances of acid-base balance
Why are arterial blood gases (ABGs)
caused by a respiratory disorder or a metabolic
disorder or both.
a pH of less than 7.35 indicates.... acidosis
a pH greater than 7.45 indicates.... alkalosis
a decreased pH (<7.35) and an
respiratory acidosis
elevated PaCO2 (>45) indicates...
An elevated pH (>7.45) and a
respiratory alkalosis
decreased PaCO2 (<35) indicates....
To determine whether an acid-base
imbalance has a metabolic cause, you bicarbonate (HCO3)
should look at...
A decreased pH (<7.35) and a metabolic acidosis
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decreased HCO3 (<24) indicates...

An elevated pH (>pH 7.45) and an
metabolic alkalosis
elevated HCO3 (>28> indicates....
pH 7.35-7.45 PaCO2 35-45 PaO2 75-100
Adult ABG reference values...
HCO3 24-28 BE +2 to -2 (base excess)
pH 7.36-7.44 PaCO2 35-45 PaO2 75-100
Child ABG reference values...
HCO3 24-28 BE +2 to -2 (base excess)
COPD, (emphysema, chronic bronchitis, severe
What can cause respiratory acidosis?
asthma)ARDS, Guillian-Barre syndrome,
(pH <7.35, PaCO2 >45)
anesthesis, pneumonia
DKA, severe diarrhea, starvation/malnutrition,
What can cause metabolic acidosis?
kidney failure, burns, shock, acure myocardial
(pH <7.35, HCO3 <24)
What drugs may cause a low pH? narcotics, barbiturates
salicylate toxicity (early phase) anxiety,
What can cause respiratory alkalosis? hysteria, tetany, strenuous exercise,
(pH >7.45, PaCO2 <35) (swimming, running) fever, hyperthyroidism,
delirium tremens, PE
severe vomiting, gastric suction, peptic ulcer,
What can cause metabolic alkalosis? potassium loss (hypokalemia) excess
(pH >7.45, HCO3 >28) administration of sodium bicarbonate, cystic
fibrosis, hepatic failure.
What drugs may cause an elevated sodium bicarbonate, sodium oxalate, potassium
pH? oxalate
is formed from the breakdown of hemoglobin
by the reticuloendothelial sytem and is carried
What is bilirubin?
in the plasma to the liver where it is conjugated
or unconjugated.
direct and indirect bilirubin levels do not need
If the total bilirubin (serum bilirubin)
to be analyzed. If total bilirubin elevated, look
is within normal range, then what?
at direct bilirubin.
If one value of bilirubin is reported,
the total bilirubin
what does it represent?
Jaundice is frequently present when
3 mg/dL Remember to check sclera of the eyes
serum bilirubin (total) is greater
and inner aspects of the arm for jaundice.
obstructive jaundice, either extrahepatic (from
Increased direct or conjugated
stones or tumor) or intrahepatic (damaged liver
bilirubin is usually the result of ...
Indirect or onconjugated bilirubin is
increased destruction of RBCs (hemolysis)
associated with...
Adult Reference values for Bilirubin Total: 0.1-1.2 mg/dL Direct(conjugated): 0.0-
Super Condensed Portable HESI Study Guide 163

0.3 mg/dL Indirect (unconjugated):0.1-1.0

(Total, Direct, Indirect) serum:
Newborn Reference values for
Total: 1-12 mg/dL
Bilirubin (Total) serum:
Child Reference values for Bilirubin
Total: 0.2-0.8 mg/dL
(Total) serum:
What can cause a decreased direct
iron deficiency anemia
bilirubin level?
What drugs may decrease bilirubin
barbituates, ASA (in large amts), PCN, caffeine
obstructive jaundice caused by stones or
What can cause an increased direct neoplasms, hepatits, cirrhosis of the liver,
bilirubin level? infectious mononucleosis, liver CA, Wilson's
erythroblastosis fatalis, sickle cell anemia,
What can cause an increased indirect transfusion reaction, hemolytic anemias,
bilirubin level? pernicious anemia, malaria, septicemia, CHF,
decompensated cirrhosis
ABX, sulfonamides, diuretics, INH, valium,
What drugs may increase bilirubin narcotics, barbiturates, Dalmane, Indocin,
value: Aldomet, Pronestyl, steroids, oral
contraceptives, orinase, vitamins A, C and K
How do you figure out the indirect subtract the direct bilirubin from the total
bilirubin? bilirubin.
Avoid hemolysis. Pt to be NPO except for
water. List drugs pt is taking protect sample
What should a nurse remember when
from sun and light. Blood should be sent asap
drawing a bilirubin sample?
to lab. Tell pt to NOT eat carrots or foods high
in fat the night before test.
Collect blood in heparinized needle and syringe
place syringe with arterial blood in an ice bag
What should a nurse remember when and deliver to lab asap. indicate on lab slip if pt
drawing ABGs? is receiving O2 and what rate. apply pressure
for 2-5 min. blood not to be drawn from same
arm as IV No food or fluid restriction.
restrict food for 1-2 hours before the blood
What should a nurse remember when
sample is drawn. if pt ate or received a narcotic
drawing an amylase test?
2 hrs before test, may be invalid.
What are 2 methods to test bleeding
Ivy and Duke method
to determine whether bleeding time is normal
Why are bleeding time tests done? or prolonged. frequently done when pt has a hx
of bleeding (easy bruising) familial bleeding or
Super Condensed Portable HESI Study Guide 164

peroperative screening.
cleanse below the antecubital space w/alcohol
and allow to dry. inflate BP cuff to 40mm Hg
and leave inflated during test.puncure skin 2.5
Describe Ivy method:
mm deep. start timing on stopwatch. blot blood
q 30 sec until bleeding stops. the time required
for bleeding to stop is recorded.
when pt is taking anticoagulants or ASA. Pt
When should Ivy test method not be should stop these meds 3-7 days prior to test w/
done? more popular than Duke method Drs permission. ASA therapy will prolong
bleeding time.
Describe Duke method: earlobe is used. no food or fluid restriction.
thrombocytopenia (decreased platelet count
<50,000), platelet function abnormality,
What can disorders can increase vascular abnormalities, severe liver dx,
bleeding times (prolonged time)? disseminated intravascular coagulation (DIC)
aplastic anemia, factor deficiencies (V, VII, XI)
Christmas disease, hemophilia, leukemia
What drugs may increase bleeding salicylates, (ASA, others) warfarin (Coumadin)
time? dextran, streptokinase (fibrinolytic agent)
What are adult reference values for Ivy
3-7 minutes
What are adult reference values for
1-3 minutes
Duke method?
What is urea? Urea is an end product of protein metabolism.
If both BUN and Creatinine levels are
kidney disease
elevated, nurse should suspect what?
What should nurse do w/Dr's
Encourage fluids.
permission if pt's BUN is 26-35?
serum calcium (Ca) normal range for
adult: 4.5-5.5 mEq/L, 9-11 mg.dL
newborn: 3.7-7.0 mEq/L, 7.4-14.0 mg/dL
serum calcium (Ca) normal range:
Infant: 5.0-6.0 mEq/L, 10-12 mg/dL Child: 4.5-
newborn, infant, child
5.8 mEq/L, 9-11.5 mg/dL
what is total serum calcium? ionized and nonionized calcium level together.
How does pH affect calcium acidosis-more Ca ionized alkalosis-most of Ca
ionization? is bound to protein and cannot be ionized.
What does a calcium deficit cause? tetany symptoms, unless acidosis is present
What can a calcium excess cause? cardiac dysrhythmias
What can a 24-urine specimen for
parathyroid disorders
calciuria determine?
In hyperparathyroidism, increased. it is decreased in
Super Condensed Portable HESI Study Guide 165

hyperthyroidism and osteolytic

disorders, the urinary calcium hypoparathyroidism.
excretion is usually...
malabsorption of Ca from GI tract, lack of Ca
& Vit D intake, hypoparathyroidism, CRF
What can cause a decreased level of
caused by PH retention, laxative abuse,
serum calcium?
extensive infections, burns, pancreatitis,
alcoholism, diarrhea, pregnancy
cortisone preparations, ABX (gentamicin,
methicillin), Mg products (antacids), excess
What drugs can decrease Ca value?
laxatives, heparin ,insulin, mithramycin,
acetazolamide (Diamox)
hyperPTH, malignant neoplasm of bone, lung,
breast, bladder or kidney, hypervitaminosis Vit
What can cause elevated level of
D, multiple myeloma, prolonged
serum calcium?
immobilization, multiple fx, renal calculi,
exercise, milk-alkali syndrome
thiazide diuretics, alkaline antacids, calcium
What drugs can increase Ca value?
salts, estrogen preparation, vit D
tetany: muscular twitching and tremors, spasms
What are sx of decreased level of Ca? of the larynx, parathesis, facial spasms and
spasmodic contractions
a spasm of the facial muscles following a tap
What is Chvostek's sign? on one side of the face over the facial nerve. +
in hypocalcemia
muscular spasm resulting from pressure applied
What is Trousseau's sign? to nerves and vessels of the upper arm such as
inflating a BP cuff) + in hypocalcemia
Why should nurse look for sx of tetany
citrates prevent calcium ionization. serum
when pt receives massive transfusions
calcium level may not be affected.
of citrated blood?
What can occur if pt receives ca
digitalis toxicity (sx: N/V, anorexia,
supplements and a digitalis
GIVE SLOWLY. Ca should be administered in
What should nurse do when giving IV
D5/W and not in saline solution. Na promotes
fluids with 10% Ca gluconate?
Ca loss.
Why should Ca not be added to
rapid precipitation will occur.
solutions containing bicarbonate?
lethargy, HA, weakness, muscle flaccidity,
What are sx of hypercalcemia?
heart block, anorexia, N/V
What should nurse teach pt who is avoid high ca foods, be ambulatory when
hypercalcemic? possible, and increase oral fluid intake.
Super Condensed Portable HESI Study Guide 166

What should nurse promote if pt is active and passive exercises. this will prevent
bedridden? ca loss from bone.
What happens when pt is
thiazide diuretic inhibit ca excretion and
hypercalcemic and is taking a thiazide
promote hypercalcemia.
What is normal Chloride serum level
95-105 mEq/L
for adult?
What is normal serum Chloride level newborn: 94-113 mEq/L infant: 95-110 mEq/L
for newborn, infant and child? child: 98-105 mEq/L
Where is chloride found, extracellular
It is found in the extracellular fluid.
or intracellular?
maintain body water balance, osmaolality of
What roles does chloride play? body fluids (with sodium), and acid-base
vomiting, gastric suction, diarrhea, low serum
K+ or Na (or both), Low Na diet, continuous
What causes decreased levels of IV D5/W, adrenal gland insufficiency, heat
chloride? exhaustion, acute infections, burns, excess
diaphoresis, metabolic alkalosis, chronic resp
acidosis, CHF
What drugs may decrease chloride
thiazide and loop diuretics, bicarbonates
dehydration, high serum Na level, adrenal
gland hyperfunction, multiple myeloma, head
What causes increased levels of
injury, eclampsia, cardiac decompensation,
excessive IV saline (0.9% NaCl) kidney
ammonium chloride, cortisone preparations,
What drugs may increase chloride
ion exchange resins, acetazolamide (Diamox),
prolonged use of triamterene (Dyrenium)
hyperexcitability of the nervous system and
What should nurse look for in
muscles, tetany, slow and shallow breathing,
What should nurse tell Dr can happen
a chloride deficit can occur.
with continuous IV D5/W?
What should nurse encourage the pt drink fluids containing sodium and chloride
who is Cl deficient to do? (ex. broth, tomato juice) NO PLAIN WATER)
What other labs should nurse look at if serum K+ and Na levels. Cl is frequently lost
pt's Cl is decreased? with Na and K+.
What are sx of overhydration when pt Na holds water. Sx of overhydration: constant,
is receiving several L of normal saline irritating cough, dyspnea, neck&hand vein
for Na and Cl replacement? engorgement, chest rales.
What are sx of hyperchloremia? Sx similar to acidosis; weakness, lethargy and
Super Condensed Portable HESI Study Guide 167

deep, rapid vigorous breathing

tell pt to avoid drinking or eating salting foods
What should nurse instruct pt to do if
and to use a salt substitute. (avoid Ca chloride
and K+ chloride substitutes)
If pt is hyperchloremic, what IV fluid NS. Nurse should check for sx of
would be a concern? overhydration.
If pt is hyperchloremic, what could be
monitored to determine fluid daily weight and intake and output
What is desirable serum Cholesterol
< 200 mg/dL
level for adult?
What serum cholesterol level for adult
200-240 mg/dL moderate risk >240 mg/dL
is a risk?
may go to high risk levels (>240 mg/dL) but
What may happen to cholesterol levels
returns to prepregnancy values 1 month after
during pregnancy?
What are infant serum level of
90-130 mg/dL
What are child (age 2-19 yr)serum
desirable level: 130-170 mg/dL moderate risk:
level of cholesterol? normal and risky
171-184 mg/dL high risk: > 184 mg/dL
Why should nurse look for sx of tetany
citrates prevent calcium ionization. serum
when pt receives massive transfusions
calcium level may not be affected.
of citrated blood?
What can occur if pt receives ca
digitalis toxicity (sx: N/V, anorexia,
supplements and a digitalis
GIVE SLOWLY. Ca should be administered in
What should nurse do when giving IV
D5/W and not in saline solution. Na promotes
fluids with 10% Ca gluconate?
Ca loss.
Why should Ca not be added to
rapid precipitation will occur.
solutions containing bicarbonate?
lethargy, HA, weakness, muscle flaccidity,
What are sx of hypercalcemia?
heart block, anorexia, N/V
What should nurse teach pt who is avoid high ca foods, be ambulatory when
hypercalcemic? possible, and increase oral fluid intake.
What should nurse promote if pt is active and passive exercises. this will prevent
bedridden? ca loss from bone.
What happens when pt is
thiazide diuretic inhibit ca excretion and
hypercalcemic and is taking a thiazide
promote hypercalcemia.
What is normal Chloride serum level 95-105 mEq/L
Super Condensed Portable HESI Study Guide 168

