NCLEX-PN® Examination flashcards

Clients with CVA are at high risk for aspiration due to neurological deficits affecting swallowing and airway protection. Initial interventions focus on positioning and careful assessment.

• Neurological deficits post-CVA impair swallowing and gag reflex.
• Elevating the head of the bed is a primary non-pharmacological intervention.
• A swallow screen should be performed before oral intake.

Memory trick: Head of bed up high, keeps the lungs dry!

Cerebral Perfusion Pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain, calculated as Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP).

• Formula: CPP = MAP - ICP.
• Normal CPP is 70-100 mmHg; desired for TBI is often 60-70 mmHg.
• Maintaining adequate CPP is vital to prevent cerebral ischemia.

Memory trick: MAP minus ICP, gives the brain its blood, you see!

Priority nursing care for a suspected ruptured cerebral aneurysm (subarachnoid hemorrhage) focuses on preventing rebleeding, managing intracranial pressure, and reducing cerebral vasospasm.

• Symptoms include 'worst headache of life,' nuchal rigidity, photophobia.
• A quiet, calm environment is crucial to minimize stimuli and prevent ICP spikes.
• Strict blood pressure control and seizure precautions are also vital.

Memory trick: Quiet brain, low light, prevents the aneurysm's bite!

Bleeding from esophageal varices is a life-threatening complication of portal hypertension, requiring rapid intervention to reduce portal pressure and control hemorrhage.

• Octreotide is the first-line pharmacologic treatment for acute variceal bleeding.
• It works by decreasing splanchnic blood flow.
• Endoscopic interventions (banding, sclerotherapy) are also crucial.

Memory trick: Octreotide Obstructs Outflow.

Competent adult clients have the legal and ethical right to refuse any medical treatment, even if that refusal could lead to serious harm or death.

• Applies to alert and oriented adults.
• Healthcare providers must respect this decision.
• Requires thorough documentation and communication to the healthcare team.

Memory trick: Refusal means report, right, and respect.

The process by which healthcare providers and clients are cooperatively involved in ongoing healthcare management toward the shared goal of high-quality, cost-effective medical care.

• Ensures seamless transition between care settings.
• Reduces fragmentation of care and potential for errors.
• Requires effective communication and information sharing among providers.

Memory trick: Medications are the lifeline to a new home.

The legal and ethical process where a client gives voluntary permission for a medical procedure or treatment after receiving and understanding all necessary information, including risks, benefits, and alternatives.

• Physician is responsible for providing comprehensive information.
• LPN's role is to witness the signature and ensure client appears to understand.
• If client has questions, LPN must notify RN/physician for further clarification.

Memory trick: Consent is clear understanding, not just a signature.

Regular laboratory testing to ensure warfarin's anticoagulant effect is within a therapeutic range, preventing both excessive bleeding and clot formation.

• Warfarin is a vitamin K antagonist.
• Monitored by PT/INR.
• Therapeutic INR range is typically 2.0-3.0 for most conditions.

Memory trick: Warfarin is 'War P-T/INR', Heparin is 'Hep aPTT'.

A sudden worsening of asthma symptoms, including shortness of breath, wheezing, and chest tightness, often requiring immediate intervention.

• Symptoms include dyspnea, wheezing, cough, accessory muscle use.
• Hypoxemia and anxiety are common.
• Immediate interventions focus on oxygenation and bronchodilation.

Memory trick: Airway first, then drugs and docs.

An elevated potassium level in the blood (typically >5.0 mEq/L), which can cause serious cardiac and neuromuscular complications.

• Common in kidney failure, acidosis, crush injuries, certain medications (e.g., ACE inhibitors)
• Symptoms: muscle weakness, fatigue, paresthesias, cardiac dysrhythmias
• Treatment: IV calcium gluconate, insulin/glucose, diuretics, potassium binders, dialysis

Memory trick: Don't Delay, Report Today!

A low-flow oxygen delivery device that provides supplemental oxygen via two prongs inserted into the client's nostrils.

• Flow rate: 1-6 L/min
• FiO2 (fraction of inspired oxygen) varies with flow rate and client's breathing pattern
• Appropriate for clients requiring low-to-medium oxygen concentrations and stable breathing

Memory trick: Nasal Cannula: Not Too Low, Not Too High, Just Right for SpO2!

Nursing care for continuous bladder irrigation after transurethral resection of the prostate, focusing on maintaining patency, assessing drainage, and managing complications.

• Purpose: prevent clot formation and obstruction.
• Monitor drainage color and for clots.
• Adjust flow rate to keep drainage clear or pinkish.

