PLEASE MEMORIZE MASTER

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MEDICAL-SURGICAL NURSING NOTE

What is the nursing priority for a patient with epiglottitis?A.administer steroids B.assist in endotracheal intubation C.assist in tracheostomy D.apply warm moist pack The correct answer is C. Epiglottitis is an emergency situation requiring immediate intervention: the inflamed epiglottis is blocking the entrance to the trachea, therefore clearing the patient’s AIRWAY is the priority nursing action (eliminate options A and D).Option C is better than Option B; endotracheal intubation will be di!cult because the inflamed epiglottis will not permit the insertion of a laryngoscope.The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT: A.dry skin B.lethargy C.insomnia D.sensitivity to cold The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in turn causes decreased metabolism. Options A, B and D are all consistent with decreased metabolism. Option C is a symptom of increased metabolism found in hyperthyroidism.ƒThyroid gland secretions (T3 and T4) are metabolic hormones Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs, and increased GI motility (diarrhea)

HYPOTHYROIDISMHYPERTHYROIDISM

All body systems are DECREASED except WEIGHT and MENSTRUATION!All body systems are INCREASED except WEIGHT and MENSTRUATION!

 decreased CNS: drowsiness, memory

problems (forgetfulness)

 increased CNS: tremors, insomnia

 decreased v/s: hypotension, bradycardia,

bradypnea, low body temp

 increased v/s: hypertension, tachycardia,

tachypnea, fever

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NCLEX PAST QUESTIONS 1 / 4

 decreased GI motility: constipation  increased GI motility: diarrhea  decreased appetite (anorexia) but with

WEIGHT GAIN

[low metabolism causes decreased burning of fats and carbs] This leads to increased serum cholesterol  atherosclerosis (hardening of arteries due to cholesterol deposits) Because of increased cholesterol, hypothyroid patients are prone to hypertension, myocardial infarction, CHF and stroke  increased appetite (hyperphagia) but with WEIGHT LOSS [high metabolism causes increased burning of fats and carbs]  decreased metabolism causes decreased perspiration  DRY SKIN and COLD INTOLERANCE  increased metabolism causes increased perspiration  MOIST SKIN and HEAT INTOLERANCE  Menorrhagia (excessive bleeding during menstruation)  Amenorrhea (absence of menstruation)

Pathognomic sign: EXOPHTHALMOS (bulging

eyeballs)

ƒNursing Management for hypothyroidism:

Low calorie diet Warm environment

ƒNursing Management for hyperthyroidism:

High calorie diet Cool environment What is the best way to prevent the spread of STDs?A.Use condoms B.Monogamous relationship C.Abstinence D.Practice Safe Sex The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember the Board of Nursing is composed of older women with traditional values who do not approve of promiscuity (implied in options A and D). Telling the patient to abstain from sex (Option C) is not an acceptable response from the nurse.

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What is the nursing priority if the client is su"ering from 1 st , 2 nd , 3 rd or 4 th degree burns?A.fluid and electrolyte balance B.infection C.pain D.airway The correct answer is B. Infection is a priority for all types of burns. Airway is a priority only for burns to the face and neck. Pain is a second priority for 1 st and 2 nd degree burns. Fluid and electrolyte balance is a second priority for 3 rd and 4 th degree burns [no pain because nerve endings are damaged].What is a normal physical finding of the thyroid gland?A.nodular consistency B.asymmetry C.tenderness D.palpable upon swallowing The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable only if the patient has goiter. The palpable mass on the neck is the thyroid cartilage. It is present in both males and females but is larger in males; it develops during puberty What food is most appropriate for a toddler?A.hotdog B.grapes C.milk D.spaghetti The correct answer is D. Toddlers need a high-carb diet to sustain their active play lifestyle. Toddlers are also at risk for aspiration, therefore eliminate foods that are choking hazards (options A and B). Milk is not the best food for toddlers because of its low IRON content; Milk is the primary cause of Iron-deficiency Anemia in children.

TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD

DETAILS TO THE QUESTION. Do not justify a wrong answer.

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What would the nurse include in the teaching plan for a paraplegic client?A.self-catheterization B.assisted coughing C.adapted feeding techniques D.compensatory swallowing The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed bladder and bowel). Therefore the nursing priority is ELIMINATION.

Review:

Monoplegia -- 1 limb paralysis Hemiplegia -- Right or Left side paralysis Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity paralysis) Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a quadriplegic patient is AIRWAY.

NERVOUS SYSTEM

ƒCNS: brain and spinal cord

ƒPNS: 12 cranial nerves + 31 spinal nerves

8 cervical nerves (C1 to C8) 12 thoracic nerves (T1 to T12) 5 lumbar nerves (L1 to L5) 5 sacral nerves (S1 to S5) 1 coccygeal nerve (Co) ƒThe spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5 (no risk of paralysis from spinal cord damage)

AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System (SNS)Parasympathetic Nervous System (PNS) ƒ“Fight” or aggression response ƒ“Flight” or withdrawal response ƒAlso termed adrenergic or parasympatholytic response ƒAlso termed cholinergic or sympatholytic response ƒThe neurotransmitter for the SNS is norepinephrine ƒThe neurotransmitter for the PNS is acetylcholine (Ach) All body activities are INCREASED except GIT!All body activities are DECREASED except GIT! increased blood flow to brain, heart and

skeletal muscles: These are the most important organs

during times of stress  normalized blood flow to vital organs

 increased BP, increased heart rate:

To maintain perfusion to vital organs  decreased BP, decreased heart rate

 bronchodilation and increased RR:

To increase oxygen intake  bronchoconstriction, decreased RR  urinary retention  FLUID VOLUME EXCESS Fluids are withheld by the body to maintain circulating volume  urinary frequency  FLUID VOLUME

DEFICIT

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