for adult?
What is normal serum Chloride level newborn: 94-113 mEq/L infant: 95-110 mEq/L
for newborn, infant and child? child: 98-105 mEq/L
Where is chloride found, extracellular
It is found in the extracellular fluid.
or intracellular?
maintain body water balance, osmaolality of
What roles does chloride play? body fluids (with sodium), and acid-base
vomiting, gastric suction, diarrhea, low serum
K+ or Na (or both), Low Na diet, continuous
What causes decreased levels of IV D5/W, adrenal gland insufficiency, heat
chloride? exhaustion, acute infections, burns, excess
diaphoresis, metabolic alkalosis, chronic resp
acidosis, CHF
What drugs may decrease chloride
thiazide and loop diuretics, bicarbonates
dehydration, high serum Na level, adrenal
gland hyperfunction, multiple myeloma, head
What causes increased levels of
injury, eclampsia, cardiac decompensation,
excessive IV saline (0.9% NaCl) kidney
ammonium chloride, cortisone preparations,
What drugs may increase chloride
ion exchange resins, acetazolamide (Diamox)
prolonged use of triamterene (Dyrenium)
hyperexcitabillity of the nervous system and
What s&s should nurse look for in
muscles, tetany slow and shallow breathing,
Why should nurse inform Dr when pt
a chloride deficit could occur.
is receiving IV D5/W continuously?
what should nurse encourage to do drink fluids containing sodium and chloride
with hypochloremia? (broth, tomato juice) NO PLAIN WATER!
Why should nurse check serum
chloride is frequently lost with sodium and
potassium and sodium levels in pt that
is hypochloremic?
What should nurse look for when pt is Sx of overhydration. Sodium holds water. Sx
receiving several L of NS for sodium include: constant irritating cough, dyspnea,
and chloride replacement? neck and hand vein engorgement, chest rales.
similar to acidosis, (weakness, lethargy and
What are s&s of hyperchloremia?
deep, rapid, vigorous breathing)
avoid drinking or eating salty foods and to use
What should nurse instruct pt do when
a salt substitute (avoid calcium chloride and
potassium chloride substitutes)
Why should nurse notify dr when pt NS increases chloride level more. check for
Super Condensed Portable HESI Study Guide 169

receiving NS IV fluids and has an

elevated serum chloride?
What should nurse do when pt Monitor daily weights and intake and output to
hyperchloremic? determine whether fluid retention is present.
What is desirable level for cholesterol
<200 mg/dL
in adults?
What are risky levels for cholesterol in moderate risk: 200-240 mg/dL high risk: >240
adults? mg/dL
What can happen to cholesterol levels can be a high risk levels but returns to
in pregnancy? prepregnancy values 1 month after delivery.
What are desirable cholesterol levels
90-130 mg/dL
in infant?
What are cholesterol levels in child (2- desirable: 130-170 mg/dL moderate risk: 171-
19yr)? 184 mg/dL High risk: >184 mg/dL
blood lipid synthesized in liver. used by body
What is cholesterol and where is it to form bile salts for fat digestion and for
produced? formation of hormones by the adrenal glands,
ovaries and testes.
What hormones decrease the
thyroid and estrogen
concentration of cholesterol?
What causes decreased level of serum
hyperthyroidism, starvation, malabsorption
What drugs may decrease cholesterol thyroxine, estrogens, ASA, ABX (tetracycline,
level? neomycin) nicotinic acid, heparin, colchicine
hypercholesterolemia, atherosclerosis,
hypothyroidism, AMI, uncontrolled DM,
what causes increased level of serum
biliary cirrhosis, pancreatectomy, pregnancy
(3rd sem) heavy stress periods, nephrotic
syndrome, high cholesterol diet.
oral contraceptives, vit A & D, phenothiazines,
What drugs may increase cholesterol
epinephrine, sulfonamides, phenytoin
decrease the intake of foods rich in cholesterol
What should nurse instruct pt with
(i.e. bacon, eggs, fatty meats, seafood,
chocolate and coconut) encourage weight loss.
detects free circulating antibodies in the serum.
checks for antibodies in recipients's and donor's
What is the Coombs' indirect (serum)
serum prior to transfusions to avoid a reaction.
antibody screen test?
does not identify specific antibodies. is part of
cross-match blood test.
(+1 TO +4) When incompatible cross-matched
When is the Coombs' indirect antibody
blood, specific antibody (previous transfusion)
screen test positive?
anti-Rh antibodies, acquired hemolytic anemia.
Super Condensed Portable HESI Study Guide 170

ABX (cephalosporins (Keflin) PCN,

tetracycline, streptomycin, amnopyrine
What drugs may increase Coombs'
(Pyradone) Dilantin, Thorazine, sulfonamides,
antiarrhythmics, quinidine, pronestyl) L-dopa,
Aldomet, INH, rifampin
What result do we want with the
Negative in both adult and children
Coombs' indirect antibody screen test?
detects antibodies other than the ABO group
What is the Coombs' direct
which will attach to RBCs. The RBCs are
antiglobulin test?
tested and if sensitized will agglutinate.
(+1 to +4) when antibodies are present on
When is the Coombs' direct RBCs. erythroblastosis fetalis, hemolytic
antiblobulin test positive? anemia, transfusion hemolytic reactions,
leukemias, SLE
ABX (cephalosporins (Keflin) PCN,
tetracycline, streptomycin, amnopyrine
What drugs may increase the Coombs'
(Pyradone) Dilantin, Thorazine, sulfonamides,
direct test?
antiarrhythmics, quinidine, pronestyl) L-dopa,
Aldomet, INH, rifampin
What are sx of blood transfusion
chills, fever (slight temp elevation) rash
CRP appears in blood 6-10 Hrs after an acute
inflammatory process or tissue destruction
What is CRP? (C-Reactive Protein)
(necrosis), or both, peaks within 48-72 Hrs. is a
non-specific test.
What are reference values for CRP
Not usually present in both. >1:2 titer =
serum in adults and children? (C-
Reactive Protein)
during bacterial infections but not viral
infections. RA, rheumatic fever, acute
When is CRP (C-Reactive Protein)
myocaridal infarction (AMI) pyelonephritis,
SLE, inflammatory bowel disease, CA with
metastasis, late pregnancy, Burkitt's lymphoma
What drugs may increase CRP value?
oral contraceptives
(C-Reactive Protein)
s&s of an acute inflammatory process (pain,
If CRP positive, (C-Reactive Protein),
swelling in joints, heat, redness, increased body
what should nurse look for in pt?
a by-product of muscle catabolism, is derived
from the breakdown of muscle creatine and
creatine phosphate. amt of creatinine produced
What is creatinine?
is proportional to muscle mass. kidneys excrete
creatinine. When 50% or > nephrons destroyed,
serum Cr level increases. evaluates glomerular
Super Condensed Portable HESI Study Guide 171

serum: 0.5-1.5 mg/dL Females may have
What are normal reference values for
slightly lower values d/t less muscle mass.
adult serum and urine creatinine?
urine: 1-2 g/24 hr
newborn: 0.8-1.4 mg/dL infant: 0.7-1.7 mg/dL
What are normal reference values for 2-6yo: 0.3-0.6 mg/dL older child: 0.4-1.2
newborn, infant, 2-6 yo, older child mg/dL elderly: may have decreased values d/t
and elderly? decreased muscle mass and decreased
creatinine production.
Question Answer Hint
Albumin normal levels 3.5 - 5.0 mg/dl
Decreased: cystic fibrosis, chronic
glomerulonephritis, alcoholic cirrhosis,
Hodkin's disease, malnutrition, nephrotic
Albumin Increased serum values?
syndrome, multiple myeloma, inflammatory
bowel disease, leukemia, collagen-vascular
Aldosterone Increased in which Increased: hyperaldosterism (primary or
pathologies secondary).
Aldosterone Decreased in which Decreased: adrenal insufficiency,
pathologies panhypopituitarism.
Increased: acute pancreatitis, pancreatic duct
obstruction, alcohol ingestion, mumps,
Amylase Increased in which
parotitidis, renal disease, cholecystitis, peptic
ulcers, intestinal obstruction, mesenteric
thrombosis, postop abdominal surgery
Amylase Decreased in which Decreased: Liver damage, pancreatic
pathologies destruction (pancreatitis, cystic fibrosis)
Bilirubin Normal Serum values Total: 0.2 - 1.2 mg/dl
Increased total: hepatic damage (hepatitis,
toxins, cirrhosis), biliary obstruction,
Bilirubin Increased in which
hemolysis, fasting. Increased direct
(conjugated): biliary obstruction / cholestasis,
drug induced cholestasis.
BUN Normal Serum values 7-20 mg/dl
Increased: renal failure, pre-renal azotemia,
shock, volume depletion, postrenal
BUN Increased in which pathologies
(obstruction), GI bleeding, stress, drugs
(aminoglycosides, vanco etc).
Decreased: starvation, liver failure, pregnancy,
BUN decreased serum values
infancy, nephrotic syndrome, overhydration.
Calcium serum values 8.8 - 10.3 mg/dl
Super Condensed Portable HESI Study Guide 172

Increased: primary hyperthyroidism,

parathyroid hormone secreting tumors, vitamin
D excess, metastatic bone tumors, chronic renal
Calcium Increased serum values
failure, milk-alkali syndrome, osteoporosis,
thiazide drugs, pagets disease, multiple
myeloma, sarcoidosis.
Decreased: hypoparathyroidism, insufficient
vitamin D, hypomagnesemia, renal tubular
Calcium Decreased serum values
acidosis, hypoalbuminemia, chronic renal
failure (phosphate retention), acute pancreatitis
CO2 ABG value 35-45 mm HG
Increased: respiratory acidosis, compensation
for metabolic acidosis, severe vomiting,
CO2 Increased ABG value
primary aldosteronism, volume contraction,
Decreased: Respiratory alkalosis, starvation,
DKA, lactic acidosis, alcoholic ketoacidosis,
CO2 Decreased ABG value
severe diarrhea, renal failure, drugs (salicylates
etc), dehydration.
Chloride Normal Serum values 95-107 meq/l
Increased: diarrhea, renal tubular acidosis,
mineralocorticoid deficiency,
Chloride Increased serum values
hyperalimentation, medications (acetazolamide,
ammonium chloride).
Decreased: mineralocorticoid excess, vomiting,
Chloride Decreased serum values
diabetes mellitus with ketoacidosis
Creatinine Normal Serum values 0.5 - 1.4 mg/dl
Increased: renal failure including prerenal,
Creatinine Increased serum values drug-induced (aminoglycosides, vancomycin,
others), acromegaly.
Creatinine Decreased serum values Decreased: loss of muscle mass, pregnancy.
Magnesium Normal Serum values 1.6 - 2.6 mg/dl
Increased: renal failure, hypothyroidism, severe
Magnesium Increased serum values dehydration, lithium intoxication, antacids,
Addison's disease.
Decreased: hyperthyroidism, aldosteronism,
diuretics, malabsorption, hyperalimentation,
Magnesium Decreased Serum values nasogastric suctioning, chronic dialysis, renal
tubular acidosis, drugs (aminoglycosides,
cisplatin, ampho B)
Phosphorus Normal Serum values 2.5 - 4.5 mg/dl
Increased: hypoparathyroidism, excess vitamin
Phosphorus Increased serum values
D, secondary hyperparathyroidism, renal
Super Condensed Portable HESI Study Guide 173

failure, bone disease, addisons disease.