Memory trick: TURP CBI: 'T'hink 'U'rine 'R'ed, 'P'ush 'F'luid.

Conditions or implanted devices that make a magnetic resonance imaging (MRI) procedure unsafe or impossible due to the powerful magnetic field.

• Absolute contraindications: pacemakers, certain cochlear implants, cerebral aneurysm clips
• Relative contraindications: some artificial joints, metal fragments in eyes/body, pregnancy
• Safety screening is paramount before MRI

Memory trick: MRI: Metal Risk Inside!

Nursing care and client education following a barium swallow study to facilitate barium excretion and monitor for complications.

• Barium can cause constipation and impaction
• Increased fluid intake is essential to excrete barium
• Stools will be white or light-colored for 24-72 hours
• Monitor for abdominal pain, distention, or absence of stool

Memory trick: Barium Out: Drink and Poo White!

Systematic analysis of arterial blood gas values (pH, PaCO2, HCO3) to determine acid-base status and compensation.

• pH indicates acidosis (<7.35) or alkalosis (>7.45).
• PaCO2 reflects respiratory component (acidic if high, alkaline if low).
• HCO3 reflects metabolic component (acidic if low, alkaline if high).

Memory trick: pH: 'Power' (acid/base); PaCO2: 'Puffs' (lungs); HCO3: 'Hydration' (kidneys)

A non-invasive ultrasound test that uses sound waves to create live images of your heart, showing its size, structure, and how well it's pumping blood.

• Non-invasive, uses a transducer on the chest.
• Client lies still, usually on left side.
• Takes 30-60 minutes; no special prep needed.

Memory trick: Echo: 'Echo' (sound waves), 'Chest' (TTE), 'Throat' (TEE), 'Run' (Stress).

The specific body position required for a client undergoing a lumbar puncture to optimize access to the subarachnoid space and ensure client safety.

• Goal: maximize space between lumbar vertebrae
• Common positions: side-lying fetal position or sitting position leaning forward
• Proper positioning is crucial for successful and safe needle insertion

Memory trick: Lumbar Puncture: Curl Up Like a Cat!

A medical emergency characterized by excessive fluid in the lungs, often caused by left-sided heart failure, leading to severe respiratory distress.

• Symptoms: severe dyspnea, orthopnea, pink frothy sputum, crackles, hypoxemia
• Interventions: elevate HOB, oxygen, diuretics, vasodilators (e.g., nitroglycerin), morphine
• Priority: improve oxygenation and reduce fluid overload

Memory trick: ABC: Airway, Breathing, Circulation – Always First!

The process of calculating how many drops per minute are needed to deliver a prescribed volume of intravenous fluid over a specific time, using the tubing's drop factor.

• Formula: (Volume in mL/hr * Drop factor) / 60 min/hr.
• Drop factor is specific to the IV tubing.
• Result is rounded to the nearest whole number.

Memory trick: Volume x Drop Factor, then Divide by 60.

Potential adverse effects following thyroid gland removal, including hemorrhage, airway obstruction, and hypocalcemia.

• Hypocalcemia is a risk due to parathyroid gland injury/removal.
• Signs of hypocalcemia include tetany, tingling, muscle spasms.
• Hemorrhage and airway compromise are also critical concerns.

Memory trick: THYROID: Tingling, Hemorrhage, Airway, Voice, Infection, Recurrent laryngeal nerve Damage.

A temporary cessation of intestinal peristalsis, often occurring after abdominal surgery, leading to bowel obstruction symptoms without a physical blockage.

• Causes: abdominal surgery, opioids, electrolyte imbalances, inflammation
• Symptoms: abdominal distention, nausea, vomiting, absent bowel sounds, pain
• Management: NPO, NGT decompression, IV fluids, ambulation, avoiding opioids if possible

Memory trick: Post-Op Problems: Don't Get Paralyzed by Pain!

A condition in which air leaks into the space between the lung and chest wall (pleural space), causing the lung to collapse.

• Can be spontaneous, traumatic, or iatrogenic (e.g., after thoracentesis)
• Symptoms include sudden chest pain, shortness of breath, diminished breath sounds
• Treatment often involves chest tube insertion

Memory trick: Post-Procedure Problems: Ponder Patient's Pains!

A white blood cell (WBC) count above the normal range (typically >10,000/µL), indicating an inflammatory or infectious process in the body.

