Milestone 2 Retake study guide Latest Update
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ABG head injury - CORRECT ANSWER: Respiratory acidosis causes hypercapnia
(excess CO2) which causes vasodilation of cerebral arteries, increasing intracranial
pressure
ABGs - PE - CORRECT ANSWER: Hypoxemia - Reduced P02
Hypocapnia - Reduced PC02
Defined as Respiratory acidosis
Low pH <7.35
PaC02 >42 mm Hg
Acrocyanosis monitor - CORRECT ANSWER: Persistent cyanosis of fingers, hands,
toes, and feet with mottled blue or red discoloration and coldness
May be seen in newborns during the first few weeks of life in response to exposure to
cold. Acrocyanosis is normal and intermittent.
Acute pancreatitis lipase - CORRECT ANSWER: Elevated lipase
Younger than 60 normal level is 10 - 140 U/L
60 and older normal level is 24- 151 U/L
In most cases, serum amylase and lipase levels are elevated within 24 hours of the
onset of the symptoms (diagnostic)
Addiction & relapse - CORRECT ANSWER: Family members and friends should be
aware that clients who begin to revert to old behaviors, return to substance-using
,acquaintances, or believe they can "handle myself now" are at high risk for relapse, and
loved ones need to take action.
Addison's disease - glucose - CORRECT ANSWER: Severe hypoglycemia can result
from Addison's
Administer IV glucose (D5NS)
ADHD early school age - CORRECT ANSWER: A key feature of ADHD is the
consistency of the child's behavior
Strategies for Home and School:
· Medications, behavioral/environmental strategies
· Giving stimulants during daytime combats insomnia
Aggression source - CORRECT ANSWER: When predictability of meetings or groups
and staff-client interactions is lacking, clients often feel frustrated and bored, and
aggression is more common and intense
Triggering phase - the nurse should approach the client in a nonthreatening, calm
manner in order to deescalate the client's emotion and behavior
Escalation phase - nurse should provide directions to the client in a calm, firm voice.
The client should be directed to take a time-out for cooling off in a quiet area or his or
her room
Crisis phase - physically violent; staff must take charge of the situation for the safety of
the client, staff, and other clients.
, Anemia labs - CORRECT ANSWER: - Decrease in RBC Men <4.0 or Women <3.8
- Decrease in hemoglobin Men <14 or Women <12
ARDS - PaO2 level - CORRECT ANSWER: Notify provider if PaO2 < 80
A rapid onset of severe dyspnea
Arterial hypoxemia that does not respond to supplemental oxygen
Respiratory acidosis can occur (PaCO2 > 45)
Atrial fib - CORRECT ANSWER: No P wave = Fibrillation flopping
Rate 120-200 bpm
Causes
Valvular disease
Heart failure
Pulmonary hypertension
COPD
after heart surgery
Treatment
1. Cardioversion (after TTE to rule out clots)
2. Digoxin- Deep contraction (Check ATP before giving: A - Apical pulse 60
T - Toxicity (Max 2.0 range) visual disturbances, N/V, Anorexia
P - Potassium below 3.5- HIGHER risk for toxicity
3. Anticoagulants like warfarin (monitor INR, Vit K Antidote, moderate green leafy
veggies)
Biliary atresia - CORRECT ANSWER: - an absence of some or all of the major biliary
ducts, resulting in obstruction of bile flow
- causes cholestasis resulting in jaundice and eventual progressive fibrosis with end-
stage cirrhosis of the liver
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