Decreased: hyperparathyroidism, alcoholism,
diabetes, hyperalimentation, acidosis,
Phosphorus Decreased Serum values
hypomagnesemia, diuretics, vitamin D
deficiency, phosphate-binding antacids.
Question Answer Hint
Birth weight doubled by _____, tripled
6 months; 12 months
by _____.
Birth length increased by 50% at
12 months
Posterior fontanel closes by _____. 8 weeks (2 months)
A child can socially smiles at _____. 2 months
A child should be able to turn head to
3 months
locate sounds at _____.
Moro reflex disappears around _____. 4 months
A child should be able to achieve
4 months
steady head control at _____ of age.
A child can turn completely over at
5 to 6 months
_____ of age.
A child can play peek-a-boo after
6 months
_____ of age.
A child should be able to transfers
7 months
objects hand to hand at _____.
A child develops stranger anxiety at
7 to 9 months
A child should be able to sit
8 months
unsupported at _____.
The infant crawls at _____. 10 months
Fine pincer grasp appears at _____. 10 to 12 months
A child should be able to waves bye-
10 months
bye at _____.
A child should be able to walks with
10 to 12 months
assistance at _____.
The infant says a few words in
addition to "mama" or "dada" at 12 months
From birth to one year, the baby
explores environment by _____ and motor; oral
_____ means.
From birth to one year is what stage of
Trust vs Mistrust (Developing a sense of trust)
Erikson's theory?
Super Condensed Portable HESI Study Guide 174

What are some age-appropriate toys mobiles rattles squeaking toys picture books
for hospitalized infants? balls colored blocks activity boxes
Birth weight quadruples by _____. 30 months
Achieves 50% of adult height by ___. 2 years
Anterior fontanel closes by _____. 12 - 18 months
A child should be able to throw a ball
18 months
overhand at _____.
The nurse tells a mother that her child
24 months
should be able to kicks a ball at _____.
A child should be able to feeds self
2 years
with spoon and cup at _____.
Day time toilet training can usually be
2 years of age
started around _____.
A child should be able to speak two to
2 years (24 months)
three word sentences at _____.
A child should be able to speak three
to four word sentences at _____ of 3 years
A child should be able to states his/her
2.5 to 3 years
own first and last name by _____.
Is temper tantrums common among
toddlers (1 to 3 years)?
What is the import developmental task
of a toddler according to Erikson's Developing a sense of autonomy.
What are some age-appropriate toys board and mallet push/pull toys toy telephone
for the hospitalized toddler? stuffed animals storybooks with pictures
Toddlers benefit from being taken to the
What can the nurse do to promote the
hospital playroom, as mobility is very
developemental task of a toddler?
important to their development.
What are the average weight and
Each year gain about 5 lbs and grows 2.5 to 3
height gain for preschool children (3 to
5 years old)?
A child can use sissors at _____ of
4 years
A child should be able to ties shoelaces
5 years
at _____ of age.
Visual acuity approaches 20/20 at
Preschool age (3 to 5 years)
A preschool child thinking is _____
egocentric; concrete
and _____.
Super Condensed Portable HESI Study Guide 175

A child should be able to use sentences

3 to 5 years Preschool
of 5 to 8 words at _____ of age.
At this stage of developement, a child
learns sexual identity (curiosity and 3 to 5 years Preschool
masturbation common).
At this stage of development,
imaginary playmates and fears are Preschool (3 to 5 years)
At child at this development stage
begins to stands erect with more Preschool (3 to 5 years)
slender posture.
At this stage of development, a child
Preschool (3 to 5 years)
learns to run, jump, skip, and hop.
A child at this developmental stage
Preschool (3 to 5 years)
learns colors and shapes.
Imaginary playmates and fears are
Preschool (3 to 5 years)
common at this stage of development:
Aggressiveness at _____ is replaced
4 years; independence
by more _____ at 5 years.
Preschool child's major developmental
Developing a sense of initiative
taks according to Erikson theory is:
At this stage of development, the child
appears to be bowlegged and TODDLER (1 TO 3 YEARS)
At this stage of development, all
primary teeth (20) are present.
Nursing implications of hospitalized
egocentricity; (Explain that he/she did not
preschoolers (3-6 years) needs to
cause the illness and that painful procedures are
emphasize understanding of the child's
not a punishment for misdeeds.)
_____ or medical play to allow the
child to act out their experiences is Therapeutic play; Preschoolers
helpful for _____.
At this stage of development, fear of
mutilation from procedures is Preschool (3 to 5 years)
coloring books puzzles cutting and pasting
Toys and play for the hospitalized dolls building blocks clay toys that allow the
preschooler include: preschooler to work out hospitalization
The _____ needs preparation for
procedures. He or she needs to preschooler (3 to 6 years)
understand what is and what is not
Super Condensed Portable HESI Study Guide 176

going to be "fixed." Simple

explanations and basic pictures are
helpful. Let child handle equipment or
models of the equipment.
_____ are learning to name body parts
Toddlers (1-3 years)
and are concerned about their bodies.
During hospitalization, enforced
separation from parents is the greatest
toddler's (1 to 3 years)
threat to the _____ psychological and
emotional integrity.
Security objects or favorite toys from
toddlers (1 to 3 years)
home should be provided for _____.
Normal gain in weight and height for Each year gain 4 to 6 pounds and about 2
school-age child (6 to 12 years) are: inches in height.
Loss of primary teeth and eruption of
school-age child (6 to 12 years)
most permanent
At this stage of development fine and
school-age child (6 to 12 years)
gross motor skills mature.
During this developmental stage, girls
school-age (6 to 12 years)
may experience menarche.
At this stage of development, a child
should be able to dresses self- school-age child (6 to 12 years)
At this stage of development,
egocentric thinking is replaced by school-age child (6 to 12 years)
social awareness of others.
At this stage of development, a child
learns to tell time and understands school-age child (6 to 12 years)
past, present, and future.
At this stage of development, a child
school-age child (6 to 12 years)
learns cause and effect relationships.
Socialization with peers becomes
school-age child (6 to 12 years)
important at this stage of development:
A child's molars should erupt at _____. 6 years
According to Erikson's theory,
developing a sense of industry occurs school-age child (6 to 12 years)
at this stage:
A child should be able to write script
8 years
at _____.
The hospitalized _____ may need
more support from parents than they school-age child
wish to admit.
Super Condensed Portable HESI Study Guide 177

Maintaining contact with peers and

school activities is important during school-age child
hospitalization for a _____.
For school-age child, _____ and _____
privacy; modesty e.g., close curtains during
are important, and should be respected
procedures, allow privacy during baths, etc.
during hospitalization.
Participation in care and planning with
staff fosters a sense of _____ and
involvement; accomplishment
_____ for a school-age child (6-12
Toys for the hospitalized school-age (6 board games card games hobbies (such as
to 12 years) child include: stamp collecting, puzzles, and video games)
School-age children are in Erikson's
stage of _____, meaning they like to
do and accomplish things. _____ are industry; Peers
also becoming important for this age
Girls' growth spurt during adolescent
begins _____ than boys (may begin as earlier; 10
early as ___ for girls).
Boys catch up to girls' growth at age
_____ and continue to grow.
Girls finish growth around _____,
15; 17
boys around _____.
Adult-like thinking begins around age
_____. They can _____ and use _____ 15; problem solve; abstract
Secondary sex characteristics begins at
this developmental stage:
At this stage of development, family
connflict commonly occurs.
Hospilalization of adolescents disrupts
_____ and _____ activities; they need school; peer
to maintain contact with both.
Illness, treatments, or procedures
which alter the body image can be adolescent
viewed as devastating by the _____.
For this develpmental stage, teaching
about procedures should include time adolescent (12 to 18 years)
without parents present.
For this developmental group, some
assessment questions should be asked adolescent
without parents' presence.
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When teaching adolescent needs, the here and now i.e., how will this affect me
focus should be on _____. today?
Infants: After 6 months, their cognitive
Infants' concept of bodily injury:
development allows them to remember pain.
Toddlers' concept of bodily injury Toddlers: Fear intrusive procedures.
Preschoolers' concept of bodily injury Preschoolers: Fear body mutilation.
School ages' concept of bodily injury: School age: Fear loss of control of their body.
Adolescent: Major concern is change in body
Adolescents' concept of bodily injury:
administered at _____ months of age
12 to 15; 4 to 6; 11 to 12
and repeated at _____ years or by
_____ years.
In times of measles epidemic, it is
possible to give measles protection at 6 months; 15 months
_____ and repeat the MMR at _____.
Measles vaccine is contraindicated for
persons with history of anaphylactic
reaction to _____ or _____, those with neomycin; eggs; immunodeficiency; pregnant
known altered _____ and _____
MMR vaccine may be given to those
with HIV and breastfeeding women. T True
or F
MMR vaccines are administer _____
at separate sites.
A child may have a light transient ___
2 weeks after administration of MMR rash
DTaP Vaccine administration begins at
age ____, administer three doses at 2 months; 2 months
_____ intervals.
DTaP Vaccine: Booster doses given at
15; 18 months; 4 to 6 years.
_____ to _____; and at _____.
DTaP Vaccine: administer _____
(separate site from other vaccine).
DTaP Vaccine is not given to children
past the ______ birthday; they receive
_____ which contains full strength 7th; Td
protection against tetanus and lesser
strength diphtheria protection.
When pertussis vaccine is DT (full strength diphtheria and tetanus without
Super Condensed Portable HESI Study Guide 179

contraindicated, give _____, until 7th

pertussis vaccine)
Contraindications to pertussis vaccine
include: 1. _____ within 7 days of
previous dose of DTP. 2. History of Encephalopathy; seizures; Neurologic;
_____. 3. _____ symptoms after Systemic
receiving the vaccine. 4. _____
allergic reactions to the vaccine.
Parents should be instructed to begin
_____ administration after the
acetaminophen (Tylenol); 10 to 15
immunization (normal dosage is _____
IPV is recommended for all person
under the age of _____.
IPV is administer at _____ of age and
2 months; 4 months; 6 to 15 months; 4 to 6
again at _____ of age. Boosters are
given at _____ , and _____.
Administer IPV _____ or _____ at
subcutaneously; IM
separate site.
IPV is contraindicated for those with
history of anaphylactic reaction to neomycin; streptomycin
_____ or _____.
PRP-OPMs can be given as early as
2 months
____ of age.
DaTP/Hib combinations should not be
used as primary immunizations at ages 2; 4; 6 months
___, ___, or ___.
Children at high risk who were not
immunized with Hib previously should 5
be immunized after age _____.
Hib is administer ______. intramuscularly
_____ offers protection against
bacteria that causes serious illness
(epiglottitis, bacterial meningitis,
septic arthritis) in small children or
those with chronic illnesses such as
sickle cell anemia.
_____ offers protection against
hepatitis B. Typically, given to all
_____ prior to hospital discharge. Hepatitis B vaccine; newborns; 0; 18
Vaccinate all children _____ to _____
years of age.
Hepatitis B vaccine is contraindicated common baker's yeast
Super Condensed Portable HESI Study Guide 180

for persons with anaphylactic reaction

to _____.
Hepatitis B vaccine is administer
IM; 0 to 2 months; 1 to 4 months; 6 to 18
trough _____ site at _____ , _____,
and _____ of age.
_____ offers protection against
chickenpox. It is also a school entry
requirement in 33 states. And it is safe VARICELLA vaccine
for children with asymptomatic HIV
VARICELLA vaccine is administer at
12 to 18 months; 12 months
_____ of age (must beat least _____).
Give _____ and _____ vaccines on
same day or >30 days apart (separate MMR; varicella
Irritability, fever (<102 F), redness and
soreness at injection site for 2 to 3
days are normal side effects of _____
and _____ administration.
Following immunization, call health
care provider if _____, _____, or seizures; high fever; high-pitched crying occur
Following immunization, a _____ on
the thigh injection site and _____ the
warm washcloth; "bicycling"
legs with each diaper change will
decrease soreness.
Following immunization,
acetaminophen (Tylenol) is
4 to 6; 10 to 15
administered orally every _____ hours
(_____ mg/Kg).
The common cold is not a
contraindication for immunization. T True
or F
A highly contagious, viral disease that
can lead to neurologic problems or RUBEOLA (Measles)
RUBEOLA (Measles) is transmitted Direct contact with droplets from infected
by _____. person.
RUBEOLA (Measles) is contagious
mainly during the _____ which is
prodromal period; fever; upper respiratory
characterized by _____ and _____
Classic symptoms of RUBEOLA Photophobia Koplik's spots on the buccal
Super Condensed Portable HESI Study Guide 181

mucosa. Confluent rash that begins on the face

(Measles) include:
and spreads downward.
Viral disease characterized by skin
Chicken Pox lesions begin on the
_____ and spread to the _____ and trunk; face; proximal extremities
Chicken Pox progresses through
_____, _____, _____, and _____ macular; papular; vesicular; pustular
Chicken Pox transmitted by ____, direct contact; droplet spread; freshly
_____, or _____. contaminated objects
Chicken Pox communicability end
scabs have formed
when _____.
Common viral disease which has
teratogenic effects on fetus durina the RUBELLA (German Measles)
first trimester of pregnancy.
RUBELLA (German Measles) is
droplet; direct contact with infected person
transmitted by _____ and _____.
RUBELLA (German Measles) is
discrete red maculopapular rash; face; entire
charcterized by _____ starts on _____
and rapidly spreads to _____.
RUBELLA (German Measles) rash
3 days
disappears within _____.
An acute, infectious respiratory
Pertussis (Whooping cough)
disease usually occurring in infancy.
Pertussis is caused by a _____. gram-negative bacillus
PERTUSSIS (Whooping Cough)
upper respiratory symptoms
begins with _____.
_____ is a paroxysmal state of the
disease is characterized by prolonged
PERTUSSIS (Whooping Cough)
coughing and crowing or whooping
upon inspiration.
PERTUSSIS (Whooping Cough) lasts
4 to 6 weeks
from _____.
PERTUSSIS (Whooping Cough) is
direct contact; droplet spread; freshly
transmitted by _____, _____, or
contaminated objects
PERTUSSIS (Whooping Cough) is
treated with _____.
PERTUSSIS (Whooping Cough)
pneumonia; hemorrhage; seizures
complications include _____, _____,
Super Condensed Portable HESI Study Guide 182