• Normal range: 4,500-10,000/µL
• Can be caused by infection, inflammation, stress, trauma, or certain medications
• Requires further assessment to determine the underlying cause

Memory trick: WBC High? Worry, But Check Context!

Non-selective beta-blockers block both beta-1 and beta-2 adrenergic receptors, which can be problematic for diabetic patients by masking hypoglycemia symptoms and impairing glucose recovery.

• Block beta-1 (heart) and beta-2 (lungs, liver) receptors.
• Masks adrenergic signs of hypoglycemia (tremor, tachycardia).
• Can impair glucose production, prolonging hypoglycemia.

Memory trick: BAD COP: Bradycardia, Asthma, Diabetes, COPD, CHF (decompensated), Other heart blocks, Peripheral vascular disease.

The process of cleansing the colon before a colonoscopy using laxatives and a clear liquid diet to allow for clear visualization of the intestinal lining.

• Crucial for accurate diagnostic results and detection of polyps/lesions
• Involves a clear liquid diet for 1-3 days prior
• Requires consuming large volumes of prescribed laxative solution

Memory trick: Colonoscopy Prep: Clean Out, See All!

Support systems for grief, particularly support groups, provide a safe space for individuals to share experiences, receive empathy, and develop coping strategies with peers facing similar losses.

• Reduces feelings of isolation and loneliness.
• Offers validation and shared understanding.
• Can provide practical advice and emotional support.

Memory trick: Connect with Peers, Share Your Pain, Heal Together.

Interventions for OCD rituals focus on gradual reduction and delay of compulsive behaviors to help clients manage associated anxiety.

• Abrupt cessation of rituals can cause extreme anxiety.
• Gradual reduction or delaying rituals helps build coping skills.
• Exposure and Response Prevention (ERP) is a key therapy.

Memory trick: OCD: Delay, reduce, then free and loose.

The primary goal of nursing care during acute opioid withdrawal is to manage and alleviate severe withdrawal symptoms to ensure client comfort, prevent complications, and facilitate continued engagement in treatment.

• Symptoms are highly distressing but rarely life-threatening.
• Complications can include dehydration and aspiration.
• Medication-assisted treatment (e.g., buprenorphine, clonidine) is often used for symptom management.

Memory trick: Comfort First, Then Recovery.

The intervention phase of crisis intervention involves implementing planned strategies to help the client cope, reduce distress, and restore their pre-crisis level of functioning.

• Focus on immediate problem-solving and emotional support.
• May involve direct assistance with basic needs or referrals.
• Aims to stabilize the client's emotional state.

Memory trick: Assess Plans, Intervene, Resolve.

Time management involves organizing and planning how to divide your time between specific activities to increase efficiency and reduce feelings of being overwhelmed.

• Helps prioritize tasks and set realistic goals.
• Creates boundaries between work/family and personal time.
• Reduces perceived workload and improves control over schedules.

Memory trick: Relax, Organize, Breathe, Imagine.

Building trust within a therapeutic environment involves consistent care, clear communication, and demonstrating reliability, especially for clients with histories of trauma or distrust.

• Essential for clients to feel safe and engaged in care.
• Requires patience and genuine empathy.
• Consistency in actions and words is key.

Memory trick: Consistent Care, Honest Words, Safe Space.

Cultural awareness in emotional expression involves recognizing that cultural norms influence how individuals verbalize or demonstrate feelings, and offering culturally appropriate alternatives for expression.

• Direct verbal expression is not universally comfortable or appropriate.
• Non-verbal cues and alternative methods (e.g., art, writing) can be important.
• Respecting cultural boundaries builds trust and promotes client engagement.

Memory trick: Respect Their Culture, Find Their Voice.

When a client is hallucinating, therapeutic communication involves acknowledging their experience without validating the hallucination, and then focusing on their feelings or the impact of the experience.

• Do not argue or agree with the hallucination.
• Focus on the client's feelings and provide reassurance.
• Redirect to reality-based topics and activities.

Memory trick: Acknowledge Feeling, Not the Illusion.

Assessing for a specific plan and access to means is a critical component of suicide risk assessment when a client expresses thoughts of self-harm.

• Higher specificity of plan and readily available means indicate higher risk.
• Direct questioning is necessary and does not increase risk.
• Guides immediate safety interventions (e.g., 1:1 observation, removal of dangerous objects).

Memory trick: Ask Directly, Assess Plan, Ensure Safety.

Initial de-escalation involves using calm, non-threatening communication and demeanor to reduce a client's agitation and prevent escalation to violence.

• Prioritize safety for client and staff.
• Maintain personal space.
• Use active listening and empathy.