and _____.
Question Answer Hint
Which action should the nurse
Give one hour before or two hours after a meal.
implement when administering a
Average transit time from stomach to
prescription drug that should be given
duodenum is 2 hours.
on an empty stomach?
The nurse is caring for a client who is
unable to void. The plan of care
establishes an objective for the client
Drinks 240ml of fluid five times during the
to ingest 1000ml of fluid between 7am
and 3pm. Which client response
should the nurse document that
indicates a sucessful outcome?
A client with metastatic cancer is
preparing to make decisions about end It will identify someone that can make
of life issues. When the nurse explains decisions for your health care if you are in a
a durable power of attorney for health coma or vegetative state.
care, which description is accurate?
The nurse is caring for a client who is
the daughter of a local politician.
When the nurse approaches a man who
is reading the names on the hall doors,
he identifies himself as a reporter for Confidentiality
the local newspaper and requests
information about the client's status.
Which standard of nursing practice
should the nurse use to respond?
A client with acute hemorrhagic
anemia is to receive four units of
packed RBC's (red blood cells) as
Ensure the accuracy of the blood type match.
rapidly as possible. Which intervention
is most important for the nurse to
A male client who had abdominal
surgery has a nasogastric tube to Apply a water soluble lubricant to the lips, oral
suction, oxygen per nasal cannula, and mucosa, and nares. Petroleum based products
complains of dry mouth. Which action are flammable.
should the nurse implement?
A client with chronic renal failure
selects a scramble egg for his Commend the client for selecting a high
breakfast. Which action should the biologic value protein.
nurse take?
The nurse is administering meds Flush the tube with water. NGT should be
through a NG tube which is connected flushed before, after, and in between each med
to suction. After ensuring correct tube adminstered.
Super Condensed Portable HESI Study Guide 183

placement, what action should the

nurse take next?
The nurse notices that the mother of a
9 year old Vietnamese child always
Continue asking the mother questions about the
looks at the floor when she talks to the
nurse. What action should the nurse
When assessing a client with wrist
restraints, the nurse observes that the
fingers on the right hand are blue. Loosen the right wrist restraint.
What action should the nurse
implement first?
A client who is 5'5 tall and weighs
200lbs is scheduled for surgery the
What vitamin and mineral supplements do you
next day. What question is most
take? Vitamins affect meds.
important for the nurse to include
during the preoperative assessment?
An african american grandmother tells
the nurse that 4 year old grandson is
Inquire about the source and type of pain.
suffering with miseries. Based on this
Different cultural have different words.
statement, which focused assessment
should the nurse conduct?
In developing a plan of care for a
client with dementia, the nurse should often follows relocation to new surroundings.
remember that confusion in the elderly
The nurse is instructing a client with
high chholesterol about diet and life
I will limit my intake of beef to 4 ounces per
style modification. What comment
week. saturated fat from animal > cholesterol
from the client indicates that the
teaching has been effective?
The nurse is interviewing a female
client whose spouse is present. During
the nterview, the spouse answers most
Ask the spouse to step out for a few minutes.
of the questions for the client. Which
action is best for the nurse to
A young mother of three complains of
increased anxiety during her annual
Nutritional history
physical exam. What information
should the nurse obtain first?
A nurse takes a female client to the
examination room and asks her to Tell me about your undergarments so we can
remove her clothes and put on an discuss how you can have your examination
examination gown with the front open. comfortably.
The woman states "I have special
Super Condensed Portable HESI Study Guide 184

undergarments that I do not remove

for religious reasons." How should the
nurse respond?
The nurse determines that a client's
body weight is 105% above teh
standardized height-weight scale.
Inadequate lifestyle changes in diet and
Which related factor should the nurse
include in the nursing diagnosis,
"Imbalanced nutrition: more than body
A postoperative client will need to
perform daily dressing changes after
discharge. Which outcome statement Demonstrates the wound care procedure
best demonstrates the client's readiness correctly
to manage his wound care after
discharge? The client
An elderly male client who is
unresponsive following a cerebral
vascular accident (CVA) is receiving
bolus enteral feedings though a Fowlers' (Semi-sitting)
gastrostomy tube. What is the best
client position for administration of the
bolus tube feedings?
The nurse plans a teaching session
with a client but postponses the Activity intolerance related to postoperative
planned session based on which pain.
nursing diagnosis?
The nurse is preparing to adminster IV
fluid to a client with a strict fluid
restriction. IV tubing with which Buterol attachment
feature is most important for the nurse
to select?
An elderly resident of a long-term care
facility is no longer able to perform
self care and is becoming
progressively weaker. The resident
Notify the healthcare provider of the family's
previously requested that no
resusciative efforts be performed, and
the family requests hospice care.
WHat action should the nurse
implement first?
Prior to transferring a client to a chair
using a mechanical lift, what is teh
Tolerance of exertion.
most important client characteristic the
nurse should assess?
Super Condensed Portable HESI Study Guide 185

Which snack food is best for the nurse

to provide a client with myasthenia
Chocolate pudding
gravis who is at risk for altered
nutritional status?
The nurse observes that a male client
has removed the covering from an ice Observe the appearance of the skin under the
pack applied to his knee. Which action ice pack.
should the nurse take first?
While instructing a male client's wife
in the performance of passive range of
motion exercises to his contracted
Acknowledge that she is supporting the arm
shoulder, the nurse observes that she is
holding his arm above and below the
elbow. What nursing action should the
nurse implement?
When evaluating a client's plan of
care, the nurse determines that a
desired outcome was not achieved. Note which actions were not implemented.
Which action will the nurse implement
The nurse assigns a UAP to obtain
vital signs from a very anxious client.
Report the vital signs to the nurse.
What instructions should the nurse
give the UAP?
During a visit to the outpatient clinic,
the nurse assess a client with severe
Degree of flexion and extension of the client's
osteoarthritis using a goniometer.
knee joint.
Which finding should the nurse expect
to measure?
The nurse is assessing an older client
and determines that the client's left
upper eyelid droops, covering more of
Ptosis of the left eyelid.
the iris than the right eyelid. Which
description should the nurse use to
document this finding?
A female client asks the nurse to find
someone who can translate into her
Request and document the name of the certified
native language her concerns about a
treatment. Which action should the
nurse take?
The nurse is teaching a client proper
use of an inhaler. When should the
client administer the inhaler-delivered During the inhalation.
medication to demonstrated correct
use of the inhaler?
Super Condensed Portable HESI Study Guide 186

The nurse observes an unlicensed

personnel (UAP) taking a client's
blood pressure with a cuff that is too
Reassess the client's blood pressure using a
small, but the blood pressure reading
larger cuff.
obtained is within the client's usage
range. What action is most important
for the nurse to implement?
A client is brought into the emergency
department following a sudden cardiac
arrest. A full code is started. FIve
minutes later the family arrives with a
durable power of attorney signed by
Stop the code immediately.
the client requesting that no
extraordinary measures be taken,
including intubation, to save the
client's life. What action should the
nurse take?
The nurse dons gown, mask with
eyeshield, and gloves before entering a
client's room that has airborne
precautions. Upon leaving the client's Remove gloves, gown, mask, wash hands
room, in which sequence should the
nurse remove the personal protective
When documenting assessment data,
S1 murmur auscultated in supine position:
which statement should the nurse
Objective data
record in the narrative nursing notes?
An obese male client discusses with
the nurse his plans to begin a long-
term weight loss regimen. In addition
to dietary changes, he plans to begin
Be sure to have a complter physical exam
an intendive aerobic exercise program
before beginning your planned exercise
3 to 4 times a week and to take stress
managment classes. After praising the
client for his decision, which
instruction is most important for the
nurse to provide?
A male client being discharged with a
prescription for the bronchodilator
theophylline tells the nurse that he
understands he is to take three doses of
the medication each day. Since, at the 8am, 4pm, 1200 midnight. q 8hrs
time of discharge, timed-release
capsules are not available, which
dosing schedule should the nurse
advise the client to follow?
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The nurse is preparing to administer a

high volume saline enema to a client.
History of inflammatory bowel disorder
Which information is most important
scrymptoms: diarhhea, hematuria, perforation
for the nurse to obtain prior to
administering the enema?
Question Answer Hint
pH: 7.35-7.45 high--alkalosis PaCO2: 35-45
ABG Values: pH PaCO2 PaO2
high-- acidosis Pa02: 75-100
Ca+ level 9-11
Creatinine: K+: Na+: Creatinine: 0.2-1.0 K+: 3.5-5 Na+: 135-145
Mg: Phos: Mg: 1.5-2.5 Phos: 2.8-4.5
Hgb: Hct: Hgb: 12-18 Hct: 38-55
Platelets WBC'S RBC's (erthrocytes) 150-400 4-11(,000,000) 4-6
PERRLA Cranial Nerve? Smile
PERRLA: II (Optic) Smile: VII (Facial) Gag: X
Cranial Nerve? Gag reflex Cranial
(Vagus) XII (Hypoglossal) Shoulder Shrug: XI
Nerve? Shoulder Shrug Cranial
Normal Values: CCP: MAP: ICP: CCP: 70-100 MAP: 50 ICP: 0-15
What heals slowest? Cartilage, ligaments
Upper UTI sx: CVA tenderness
ITP (immune thrombocytopenia Splenectomy (reduced destruction of platelets
purpura) tx: by macrophages)
Urine Specific Gravity: 1.003-1.030
MI Lab Values: elevated Troponin 0.02 normal CK-MB 0-9 normal
Band Neutrophils normal 0-8%
acute infection-- shift to the left
increased in:
O olfactory O optic O oculomotor T trochlear T
trigeminal A abducens F facial A auditory G
Cranial Nerves:
glossopharyngeal V vagus A accessory H
Question Answer Hint
prompt zinc suspension insulin
human insulin lispro (Humalog) Rapid-Acting
insulin aspart (Novolog) Rapid-Acting
regular insulin (human) Short acting
isophane insulin (NPH) (Iletin) Intermediate acting
insulin zinc suspension (Humulin L) Intermediate acting
protamine zinc (PZI) Long-Acting
Super Condensed Portable HESI Study Guide 188

extended zinc suspension (Ultralente) Long-Acting

insulin glargine (Lantus) Long-Acting
prompt zinc suspension insulin
0.5 to 1 hour 2 to 3 hours
(Semilente) Onset Peak
human insulin lispro (Humalog) Onset
0.5 to 1 hour 2 to 4 hours
5 to 15 minutes 0.75 to 1.5 hour Give within 15
insulin aspart (Novolog) Onset Peak
min of a meal.
Lispro may be given intravenously. Give within
Nursing implications for Lispro (2)
15 min of a meal.
isophane insulin (NPH) (Iletin) Onset
1 to 2 hours 6 to 12 hours
insulin zinc suspension (Humulin L)
1 to 2 hours 6 to 12 hours
Onset Peak
protamine zinc (PZI) Onset Peak 4 to 8 hours 14 to 20 hours Not to be given IV.
extended zinc suspension (Ultralente)
1.1 hours 5 hours
Onset Peak
insulin glargine (Lantus) Onset Peak 1.1 hours 5 hours
30 to 60 minutes 2 to 3 hours Regular insulin
regular insulin (human) Onset Peak
may be given IV.
Question Answer Hint
What are the 5 steps of the nursing assessment analysis planning implementation
process? evaluation
Define assessment? gather objective and subjective data verify data
interpret data collect additional data when
necessary identify and communicate nursing
Define analysis?
diagnoses determine health team's ability to
meet client's needs
determine and prioritize goals of care. Include
client, significant others, and health team in
Define planning?
setting goals develop and modify plan for
delivery of client's care
organize and manage the client's care perform
or assist in performance of client's care counsel
Define implementation? and teach client, significant others, and health
team provide care specifically directed toward
achieving goals
compare actual outcomes with expected
outcomes evaluate compliance with the
Define evaluation? established regimen or plan record and describe
client's response to plan modify plan as
indicated, and set priorities
Super Condensed Portable HESI Study Guide 189

What are the 2 components of the

response etiology
nursing diagnosis?
includes potential or actual health response
describes measurable outcomes that can be
The RESPONSE component of a
derived cites potential for changes based on
nursing diagnosis is?
nursingn actions example: alteration in
comfort, pain
includes potential or actual health response
The ETIOLOGY component of a addresses independent, inter- dependent, and
nursing diagnosis is? dependent nursing functions example: related
to fractured left ankle
activity/rest circulation elimination emotional
Name 13 NANDA-Approved Nursing reactions food/fluid hygiene neurologic pain
Diagnoses? relationship alterations safety sexuality
teaching/learning ventilation
Activity Intolerance Activity Intolerance,
Name the Activity/Rest NANDA- Potential Disuse Syndrome, Potential for
Approved Nursing Diagnoses? (7) Diversional Activity Deficit Fatigue Physical
Mobility, Impaired Sleep Pattern Disturbance
Decreased Cardiac Output Tissue Perfusion,
Name the Circulation NANDA- Altered (Specify type: renal, cerebral,
Approved Nursing Diagnoses? (3) cardiopulmonary, GI, peripheral) high risk for
peripheral neurovascular dysfunction
Constipation Constipation, Colonic
Constipation, Perceived Diarrhea Incontinence,
Name the Elimination NANDA- Bowel Incontinence, Functional Incontinence,
Approved Nursing Diagnoses? (12) Reflex Incontinence, Stress Incontinence, Total
Incontinence, Urge Urinary Elimination,
Altered Urinary Retention
Adjustment, Impaired Anxiety Body Image
Disturbance Individual Coping, Ineffective
Defensive Coping Denial, Ineffective
Decisional Conflict (Specify) Fear Grieving,
Anticipatory Grieving, Dysfunctional
Name the Emotional Reactions Hopelessness Post-Trauma Response
NANDA-Approved Nursing Powerlessness Personal Identity Disturbance
Diagnoses? (22) Rape-Trauma Response Rape-Trauma
Syndrome Rape-Trauma Syndrome: Compound
Reaction Rape-Trauma Syndrome: Silent
Reaction Relocation Stress Syndrome Self-
Esteem, Chronic Low Self-Esteem, Situational
Low Spiritual Distress
Breastfeeding, Ineffective Interrupted
Name the Food/Fluid NANDA-
Breastfeeding Fluid Volume, Excess Fluid
Approved Nursing Diagnoses? (12)
Volume Deficit, Potential Nutrition Less than
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Body Requirements, Altered Nutrition More

than Body Requirements, Altered Nutrition,
Potential for more than Body Requirements,
Altered Oral Mucous Membrane, Altered
Swallowing, Impaired Ineffective Infant
Feeding Pattern
Health-Seeking Behaviors (Specify) Self-Care
Name the Hygiene NANDA-Approved
Deficit: ---Bathing/Hygiene ---Toileting
Nursing Diagnoses? (2)
---Feeding ---Dressing/Grooming
Communications, Impaired Verbal Dysreflexia
Unilateral Neglect Sensory/Perceptual
Name the Neurologic NANDA-
Alterations (Specify type: visual, auditory,
Approved Nursing Diagnoses? (5)
kinesthetic, gustatory, tactile, olfactory)
Thought Process, Altered
Name the Pain Nanda-Approved
Pain Pain, Chronic
Nursing Diagnoses? (2)
Family Coping: Compromised, Ineffective
Family Coping: Disabling, Ineffective Family
Process, Altered Parental Role Conflict
Name the Relationship Alterations Parenting, Altered Role Performance, Altered
NANDA-Approved Nursing Self-Esteem, Chronic Low Self-Esteem,
Diagnoses? (13) Situational Low Self-Esteem Disturbance
Social Interaction, Impaired Social Isolation
Caregiver Role Strain High Risk for Caregiver
Body Temperature, Potential Altered Health
Maintenance, Altered Home Maintenance
Management, Impaired Hyperthermia
Hypothermia Infection, Potential for Injury,
Potential for Poisoning, Potential for
Name the Safety NANDA-Approved
Suffocation, Potential for Trauma, Potential for
Nursing Diagnoses? (17)
Skin Integrity, Impaired Skin Integrity,
Potential Impaired Thermoregulation,
Ineffective Tissue Integrity, Impaired Violence,
Potential for: Self-directed or directed at others
High Risk for Self-Mutilation
Name the Sexuality NANDA-
Sexual Dysfunction Sexual Patterns, Altered
Approved Nursing Diagnoses? (2)
Growth and development, altered Knowledge
Name the Teaching/Learning deficit (specify) Noncompliance (specify)
NANDA-Approved Nursing Ineffective management of therapeutic regimen
Diagnoses? (5) (individuals) Therapeutic regimen:
(community, families): ineffective management
Name the Ventilation NANDA- Airway clearance, ineffective Aspiration,
Approved Nursing Diagnoses? (6) potential for Breathing pattern, ineffective Gas
Super Condensed Portable HESI Study Guide 191

exchange Dysfunctional ventilatory weaning

response Inability to sustain spontaneous
Name Maslow's Hierarchy of Needs in Physiologic Safety Love and Belonging Esteem
order. (6) and Recognition Self-Actualization Aesthetic
What is the definition of Maslow's Biologic needs for food, shelter, water, sleep,
Physiologic? oxygen, sexual expression
What is the definition of Maslow's Avoiding harm; attaining security, order, and
Safety? physical safety
What is the definition of Maslow's Giving and receiving affection; companionship;
Love and Belonging? and identification with a group
What is the definition of Maslow's Self-esteem and respect of others; success in
Esteem and Recognition? work; prestige
What is the definition of Maslow's
Fulfillment of unique potential
What is the definition of Maslow's
Search for beauty and spiritual goals
The priority biologic need is? breathing i.e. open airway
Ensuring that the client's environment
is 1____ is a priority, e.g., teaching an
older client to remove throw rugs
which pose a safety hazard when
1 SAFE 2 safety 3 coping
ambulating would have a greater
priority than teaching how to use a
walker - FIRST priority is 2____, then
3____ skills.
Which action has a higher
priority...assisting the client in
sense of belonging comes first, and such a
becoming a part of a support group...or
sense might help in developing self-esteem
assisting him/her in developing self-
What provides the laws that control
Nurse Practice Acts
the practice of nursing in each state?
A tort is an act involving injury or
damage to another (except 1_____ of
contract) resulting in 2_____ liability 1 breech 2 civil 3 criminal
(i.e. the victim can sue) instead of
3_____ liability (see crime).
Two unintentional torts are? negligence malpractice
Negligence is a form of ______ tort
whereby performing an act that a
unintentional reasonableness
reasonable and prudent person would
not do. Measure of negligence is
Super Condensed Portable HESI Study Guide 192

"_____" (i.e. would a reasonable and

prudent nurse act in the same manner
under the same circumstance?)
Malpractice is a form of ______ tort
whereby there is negligence of
professional _____, e.g., professional
unintentional misconduct
misconduct, or unreasonable lack of
skill in carrying out professional
What four elements are necessary to
prove negligence/malpractice and if
duty breach of duty injury/damages causation
any element is missing, it cannot be
What is DUTY? (one of the four The obligation to use due care (what a
elements that proves reasonable, prudent nurse would do) Failure to
negligence/malpractice and cannot be care for and/or to protect others against
missing) unreasonable risk.
DUTY (one of four elements of
negligence/malpractice) must _______
foreseeable risks. Example: If a floor
has water on it, the nurse is
responsible for anticipating the risk to
the client of falling.
What is BREACH OF DUTY? (one of
the four elements that proves Failure to perform according to the established
negligence/malpractice and cannot be standard of conduct in providing nursing care.
What is INJURY/DAMAGES? (one of
Failure to meet standard of care, which causes
the four elements that proves
actual injury or damage to the client, either
negligence/malpractice and cannot be
physical or mental.
What is CAUSATION? (one of the
A connection exists between conduct and the
four elements that proves
resulting injury referred to as "proximate
negligence/malpractice and cannot be
cause" or "remoteness of damage"
Hospital policies provide a guide for
nursing 1_____. They are NOT 2____,
but courts generally rule against nurses
who have violated the employer's 1 actions 2 laws
policies. Hospitals can be liable for
poorly formulated or poorly
implemented policies.
What alerts administration to possible
liability claims and the need for Incident report protect
investigation; they do NOT _____
Super Condensed Portable HESI Study Guide 193

against legal action being taken for

negligence or malpractice.
Burning a client with a hot water bottle
or heating pad is an example of?
Two forms of intentional tort are? assault battery
What is the term used for mental or
physical threat, e.g., forcing (without
touching) a client to take a medication
or treatment?
What is the term used when touching,
with or without the intent to do harm,
e.g., hitting or striking a client. If a
mentally competent adult is forced to
have a treatment and has refused, this
Leaving sponges or instruments in a
client in surgery is an example of?
What is the term for encroachment or
trespassing on another's body and/or invasion of privacy
Confinement without authorization? false imprisonment
Exposure or discussion of the client's
case. After death, the client has a right
to be unobserved, excluded from
exposure of a person
unwarranted operations, and protected
from unauthorized touching of the
Performing incompetent assessments
is an example of?
Divulgence of privileged information
or communication, e.g., from charts, defamation
conversations, or observations?
Failing to heed warning signs of shock
or impending MI is an example of?
Willful and purposeful
misrepresentation that could cause, or
has caused, loss or harm to a person or
Ignoring signs and symptoms of
bleeding is an example of?
Presenting false credentials for the
purpose of entering nursing school, fraud
obtaining a license, or obtaining
Super Condensed Portable HESI Study Guide 194

employment is termed?
A legal term meaning the accused is
not criminally responsible for the
unlawful act committed due to mental
Forgetting to give a medication or
giving the wrong medication is an negligence/malpractice
example of?
An act contrary to a criminal statute.
Wrongs punishable by the state,
committed against the state, with
intent usually present.
Legal hearing that is held to determine
a person's capability to make
competency hearing
responsible decisions about self,
dependent, or property?
Persons declared incompetent have the
vote make contracts or wills drive a car sue or
legal status of a minor, i.e., they
be sued hold a professional license
cannot? (5)
If a person is incompetent, a _____ is
appointed. Declaring a person
guardian state
incompetent can be initiated by the
____ or family.
An admission whereby any adult may
apply for another. However, medical
emergency admmission
or judicial approval is required to
detain anyone beyond 24 hours.
Emergency admissions allow persons
held against their will to file a ____
habeas corpus
_____ to try and get the court to hear
their case and release them.
With emergency admissions, the court
determines the ____ and alleged sanity
unlawful restraint of a person.
Question Answer Hint
1 km = _ m 1,000
1 m = _ cm 100
1 cm = _ mm 10
1 L = _ ml 1000
1 ml = _ cm3 1
1 kg = _ g 1000
1 g =_ mg 1,000
Super Condensed Portable HESI Study Guide 195

1 mile = _ yds 1760 yds

1 mile =_ ft 5280 ft
1 yd = _ ft 3 ft
1 ft =_ in 12 in
1 gallon = _ qts 4 qts
1 gallon = _ oz 128 oz
1 qt = _ pints 2 pints
1 pint = _ cups 2 cups
1 cup =_ oz 8 oz
1 oz = _ cm3 30
1 kg =_g 1000
1 g = _ mg 1000
1 ton =_ Ibs 2,000
1 Ib=_ oz 16 oz
1 Kg = __ lbs. 2.2 lbs.
1 oz = __ g 30 g
15 g = __ dr 4 dr
1 g = __ gr 15 gr
1 gr = __ mg 60 mg
1 qt = __ pints 2 pints
1 pint = __ fluid oz 16 fluid oz
1 fluid oz = __ fluid drams 8 fluid drams
1 fluid dram = __ (m) minims 60 m (minims)
1 minim = __ drops (gt) 1 drop
1 oz = __ grains 480 gr
1 oz = __ drams 8 drams
1 dram = __ grains 60 grains
1 t = __ drops 60 drops
1 T = __ t 3t
1 oz = __ T 2T
1 L = __qt; __oz 1 qt; 32 oz
1 in = __ cm 2.54 cm
1 oz = __ml; __dr; __T; __t 30 ml; 8 dr; 2 T; 6 t
Question Answer Hint
List the major CNS danger signals that Lethargy, high-pitched cry, jitteriness, seizure,
occur in the neonate. and bulging fontanelles.
Super Condensed Portable HESI Study Guide 196

A baby is deleivered blue, and with

Begin oxygenation by bag and mask at 30 to 50
heart rate <100. The nurse dries the
breaths per minute. If heart rate is <60, start
infant, suctions the oropharynx and
cardiac massage at 120 events per minute. (30
gently stimulates the infant while
breaths and 90 compressions). Assist health
blowing O2 over the face. The infant
care provider in setting up for intubation
still does not respond. What is the next
nursing action?
What does the Silverman-Anderson
Respiratory difficulty.
index measure?
What ar two complications of O2 Retroplacental fibroplaisas and
toxicity? bronchopulmonary dysplasia
Necrotizing enterocolitis results from
Ischemic hypoxia, abdominal distetion, sespis,
___________ and is manifested
and a lack of absorption from intestines; injury
by_______. Ischemia/hypoxia results
to the inestinal mucosa.
in _____-__.
Inraventricular hemorrhage is more
premature neonates and VLBW babies;
common __________and results in
increased intracranial pressure
symptoms of ___________.
Respiratory distress syndrome: alveolar
Wht conditions make oxygenation of
prematurity and lack of surfactant; anemia;
the newborn more difficult?
In order to prevent problems with
oxygenating the newborn, what Po2 50 to 90; SvO2 60 to 80mmHg
parameters can the nurse observe?
Lethargy, tempetature instability, difficulty
What are the cardinal symptoms of
feeding, subtle color changes, subtle behavioral
sepsis in a newborn?
changes, and hyperbilirubinemia.
Place under radiant warmer or in incubator
A premature baby is born and develops
with temperature skin probe over liver. Warm
hypothermia. State the major nursing
all items touching newborn. Place plastic wrap
interventions t treat hypothermia.
over neonate.
Nurses often weigh diapers in order to Daiper is weighed in grams before being
determine exact urine output in the applied to infant. Diaper is weighed after infant
high-risk neonate. Explain this has wet it. Each gram of added weight is
procedure. calculated and recorded as 1 ml of urine.
What factors does a nurse look for in infant has good suck, has coordinated suck-
determining a newborn's ability to take swallow, takes less than 20 minutes to feed,
in nourishment by nipple and mouth? gains 20 to 30g/day.
What complications are associated Hyperglycemia, electrolyte imbalance,
with total parenteral nutrition? dehydration, and infection.
In order to prevent rickets in the
preterm in the preterm newborn, what Calcium and Vitamin D.
supplements are given?
Super Condensed Portable HESI Study Guide 197