Memory trick: Calmly Assess, Speak Slowly, Maintain Space, Offer Choices.

Denial is a common defense mechanism where an individual consciously or unconsciously refuses to acknowledge a painful reality or truth.

• Often seen in addiction, grief, and serious illness.
• Protects the ego from anxiety or overwhelming information.
• Can hinder treatment and recovery if persistent.

Memory trick: DR. P. S. R. I. D. D. C. - Denial, Repression, Projection, Sublimation, Rationalization, Isolation, Displacement, Dissociation, Compensation.

The anger stage of grief is characterized by feelings of frustration, outrage, resentment, and a sense of injustice.

• Often directed at self, others, or a higher power.
• Expressed as 'Why me?' or 'It's not fair.'
• A natural response to loss or terminal diagnosis.

Memory trick: DABDA: Don't Accept Bad Deals, Always.

Nursing interventions for anorexia nervosa prioritize re-establishing healthy eating patterns and preventing compensatory behaviors.

• Focus on nutritional restoration and weight gain.
• Monitor eating behaviors and post-meal activities.
• Address body image distortion and underlying psychological issues.

Memory trick: Anorexia: Observe the plate, prevent the escape.

Reflection is a therapeutic communication technique where the nurse repeats or rephrases the client's feelings or words to demonstrate understanding and encourage further expression.

• Validates client's feelings.
• Promotes self-awareness in the client.
• Encourages deeper exploration of thoughts/emotions.

Memory trick: Listen, Reflect, Understand: Your feelings are valid, I'm here to comprehend.

Non-pharmacological interventions for Generalized Anxiety Disorder (GAD) focus on teaching coping mechanisms to manage anxiety symptoms.

• Stress reduction techniques (e.g., progressive muscle relaxation, deep breathing).
• Cognitive-behavioral therapy (CBT) to challenge anxious thoughts.
• Lifestyle modifications (e.g., regular exercise, healthy diet, adequate sleep).

Memory trick: Anxiety's grip, release with a squeeze, then relax with ease.

The priority intervention for a client with suspected delirium is to identify and treat the underlying physiological cause, as delirium is an acute, reversible confusional state.

• Common causes: infection, dehydration, polypharmacy, electrolyte imbalance.
• Rapid onset, fluctuating course.
• Distinguished from dementia by acute onset and reversibility.

Memory trick: Find the Root, Fix the Problem.

Delirium is an acute, fluctuating disturbance of cognition, often reversible, caused by medical conditions. Dementia is a chronic, progressive cognitive decline.

• Delirium: sudden onset, fluctuating course, impaired attention.
• Dementia: gradual onset, progressive decline, intact attention early on.
• Both involve cognitive impairment but differ in onset, course, and reversibility.

Memory trick: Sudden confusion, fluctuating mind, a medical cause you must find.

Progressive muscle relaxation (PMR) is a technique where clients systematically tense and then relax different muscle groups to become aware of and reduce physical tension associated with anxiety.

• Teaches body awareness and control over tension.
• Effective for reducing physical symptoms of anxiety (e.g., muscle tension, sleep issues).
• Can be easily learned and practiced independently.

Memory trick: Relax Your Muscles, Retrain Your Mind, Plan Your Day.

Measures taken to prevent infection with the hepatitis A virus, which primarily spreads through the fecal-oral route.

• Vaccination is the most effective method.
• Good hand hygiene is crucial.
• Avoid contaminated food and water.

Memory trick: Vaccines Vanquish Viral Ventures.

The process of checking for prostate cancer in men who have no symptoms, typically involving PSA blood tests and digital rectal exams.

• Shared decision-making is emphasized.
• Benefits include early detection; risks include false positives, anxiety, overtreatment.
• Guidelines vary slightly by organization (e.g., ACS, USPSTF).

Memory trick: Discuss Decisions Diligently for Dads.

Recommendations for the amount and type of physical activity adults should engage in to achieve significant health benefits.

• 150 minutes of moderate-intensity aerobic activity per week.
• 75 minutes of vigorous-intensity aerobic activity per week.
• Muscle-strengthening activities on 2 or more days a week.

Memory trick: Moderate Movement Makes Many Muscles Move.

Lifestyle and behavioral strategies to alleviate common symptoms associated with menopause, such as hot flashes, mood swings, and sleep disturbances.

• Avoid triggers like caffeine, alcohol, and spicy foods.
• Dress in layers and keep the environment cool.
• Practice relaxation techniques and maintain good sleep hygiene.