Initiate early visittaion at ICU. Provide daily

List four nursing interventions to
information to family. Encourage partcipation
enhance family and parent adjustment
in support group for parents. Encourage all
to a high-risk newborn.
attempts at care giving (enhances bonding).
List the factors for Rh incompatibility, ABO incompatibility,
Hyperbilirubinemia. prematurity, sepsis, perinatal asphyxia
Bilirubine levles rising 5mg/day, jaundice, dark
List the symptoms of
urine, anemai, High reticulocyte (RBC) count,
hyperbilirubinemia in the neonate.
and dark stools.
Question Answer Hint
The nurse is providing instructions to a
68 year old client who is at high risk
Increase intake of soluble fiber to 10 to 25
for development of coronary heart
grams per day.
disease (CHD). Which intervention
should the nurse include?
An Adult client is admitted to the
hospital burn unit with second and
third degree burns over 40% of the
Regenerative function of the skin is absent
body surface area. In assessing the
because the dermal layer has bbeen destroyed.
potential for skin regeneration, what
should the nurse remember about thrid
degree burns?
Which description of symptoms is
Sudden, stabbing, severe pain over the lip and
charcteristic of a client diagnosed with
trigeminal neuralgia (Tic dououreux)?
Prior to a cardiac catherization, which
activity should the nurse have the Valsalva's manuever and coughing.
client practice?
A client is placed on respirator
following a cerebral hemmorhage, and
vecuronium bromide (Norcuron) . Impaired communication related to paralysis of
04mg/kg q 12h IV is prescribed. skeletal muscles.
Which nursing diagnosis is the
Which client should the nurse
Obese older male client with a short, thick
recognize as most likely to experience
sleep apnea?
A client receiving cholestyramine
(Questran) for hyperlipidemia should Vit K (Thse drugs reduce the absorption of the
be evaluated for what vitamin fat soluble vitamins ADEK.
The nurse identifies bright red
Mark the drainage on the dressing and take
drainage, about 6 cm in diameter, on
vital signs.
the dresssing of a client who is one
Super Condensed Portable HESI Study Guide 198

day post abdominal surgery. Which

action should the nurse take next?
A client is admitted to the hospital
with a diagnosis of severe acute
Lower left quadrant pain an da low-grade fever.
diverticulitis. Which assessment
(sigmoid most common site)
finding should the nurse expect this
client ot exhibit?
The nurse is assessing the lab results
for a client who is admitted with renal Serum Potassium of 5.5 mEq and total calcium
failure and osteodystrophy. Which of 6mg/dl. Renal failure (hyperKalemia and
findings are consistent with this Hypocalcemia)
client's clinical picture?
The nurse is assessing a client lab
values following administration of Serum calcium 5.0mg/dl. TLS results in
chemotherapy. Which lab values leads hyperkalemia, hypocalcemia, and
the nurse to suspect that the client is hyperuricemia.
experiencing tumor lysis syndrome?
A client who is HIV positive ask the
Aids is diagnosed when a specifc oppurtunistic
nurse, "How will I know when I have
infection is found in an other wise healthy
Aids"? Which response is best for the
nurse to provide?
A splint is prescribed for nightitme use
by a client with rhuematoid arthritis.
Which statement by the nurse provides Prevention of deformities.
the most accurate explanation for use
of the splints.
Then nurse is planning care for a client Risk for injury related to denial of deficits and
who has a right hemispheric stroke. impulsiveness. Right brain damage= difficulty
Which nursing diagnosis should the in judgement and spatial perception.
nurse include in the plan of care? Left=speech issues and language deficits
Then nurse knows that lab values
sometimes vary for the older client.
Increased protein in the urine, slightly
Which data should the nurse expect to
increased serum glucose levels.
find when reveiwing lab values of an
80 year old male?
The nurse is planning care to prevent Maintain a Fluid fo 3 to 4 l per day. Malignant
complication for a client with multiple plasma cells that infiltrate bone casue
myeloma. Which intervention is most demineralization>>>promote excretion of
important for the nurse to include? calcium
The nurse is assessing a client with
bacterial meningitis. Which Cyanosis of fingertips Emboli lodge in small
assessment finding indicates the client arterioles of extermities
may have developed septic emboli?
A client who is sexually active with Using an IUD offers no protection against
Super Condensed Portable HESI Study Guide 199

several partners requests an IUD as a

sexually transmitted diseases (STD), which
contraceptive method. Which
increae the risk of pelvic inflammatory disease.
information should the nurse provide?
In preparing a discharge plan for a 22
year old male client diagnosed with
Buerger's disease (thromboangitis Smoking cessation program.
oblitrans), which referral is most
An 81 year old male client has
emphysema. He lives at home with his
cat and manages self care with no
difficulty. When making a home visit, Help the client to determine ways to increase
the nurse notices that his tongue is his fluid intake.
somewhat cracked and his eyeballs are
sunken into his head. What nursing
intervention is indicated?
Based on the analysis of the client's Anticoagulant therapy. THe nurse should
atrial fibrillation, the nurse should prepare for anticoag therapy which is
prepare for which treament protocol. prescribed before rhythmn control.
A client with cirrhosis develops
increasing pedal edema and ascites.
What dietary modification is most Restrict salt and fluid intake.
important for the nurse to teach this
Which reaction should the nurse
identify in a client who is responding
Increased Heart rate
to stimulatiion of the sympathetic
nervous system?
Thenurse is preparing a teaching plan
for a client who is newly diagnosed
with Type 1 diabetes mellitus. Which Sweating, trembling, tachycardia Hyper: Poly
signs and symptoms should the nurse uria, dipsia, phagia, fruity breath tachypnea
describe when teaching the client
about hypoglycemia?
A client who is receiving
chemotherapy asks the nurse, "Why is
Chemotherapy affects the cells of the body that
so much of my hair falling out each
grow rapidly, both normal and malignant.
day"? WHich response by the nurse
best explains the reason for alopecia?
Which finding should the nurse
identify as most significant for a client 3+ bacteria in urine
diagnosed with polycystic disease?
A female client receiving IV
vasopressin (Pitressin) for esophageal Start an IV nitro infusion
varice rupture reports to the nurse that
Super Condensed Portable HESI Study Guide 200

she feels substernal tightness and

pressure across her chest. Which PRN
protocol should the nurse initiate?
The nurse is assessing a client with
Chronic Renal Failre. Which finding is
Potassium 6.0 mEQ>
most important for the nurse to
respond to first?
A male client receives a local
anesthetic during surgery. During the
Evaluate his blood pressure, pulse, and
post-operative assessment, the nurse
respiratory status.
notices the client is slurring his speech.
Which action should the nurse take?
Which assessment finding by the nurse
during a client's clinical breast exam A newly retracted nipple.
requires follow-up?
A client is being admitted to the
medical unit from teh emergency dept
after having a chest tube inserted. Rubber tipped clamp (assesses air leaks)
What equipment should be brought to
his client's room?
Which information should thenurse
give a client with chronic renal failure Avoid salt subsitutes
A client who is one week
postoperative after an aortic valve
replacemnt suddenly develops severe
pain in the left leg. On assessment, the
Keep client in bed in the supine position (anti-
nurse determines that the client's leg is
coagulan therapy & rest)
pale and cool, and no pulses are
palpable in the left leg. After notifying
the healthcare provider, which action
should the nurse take?
After the fourth dose of gentamicin
sulfate (Garamycin) IV, the nurse
plans to draw blood samples to 5 m,inutes before and 30 minutes after the next
determine peak and trough levels. dose.
When are the best times to draw these
When teaching diaphragmatic
Place a small book or magazine on the
breathing to a client with chronic
abdomen and make it rise while inhaling
obstructive pulmonary (COPD), which
information should the nurse provide?
A client taking a thiazide diuretic for
the past six months has a serum A potassiium supplement will be prescribed.
potassium level of 3. The nurse
Super Condensed Portable HESI Study Guide 201

anticipates which change in

prescription for the client?
A 20 year old female client calls the
nurse to report alump she found in her Most lumps are benign, but it is always best to
breast. Which response is the best for come in for an examination.
the nurse to provide?
Which intervention should the nurse
implement for a female client Encourage the client to perform Kegel
diagnosed with pelvic relaxation exercises 10 times daily.
During a health fair, a 72 year odl
male client tells the nurse that he is
experiencing shortness of breath.
Auscultation reveals crackles and
wheezing in both lungs. Suspecting productive cough with grayish-white sputum.
that the client might have chronic
bronchitis, which classic symptom
should the nurse expect this clien to
A client has taken steroids for 12 years
to help manage chronic obstructive
pulmonary (COPD). When making a C Temperature over skin color and turgor
home visit, which nursing function is steroids and infection
of greatest importnace to this client?
Assess the client's
A client has undergone insertion of a
permanent pacemaker. When
developing a discharge teaching plan,
the nurse writes a goal of, "The client Feelings of dizziness
will verbalize symptoms of pacemaker
failure. "Which symptom are the most
important to teach the client?
In assessing a client diagnosed with
primary hyperaldosteronism, the nurse
expects the lab test results to indicate a Potassium
decreased serum level of which
The healthcare provider prescribes
aluminum and magnesium hydroxde
(maalox, 1 tablet PO PRN, for a client
Question the healthcare provider prescription.
with chronic renal failure who is
(it can casue hypermagnesium)
complaining of indigestion. What
intrevention should the nurse
An elderly client is admitted with a Confusion and tachcardia
Super Condensed Portable HESI Study Guide 202

diagnosis of bacterial pnuemonia. The

nurse's assessment of the client is most
likely to reveal which sign and
A 67 year old woman who lives alone
is admitted after tripping on a rug in
her home and fractures her hip. WHic
predisposing factor probably led to the
fracture in the proximal end of her
Question Answer Hint
Abrubt Sudden
Abstain Voluntarily refrain from something
Access A means to obtain entry or a means of approach
Accountable Responsible
Adhere to hold fast or stick together
Adverse Undesired, possibly harmful
Affect Appearance of observable emotions
Annual Once a year
Apply To place, put on, or spread something
Audible Able to hear
Bilateral Present on two sides
Cease To some to an end or bring to an end
Compensatory To offset or make up for something
An undesired problem that is the result of some
other event
Comply Do as desired
Concave Rounded inward
Concise Brief, to the point
Consistency Degree of viscosity, how thick or thin a fluid is
Constrict To draw together or become smaller
Contigent Dependant
Contour Shape or outline of a shape
Contract To draw together or reduce in size
A reason why something is not advisable or
why it shouldnt be done
Defecate Expel a bowel movement
Deficit A deficiency or lack of something
Super Condensed Portable HESI Study Guide 203

Depress Press downward

Depth Downward measurement from the surface
Deteriorating Worsening
Device Tool or piece of equipment
Diameter The distance across the center or an object
Dilate To enlarge or expand
Dilute To make a liquid less concentrated
Discrete Distinct, separate
Distended Endlarged or expanded from pressure
Elevate To lift up or place in a higher position
Endogenous Produce within the body
Exacerbate To make worse or more severe
Excess More than what is needed or usual
Exogenous Produced outside the body
Expand To increase in size or amount
Question Answer Hint
When does birth weight double? 6 months
When does birth weight triple? 12 months
When does the posterior fontanel
By 8 weeks
When does a baby give its 1st social
2 months
When does a baby turn its head toward
3 months
When does the Moro reflex disappear? 4 months
When does a child achieve steady head
4 months
When does a baby turn completely
5-6 months
When does a baby transfer objects
7 months
hand to hand?
When does a baby play peek a boo for
After 6 months
1st time?
When does stranger anxiety develop? 7-9 months
When does a child sit unsupported? 8 months
When does a child crawl? 10 months
When does a child’s fine pincer grasp
10-12 months
Super Condensed Portable HESI Study Guide 204

When does a child wave bye bye? 10 months

When does a child walk with
10-12 months
When does a child say a few words in
12 months
addition to mama or dada?
When does birth weight quadruple? 30 months
When do you achieve 50% of adult
2 years
What is the appearance of a toddler? Bowlegged and potbellied
What are the teeth of a toddler (1-3
All 20 primary teeth are present
year old) like?
When does the anterior fontanel close? 12-18 months
When does a child throw a ball
18 months
overhand for 1st time?
When can a child kick a ball? 2 yrs
When does a child feed self with cup
2 yrs
and spoon?
When can daytime toilet training
2 yrs
When can kids form 2-3 word
2 yrs
When can kids form 3-4 word
3 yrs
sentences? \\
When can child state full name? 2.5-3 years
When are temper tantrums common? Toddler (1-3)
What is Erickson’s Theory of the
Developing a sense of autonomy
toddler (1-3)?
What type of toys should you give to Mobiles, rattles, squeaking toys, picture books,
babies under 1 year old? balls, colored blocks, activity boxes
What happens to a baby under 1 whose
May be inconsolable due to separation anxiety
parents are not able to stay with him?
What is Erickson’s Theory of infants
Developing a sense of trust
under 1?
Board and mallet, push/pull toys, toy phone,
What are the toys appropriate for the stuffed animals, storybooks with pictures, use
toddler (1-3)? of the hospital playroom bc of mobility (which
is important to their development).
How much weight does a preschool
child (3-5) gain each year/ inches 5 lbs and 2-3 inches/year
grown each year?
Super Condensed Portable HESI Study Guide 205

When do kids learn to run, skip, jump? Preschool

How old are you when you start riding
3 years old
At what age is standing erect began? Preschool
When do you establish handedness? Preschool
At what age do you use scissors? 4 years old
What age ties shoelaces? 5 years old
At what stage do you learn colors and
What is the visual acuity of a
What is the thinking of a preschooler
Egocentric and concrete
When does a child learn sexual
When are imaginary friends and fears
Aggressiveness at ___years old is
replaced by independence at ___years 4, 5
What should you make sure a They did not cause it, painful procedures are
preschooler knows about their illness? not punishment
When is fear of mutilation from
procedures common? How can you Preschool, put on a Bandaid
help restore body integrity?
Coloring books, puzzles, cutting/pasting, dolls,
What are appropriate toys for a
clay, toys that let you work out hospital
What is Erickson’s Theory of
Developing a sense of initiative
School age (6-12 year olds) have what
4-6 lbs and 2 inches per year
weight/height gain per year?
What is Erickson’s Theory of school-
Developing a sense of industry
When are primary teeth lost and
school age
permanent teeth established?
At what age are you able to write
8 years
Egocentric thinking in the school age
Social awareness of others
child is replaced by _________.
When are cause and effect School age
Super Condensed Portable HESI Study Guide 206

relationships learned?
When does socialization with peers
School age
become important?
When do molars erupt? School age (6 year molars)
Whose growth spurt develops 1st? As
Girls-10 years old. Boys at 14.
early as what age?
Adult-like thinking begins at what
When does growth end? Girl-15, boys-17
What is Erickson’s theory for
Developing sense of identity
adolescents (12 to 19)?
After 6 months what is the baby’s
They can remember the pain
concept of bodily injury?
What is the toddler’s concept of bodily
Fear of intrusive procedures
What is the preschooler’s concept of
Fear of body mutilation
bodily injury?
What is the school age childs concept
Fear of loss of control over their body
of bodily injury?
What is the adolescent’s concept of
Change in body image
bodily injury?
When can you start using the numeric
9 and up
pain scale?
Using the FLACC pain assessment tool, that
How can a non verbal child be
looks at the face, leg movement, activity, cry,
assessed for pain?
and consolability
What are the best nondrug measures to
Pacifiers, holding, rocking
reduce pain in infants?
What are the best nondrug measures to
reduce pain in toddlers and Distraction
What are the best nondrug measures to
reduce pain in school age and Guided imagery
At what age can you teach a child how
5 years old
to use PCA?
12-15 months and then 1 other time between 4
When is MMR vaccine given?
and 12 years old
During a measles epidemic when can
6 months and then again at 15 months
you give the MMR?
What are contraindications for MMR? Allergy to neomycin or eggs
Super Condensed Portable HESI Study Guide 207

How do you administer the MMR

SQ at 2 difft sites
After the MMR vaccine what is a
Light rash 2 weeks later
normal finding?
At 2 months, 4 months, and 6 months. THEN
When do you give the DTaP vaccine? get boosters at 15-18 months and again at 4-6
How do you give DTaP vaccine? IM apart from other vaccines
When do you have to stop giving
At age 7, bc then you switch to Td vaccine
DTaP vaccine?
After the injection of DTaP what
Give acetaminophen (Tylenol)
should the nurse tell the parents to do?
At 2 months and 4 months, THEN boosters at
When do you give the IPV vaccine?
6-18months and again at 4-6 years old
How do you administer IPV? SQ or IM at separate site from other vaccines
What is the contraindication for IPV
Allergy to neomycin or streptomycin
How and when do you administer Hib
IM at 2, 4, and 6 months
When and how do you administer the
IM at 0-2 months, 1-4 months, 6-18 months
HepB vaccine?
When and how do you give the 12-18 months –should be given with the MMR
varicella vaccine? vaccine OR over 30 days apart
What are normal side effects from Irritability, fever under 102, redness and
DPT and IPV vaccinations? soreness at injection site for 2-3 days
What can decrease soreness after thigh Warm washcloth on injection sites, bicycling
injections? the legs with each diaper change
How do you treat fever in a child with
a communicable disease?
What can you use for itching in
Diphenhydramine (benadryl)
communicable diseases?
Highly contagious, viral disease that can cause
neurologic problems or death, transmitted by
What is Rubeola (Measles)? How is it droplets; contagious mainly during prodromal
transmitted? When is it contagious? period when they have fever and upper
What are classic symptoms? respiratory symptoms; symptoms include
photophobia, Koplik’s spots in the mouth, rash
starting on face and spreading downward.
When is chicken pox no longer
Once scabs have formed on all lesions
A viral disease that can kill babies in 1st
What is German Measles?
trimester; spread by droplets and contact, a red
Super Condensed Portable HESI Study Guide 208

maculopapular rash spreads from face to rest of

body and fades in 3 days
Whooping cough; caused by bacteria prolonged
coughing for 4-6 weeks; treated with
What is pertussis?
erythromycin; complications are pneumonia,
hemorrhage, and seizures
How do you measure past nutrition in
Height and head circumference
a child?
How do you measure current nutrition
Weight, skinfold thickness, arm circumference
in a child?
How do you measure the body fat
Skinfold thickness
content of a child?
What does vitamin B2 (riboflavin) Redness and itchiness of eyes, magenta tongue,
deficiency look like? How do you treat delayed wound healing Give these kids green
it? leafy veggies, liver, cow milk, cheddar cheese
What does vitamin A deficiency Rough dry skin, cornea problems, retarded
(retinol) look like? How do you treat growth Give them orange foods (sweet
these kids? potatoes, peaches, apricots)
Poor turgor, depressed fontanels, no tears, dry
What are signs of dehydration in an
mucous membranes, weight loss, decreasued
urine output
What are lab signs of metabolic pH under 7.3, low sodium and potassium, high
acidosis (caused by dehydration)? Hct and BUN
When should you add potassium to IV ONLY when the child has adequeate urine
fluids? output
What is the expected urine output for
1-2 mL/kg/hr
both infants and children per hour?
How many children die from child
3 to 5 thousand
abuse each year?
Using the Lund-Browder Chart, which takes
How should burns in children be
into account the changing proportions fo the
child's body
How can the nurse BEST evaluate
adequacy of fluid replacement in Monitor urine output
What interventions should be done
FIRST when caring for a child who Assess repiratory, cardiac, and neuro status
has ingested poison?
Cardinal signs: restless, inc respirations, inc
What are the cardinal signs of pulse, sweating Other signs: flaring nostrils,
respiratory distress in children, and retractions, grunting, bad breath sounds,
other signs of resp. distress in kids? accessory muscle use, head bobbing, low PO2,
high PCO2, cyanosis, pallor
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Which usually occurs 1st: cardiac

failure or respiratoy failure in Respiratory failure
What is epiglottitis caused by? What is
HIB Upright sitting position with chin out and
the classic position these kids are in?
tongue protruding ("tripod position") NEVER
What do you NEVER do in these
examine the throat of this child!!
What causes bronchiolitis? What lung
RSV Wheezing and rales Respirations are
sounds do you hear? What are their
shallow and fast
respirations like?
What is given to kids under 2 yrs old
born either premature or with
lung/heart disease to give passive
immunity to RSV?
What is a risk of untreated otitis Conductive hearing loss Pulling at ears, fever,
media? What do you see on pain, enlarged lymph nodes, discharge from ear
assessment? What can you do to ear IF drum is ruptured, V/D Apply warm
for comfort? compress on ear
How can you reduce body temperature
Tepid bath or Tylenol
in children to avoid seizure risk?
Tonsillitis can be either bacterial or
bc the child can develop acute
viral. If related to strep why is
glomerulonephritis or rheumatic heart disease
treatment so important?
Prior to tonsillectomy what lab values PT and PTT, assess for history of bleeding of
must be drawn? family hx of bleeding disorders
What are signs of postoperative
Clearing throat, vomiting fresh blood, frequent
tonsillectomy bleeding? when is
swallowing 1st 24 hours and 5-10 days post
highest risk for hemorrhage? These
surgery NO STRAWS!
kids should NEVER be given what?
What is the drug of choice for an acute Epinephrine bc it is a rapid acting
asthma attack? bronchodilator
What are the normal PO2 and PCO2
values for kids in an arterial blood gas PO2: 83-100 PCO2: 35-45
pancreatic enzyme replacement, fat soluble
What nutritional support should be
vitamins, low carb, high protein, moderate fat
given to a child with CF?
What type of genetic disease is CF? autosomal recessive
How do you care for a child in a mist Monitor temperature. Keep clothing dry. Keep
tent? tent edges tucked in, assess respiratory status.
An increased respiratory rate in kids
dehydration and acid/base imbalance
puts them at risk for _____________.
What is a patent ductus arteriosus? Hole between the aorta and pulmonary artery,
Super Condensed Portable HESI Study Guide 210

which normally closes within 72 hours

postbirth. If it stays open blood from the aorta
returns to the pulmonary artery, resulting in
increased blood flow to the lungs and
pulmonary hypertension.
They can be 1 of three things: 1. L to R shunts
2. Increased pulmonary blood flow 3.
Describe acyanotic defects. Examples
Obstructive defects VSD, ASD, PDA, AS, and
coarctation of the aorta
They can be either: 1. R to L shunts 2.
Describe cyanotic heart defects. Decreased pulmonary blood flow 3. Mixed
Examples blood flow The 3 T's: Tetralogy of Fallot, TA,
Acyanotic Blood from the L ventricle is
shunted to the R ventricle through a hole and
What is a ventricular septal defect?
recirculated to the lungs, resulting in increased
pulmonary blood flow
Oxygenated blood from the L atrium is shunted
What is an atrial septal defect? into the R atrium and lungs through a hole ,
resulting in increased pulmonary blood flow.
It is a narrowing of the aorta which causes
HTN in the upper extremities and
What is a coarctation of the aorta?
decreased/absent pulses in the lower
A narrowing at or around the aortic valve;
What is aortic stenosis? Oxygenation to the systemic circulation is poor
bc cardiac output is low.
What is a common finding in children
with cyanotic heart defects (3 T's)?
When the pulmonary artery and aorta do not
What is truncus arteriosus? separate. The blood from the 2 ventricles mix
and causes cyanosis
Incompatible with life, a medical emergency
What is transposition of the great
where babies recieve prostaglandin E to keep
ductus open.
Is CHF associated more with cyanotic
or acyantoic defects?
giving digoxin what must the nurse
1. Take child's apical pulse. If bradycardic do
do? 2. What are therapeutic levels?
not administer. 2. 0.8-2.0ng/mL 3. Throwing or
What is an early sign of digoxin
spitting up 4. Hypokalemia
toxicity? What electrolyte imbalance
increases digoxin toxicity?
Rheumatic fever is an _______disease. Inflammatory Acquired heart disease B-
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It is the most common cause of

________ in children. It is associated
hemolytic strep bacteria Heart, blood vessels,
with an infection of ________.
joints, subQ tissue
Rheumatic fever is a collagen disease
that injures _________.
Chest pain, SOB, tachycardia ALL the time,
What assessment findings are joint pain, chorea (involuntary movements),
associated with rheumatic fever? Lab rash, subQ nodules over bony prominences,
values? fever Increased Erythrocyte sedimentation rate,
increased ASO titer (anistreptolysin O).
What medications are used to treat
Penicillin, eryhtromycin, and aspirin
rheumatic fever?
In ____________ (a type of congenital
heart defect) the child often Tetralogy of Fallot hypoxic episodes squatting
experiences "tet spells" (_________), or knee chest position
which are relieved by which position?
What is the nurse's goal in caring for help the child reach its OPTIMAL level of
kids with Down Syndrome? functioning
An injury to the motor centers of the brain
What is cerebral palsy? Its major risk causes neuromuscular problems of spaasticity
factor? or dyskinesia (involuntary movements) Low
birth weight
Cerebral Palsy; it occurs when legs are
What is "scissoring" a characteristic
extended and crossed over each other with feet
plantar flexed.
If a mother of a Cerebral Palsy child
says she is having "difficulty with
diapering," what is the mom
What should the nurse do while Prevent aspiiration by sitting the child upright
feeding a cerebral palsy child? and supporting the lower jaw
What is the most common allergy of
kids with spina bifida?
1. Prevent infection of the sac 2. Monitor for
What are 2 nursing priorities for the
hydrocephalus (measure head circumference,
infant with myelomeningocele?
assess fontanel, and neuro functioning).
Accumulation of CSF within the brain and is
often associated with spina bifida or meningitis
What is hydrocephalus and assessment Symptoms: Increased ICP (low pulse, high
findings? BP), change in LOC, vomiting, seizures,
bulging fontanels, widening suture lines, sunset
What is the surgery like for kids with A shunt is inserted into the brain ventricle and
hydrocephalus? tubing is then tunneled through skin to the
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peritoneum where excess CSF is drained out