Memory trick: Cool Layers, Calm Mind, Careful Choices.

Strategies used to alleviate pain following surgery, aiming to optimize comfort, facilitate recovery, and prevent complications.

• Scheduled dosing is more effective than PRN for acute pain.
• Multimodal approach (pharmacological and non-pharmacological).
• Patient education on pain scale and medication use is vital.

Memory trick: Scheduled Support Stops Suffering Swiftly.

The health hazards associated with using e-cigarettes and vaping products, particularly concerning adolescent development and addiction.

• Vaping products often contain highly addictive nicotine.
• Nicotine can harm adolescent brain development.
• Vaping aerosols contain harmful chemicals and can cause lung damage.

Memory trick: Vape's Vicious Vapors Violate Vitality.

Medical evaluations and preventive measures taken before pregnancy to optimize maternal and fetal health outcomes and reduce risks of adverse pregnancy outcomes.

• Folic acid supplementation to prevent neural tube defects.
• Rubella and varicella immunity screening/vaccination.
• Screening for STIs, chronic conditions, and genetic risks.

Memory trick: Future Family's Foundation: Folic, Fences, & Fitness.

Guidelines to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.

• Always place infants on their back to sleep.
• Use a firm sleep surface.
• Keep the crib free of soft objects, loose bedding, and bumper pads.

Memory trick: Back to Bed, Bare & Firm, Baby's Own Room.

Regular, heavy use of cannabis can lead to dependence, characterized by a compulsive need for the drug and withdrawal symptoms upon cessation.

• Psychological dependence is common.
• Withdrawal symptoms include irritability, anxiety, sleep issues, decreased appetite.
• Severity of withdrawal varies by individual and usage pattern.

Memory trick: Dependence Doesn't Discriminate: Don't Dismiss Danger.

Observable indicators that a breastfed or bottle-fed newborn is receiving sufficient milk and is well-hydrated.

• Weight gain after initial loss.
• Appropriate number of wet diapers and bowel movements.
• Audible swallowing during feeding.

Memory trick: Wet diapers and poop are proof of proper provision.

The physical, emotional, social, and financial strain experienced by individuals caring for a chronically ill, disabled, or elderly family member.

• Symptoms include stress, depression, anxiety, fatigue, social isolation.
• Respite care and support groups are key interventions.
• Nurses should assess for and address caregiver burden proactively.

Memory trick: Support and Sleep Sustain Struggling Spouses.

Techniques used to quickly alleviate symptoms of stress and anxiety during immediate, high-stress situations.

• Focus on activating the parasympathetic nervous system.
• Deep breathing is a primary technique.
• Mindfulness and grounding exercises are also effective.

Memory trick: Breathing Brings Best Benefits Immediately.

Certain nutrients, particularly vitamin C, can significantly increase the body's absorption of non-heme iron from plant-based foods.

• Vitamin C (ascorbic acid) is the most potent enhancer.
• Avoid calcium-rich foods and tannin-containing beverages (tea, coffee) with iron-rich meals.
• Non-heme iron is found in plants; heme iron in animal products.

Memory trick: Vitamin C Consumes Carefully Cooked Combinations.

Healthcare that respects and integrates a client's cultural beliefs, values, and practices into their care plan to promote better health outcomes.

• Involves active listening and open communication.
• Avoids assumptions and stereotypes.
• Collaborates with the client to adapt care to their cultural context.

Memory trick: Respectful Routines Reconcile Relevant Restrictions.

A clinical judgment about an individual's actual or potential nutritional intake that is insufficient or in excess of metabolic needs.

• Less Than Body Requirements: Intake insufficient to meet metabolic needs.
• More Than Body Requirements: Intake exceeds metabolic needs.
• Related factors can include psychological, social, economic, or physical barriers.

Memory trick: Appetite's Absence Alters Aged's Aliments.

Interventions aimed at fostering connection, engagement, and a sense of belonging in older adults to improve their social and spiritual well-being.

• Encourage participation in social activities and community groups.
• Facilitate connection with family and friends.
• Promote engagement in meaningful hobbies or volunteer work.

Memory trick: Connect, Contribute, & Cultivate Community.

Key physical, cognitive, social, and emotional achievements typically observed in children aged 3 to 5 years.

• Gross motor: hops, balances on one foot, climbs well.
• Fine motor: draws shapes, uses scissors, dresses self.
• Cognitive: asks 'why' questions, counts, knows colors.

Memory trick: Infant Inquires, Toddler Tries, Preschooler Performs, School-age Succeeds.