Seizures are more common in what
Under 2 yrs old
age group?
You get an aura. Then you lose consciousness
and the body becomes stiff (tonic). Then you
Describe tonic clonic seizures (grand stop breathing and become cyonotic before you
mal). go into spasms (clonic) and relax. Pupils will
be dilated and nonreactive to light, incontinent,
and then you lay there sleepy and disoriented
Usually occur between 4 anbd 12 years old.
You lose consciousness for 5-10 seconds and
appear to be daydreaming because posture is
Describe absence seizures (petit mal).
kept and you get minor face and hand
movements. These kids may be doing poorly in
What is the most common cause of
Medication noncompliance
increased seizure activity?
ICP, fever, chills, neck stiffness, opisthotonos,
What do you see in older children with photophobia, positive Kernig's Sign (inable to
bacterial meningitis (normally caused extend leg when knee is bent toward chest),
by HIB)? positive Brudzinski's sign (neck flexion causes
flexion movements of lower extremities)
What do you see in infants with BULGING FONTANELS, poor feeding,
bacterial meningitis? vomiting, irritable, seizures
With meningitis it is important to Bc with meningtitis there may be inappropriate
monitor hydration status and IV secretions of ADH, causing fluid retention
therapy. Why? (cerebral edema) and dilutional hyponatremia
What antibiotics are usually prescribed
Ampicillin, penicillin, chloramphenicol
for bacterial meningitis?
How do kids usually get Reye's
ASA + chicken pox/influenza
What is the most common presenting
Headache upon awakening
symptom of brain tumors?
How is a child usually positioned after
flat on his or her side
brain tumor surgery?
What is the mechanism for inheritance it is an x-linked recessive trait affecting mostly
of Duchenne muscular dystrophy? males
An indicator of muscular dystrophy; difficulty
What is "Gower's sign?" moving to standing position-child has to walk
up legs using hands to stand up.
What is the first sign of renal failure? Decreased urine output
What are the symptoms of acute blood in urine, recent strep infection, HTN,
glomerulonephritis? Dietary mild edema around eyes, positive ASO titer
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interventions? low sodium diet

severa edema, massive proteinuria, frothy
what are the symptoms of nephrosis?
urine, anorexia, negative ASO titer high protein
dietary interventions?
AND low salt
Give prednisone every other day, signs of
Decribe safe monitoring of prednisone
ededma/mood changes/GI distress should be
administration and withdrawal?
reported; the drug should always be tapered.
avoid bubble baths, pee a lot, drink lots of
How can you prevent Urinary Tract
fluids (especially acidic ones), wipe from frant
Infections in kids?
to back
When urine backflows from the bladder up into
what is the vesicoureteral reflex?
the ureters. Recurrent UTIs are common.
What do you see in a kid with Wilms Mass at midline on abdomen, fever, pallor,
Tumor? lethargy, high BP (bc of excess renin secretion)
Prevent injury to the capsulated tumor by
thing for a nurse to do w/ a child who
making sure noone palpates the abdomen.
has Wilms Tumor?
When the urethra opens on the ventral side of
What is hypospadias? Why is surgical
the penis behind the glans To schieve sexual
correction usually done before
identity, toilet training, and remove the fear of
castration anxiety
When is closure of cleft lip normally When the baby weighs 10 pounds and has Hgb
performed? After surgery how is child of 10g/dL. on side or upright in car seat (NOT
positioned? PRONE)
When is closure of cleft palate usually
1 year of age to minimize speech impairment
performed? After surgery how is the
on side or abdomen
child positioned?
How can you protect the surgical site Apply elbow restraints, minimize crying,
on a child with cleft lip/palate? maintain Logan Bow to lip if applied
When the upper esophagus ends in a blind
What is an esophageal atresia with
pouch with the lower esophagus connected to
tracheoesophageal fistula?
the trachea. It is a MEDICAL EMERGENCY!!
The 3 c's (coughing, choking, cyanosis),
In tracheoesophageal fistula what do
exxcess salivation, resp. distress, aspiration
you see on assessment?
What nursing actions are initiated for a
child suspected of having esophageal NPO immediately and suction secretions
atresia with tracheoesophageal fistula?
What are the feeding techniques for a Feed upright with lamb's nipple or prosthesis.
child with cleft lip/palate? Use frequent bubbling.
Projectile vomiting, constant hunger, weight
What assessment findings do you see
loss, dehydration, palpable olive shaped mass
in kids with pyloric stenosis?
in RUQ, visible walves of peristalsis
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Low sodium, low potassium, metabolic

What lab values are seen in kids with
alkalosis (low chloride, increased ph, increased
pyloric stenosis?
IV hydration, small frequent feedings of oral
What is postoperative nursing care for glucose or electrolyte solutions, gradually
a child with pyloric stenosis? increasing to full strength formula. Position ON
RIGHT SIDE in semi fowlers after feedings
What assessment findings do you see Intermittent abdominal pain, screaming when
in a child with intussusception (when 1 legs are pulled toward abdomen, "currant jelly
part of intestine telescopes into another stools" (blood +mucus), sausage shaped mass
part of intestine)? in RUQ with empty RLQ (Dance sign)
Why is a barium enema used to treat It reduces intestinal telescoping via hydrostatic
intussusception? pressure instead of surgery
Lack of persitalsis in area of colon where
What is Hirschsprung's Disease? ganglion cells are missing. Fecal matter
accumulates above this area.
What do you see when assessing a Failure to pass meconium in 1st 24 hours,
Hirschsprung's Disease child? How do distended abdomen, ribbon like stools Take
you take their temperature? axillary temperature.
Failure to pass meconium in 24 hours,
What are signs of anorectal
meconium appearing from a fistula or in the
urine, an unusual anal dimple
What are the Hgb norms for: 1.
Newborn 14-24 Infant 10-15 Child 11-16
Newborn 2. Infant 3. Child
What are assessment findings in kids Pale, fatigue, milk intake over 32oz/day, pica,
who have iron deficiency anemia? low Hgb, Low serum iron values
x-linked recessive transmitted by the mother
What is the genetic transmission
and expressed by male offspring. These
pattern of hemophelia?
children are missing factors 8 or 9.
What are assessment findings in a Prolonged bleeding(after circumcision or in
child with hemophelia? Never give general); loss of motion in joints, prolonged
these kids______. PTT Aspirin
Both parent must be heterozygous carriers of
Describe autosomal recessive
the trait. Each child has a 1 in 4 chance of
transmission and give examples.
having the disease. ex.) sickle cell, CF, PKU
The trait is carried on the X chromosome, so it
usually affects male offspring. With each
pregnancy of a woman who is a carrier there is
Describe X-linked recessive
a 25% chance of having a child with the
transmission. Give an example.
disease. If male there is a 50% chance of
getting disease. If female there is a 50% chance
of being a carrier. ex.) hemophelia
What is the sequence of events in a RBCs clump together and block small blood
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vessels. Cells cannot get through the

vasooclusive crisis of sickle cell capillaries, causing pain and ischemia.
anemia? Lowered O2 affects the HgbS and causes
Why is hydration a priority in treating Hydration promotes hemodilution and
sickle cell disease? circulation of RBCs through the blood vessels
Keep hydrated, avoid high altitudes, avoid
What should families and clients do to
strenuous exercises, avoid unknown sources of
prevent sickle cell episodes?
No, bc it is not caused by iron deficiency. You
Do you give supplemental iron to kids
DO give them folic acid, however, to stimulate
with sickle cell anemia?
RBC synthesis.
Nursing interventions and medical
Anemia (decreased RBCs), Infection
treatment for a child with leukemia are
(neutropenia), and bleeding thrombocytopenia
based on which 3 physiological
(decreased platelets)
What should you have nearby when
administering l-asparaginase to a Epinephrine and oxygen in case of anaphylaxis
leukemic patient?
An infant with ________is often
described as a "good, quiet baby" by Hypothyroidism
the parents.
What do you see in children with sleepy, poor feeders, flat expression,
hypothyroidism? constipations, hypoactive
What are the outcomes of untreated
Mental retardation, growth failure
congenital hypothyroidism?
An autosomal recessive disorder where the
What is phenylketonuria? What is the body cannot metabolize the aa phenylalanine
result of PKU? The buildup of phe leads to CNS damage
(mental retardation) and decreased melanin
Newborn screening using Guthrie test is
On assessment of a child with PKU positive when serum phenylalanine is 4mg/dL
what do you see? or higher. Vomiting, failure to gain weight,
hyperactive, musty urine odor
high protein foods including meat, dairy, eggs,
What are foods high in phenylalanine
aspartame. This low protein diet should be
(which should be avoided if you have
done until brain growth is complete (6-8 years
What 2 formulas are prescribed for
Lofenelac and PKU-1
kids with PKU?
What are the 3 classic signs of Polydipsia, polyuria (including
diabetes? bedwetting-"enuresis"), polyphagia
Diabetes is diagnosed if the fasting 120+
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blood sugar is greater than_____mg/dl.

Provide care for unconscious child, administer
What do you do if a diabetic child is in
REGULAR insulin IV in Normal Saline,
monitor blood gases, maintain strict I&O
tremors, sweating, headache, hunger, nausea,
What are the signs and symptoms of
lethargy, confusion, slurred speech, anxiety,
tingling around mouth, nightmares
What are the signs and symptoms of polydipsia, polyuria, polyphagia, blurry vision,
hypERglycemia? weight loss, weakness, syncope
What is the relationship between During exercise insulin uptake is increased and
hypOglycemia and exercise? the risk for hypOglycemia occurs.
What is a complete fracture? When bone fragments completely separate
What is an incomplete fracture? When bone fragments remain attached
When bone fragments of the bone shaft break
Wha is a comminuted fracture? free and lie in surrounding tissue. Rare in
What type of fractures have serious
Fractures involving the epiphyseal (growth)
consequences in terms of growth of
the affected limb?
What re the 5 "P's" that may indicate pain, pallor, pulselessness, paresthesia (pins
ischemia in the fractured limb? and needles), paralysis
Force is applied to the skin. This should
What is a skin traction? NEVER be removed unless specifically
prescribed by the MD
For the lower extremities; keeps legs extended
What is Buck's Skin Traction?
with no hip flexion.
What is Dunlop Skin/Skeletal
When there are 2 lines of pull on the arm
2 lines of pull on lower extremity (1
What is Russell Skin Traction?
perpendicular, 1 longitudinal)
Both lower extremities are flexed 90 degrees at
What is Bryant's Skin Traction? hips (rarely used bc extreme elevation of legs
causes decreased peripheral circulation)
When a pin or wire applies pull directly to the
What is a skeletal Traction?
distal bone fragment
90 degree flexion of the hip and knee. The
What is a 90 degree skeletal traction? lower leg is in a boot cast. This can also be
used on upper extremities.
A special type of cast used to immobilize the
What is a hip spica? How do you help hip joints and/or the thigh Use Bradford frame
with toileting a child with a hip spica? under the child. NEVER USE abduction bar to
turn a child.
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Damage to nerves and vasculature of an

What is compartment syndrome? extremity due to compression. You see
Assessment findings? coldness, severe pain, inability to move
extremity, poor capillary refill
Unequal skin fold of buttocks, positive Ortalani
What are the signs and symptoms of
Sign (clicking with abduction), limited
congenital hip dysplasia in infants?
abduction of affected hip, unequal leg lengths
Limp on affected side, positive Trendelenburg
What are signs of hip dysplasia in
Sign (when standing on one leg the pelvis
older children?
drops on the side opposite to the stance leg. )
Ask child to bend forward from hips with arms
How does the nurse conduct scoliosis
hanging free. Examine child for curvature of
the spine, rib hump, and hip asymmetry
Wear it 23 hours each day. Wear t-shirt under
brace. Check skin for irritation. Perform back
What instructions should the child
and abdominal exercises. Modify clothing.
with scoliosis receive about the
Maintain normal activities as able. A brace does
Milwaukee brace?
not correct the curve of a child with scoliosis. It
only stops or slows the progression.
What is the potential outcome for
respiratory difficulty
untreated scoliosis?
What is postoperative nursing care of a Frequent neuro assessments, log roll for 5 days,
child with scoliosis? keep npo, monitor NG tube/bowel sounds
Used postoperatively for scoliosis patients.
Requires 2+ people. Client is moved on a draw
sheet to the side of the bed away from which
they are to be turned (rolled toward the L if
Describe log rolling.
they are to face the R). Client is the turned in a
simultaneous motion, maintaining the spine in
a straight position. Pillows arranged for support
and comfort
What nursing care is indicated for a Prescribed exercise to maintain mobility,
child with juvenile rheumatoid splinting of affected joints, teach medication
arthritis? management and side effects