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Monday, July 21, 2008

Nclex Review Materials 3 (Saunders Nclex Notes)

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Actinic keratoses refers to lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Dry skin is called xerosis. In this condition, the epidermis lacks moisture or sebum, and is often characterized by a pattern of fine lines, scaling, and itching. Causes include too frequent bathing, low humidity, and decreased production of sebum in aging skin. Seborrhea relates to any of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Pruritus refers to the symptom of itching, an uncomfortable sensation that leads to the urge to scratch the skin.

Edema is fluid accumulating in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If the pressure leaves a dent in the skin, “pitting” edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

The electrocardiogram (ECG) with a functional ventricular pacemaker shows a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted.

When recording the results of visual acuity using the Snellen chart, the nurse would record the result using the numeric fraction noted at the end of the last successful line read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/50 means that the client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. Normal visual acuity is 20/20.

An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant preoperatively as prescribed. Even if this were unscheduled surgery, the nurse should notify the physician.

Thrombolytics are most effective when started within 4 to 6 hours of symptom onset. They act to dissolve existing thrombi that are causing a blockage.

Warfarin sodium (Coumadin) is an anticoagulant, which is used for long-term prophylaxis for the prevention of thrombosis; it does not ensure that the client will never have a problem with clots again. Clients must receive detailed instructions regarding the signs of bleeding. Hematuria is a sign of bleeding, which the client should report to the physician. Medication should not be stopped without physician approval. Stiff joints are not associated with warfarin sodium (Coumadin).

Generally a healthy diet provides adequate sources of iron. Because of the expansion of maternal blood volume and the production of fetal red blood cells, iron requirements increase in pregnancy. Hemoglobin measures the amount of oxygen in the blood.

The effects of warfarin sodium overdose can be reversed with phytonadione (vitamin K). Phytonadione is an antagonist of warfarin sodium and can reverse warfarin-induced inhibition of clotting factor synthesis. Acetylcysteine (Mucomyst) is used to treat acetaminophen (Tylenol) overdose. Heparin sodium is an anticoagulant. Protamine sulfate is the antidote for heparin sodium.

Acetylsalicylic acid (aspirin) is an antiplatelet and affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before surgery to prevent bleeding complications.

Iron is available in foods of plant and animal origin. Foods that are rich in iron include muscle meats, liver, egg yolk, Brewer’s yeast, green leafy vegetables, fish fowl, beans, and cereal grains. Fruits are high in vitamin C. Milk is high in calcium.

A thrombolytic will dissolve thrombi and may be prescribed for clients who experience ischemic strokes. For clients who can be treated within 6 hours of the onset of symptoms, progression of the stroke can many times be halted. Many of the symptoms that occur can also be reversed. A beta blocker is used for cardiac and hypertensive conditions. An oral anticoagulant and an antiplatelet may be used to assist in preventing an ischemic stroke.

Liquid iron preparations will stain the teeth. The best advice for the client that needs liquid iron is to dilute the iron in juice or water, drink it through a straw, and rinse the mouth well after taking.

Ticlopidine (Ticlid) is an antiplatelet that is used to assist in the prevention of thrombotic stroke. Ticlopidine can cause neutropenia, which is an abnormally small number of mature white blood cells. Baseline data is necessary before initiating therapy. A complete blood cell count with WBC differential is necessary to determine neutropenia. If this adverse effect does occur, therapy should be ceased, which will reverse the effects of neutropenia within 1 to 3 weeks.

Ticlopidine (Ticlid) is best tolerated when taken with meals. The most common side effect is gastrointestinal disturbances. Taking ticlopidine (Ticlid) with meals tends to lessen those effects.

Cyanocobalamin (vitamin B12) is essential for DNA synthesis. It can take up to three years for the vitamin B12 stores to be depleted and symptoms of pernicious anemia to be noticed. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly.

An anticoagulant places the client at risk for bleeding and the client should be instructed in measures that will reduce the likelihood of this adverse effect. Contact sports should be avoided because of the risk of injury and subsequent bleeding. Acetaminophen (Tylenol) should be taken for mild discomforts because aspirin has antiplatelet properties and will increase the risk of bleeding. A soft toothbrush should be used to prevent bleeding in the gums. If signs of bleeding occur, the physician is notified.

The normal INR or therapeutic level ranges from 2.0 to 3.0. A value of 2.5 indicates a normal value.

The client is instructed not to discontinue the medication without the physician’s permission.

When taking Ticlopidine (Ticlid), blood test are important to check for a reversible low white blood cell count that can occur from the medication.

Neutropenia or agranulocytosis is the most serious adverse effect associated with the use of ticlopidine (Ticlid). It occurs most often within the first three months of therapy, therefore, a complete blood count with white blood cell differential is recommended every two weeks during the first three months of therapy. If a diagnosis of neutropenia is determined, then the client will be withdrawn from therapy

The medical management of a post-term infant is very different than that of a preterm or term infant. Estimating the true gestational age is an important factor in determining management of the infant.

The most likely medication to be prescribed to prevent ophthalmia neonatorum is Erythromycin ophthalmic ointment. Trifluridine ophthalmic solution is used for herpes simplex infections. Lacrilube and artificial tears are used to prevent drying of the eyes.

Temperature regulation may be poor in the post-mature infant because fat stores have been used for nourishment in utero. The infant may need to remain in a radiant warmer or incubator until thermoregulation is stable.

The presence of surfactant in amniotic fluid is an indicator of fetal lung maturity. Sampling may be done by amniocentesis or by removal of a fluid sample from the vagina after rupture of the membranes. Generally, pulmonary status is considered mature with an L/S ratio of greater than 2:1.

During the acute stages of respiratory disease in the newborn, and most importantly after replacement surfactant therapy has occurred, frequent monitoring may be required. This allows for trending of the respiratory status and facilitates decision making in further management.

Chest radiographs in infants with respiratory distress related to hyaline membrane disease show a “ground glass” appearance that is characteristic of the disease process.

The principal source of bilirubin is the hemolysis of erythrocytes. A cephalhematoma contains a large number of erythrocytes. As the red blood cells break down in the bruised area, they add to the bilirubin load.

A common treatment for jaundice is phototherapy. During phototherapy, bilirubin in the skin absorbs the light and changes into water-soluble products (photobilirubin and lumirubin). These do not require conjugation by the liver and can be excreted in the bile and urine. During phototherapy, clothes are not needed because the infant will be wearing only a diaper to facilitate the benefit of the phototherapy. Eye patches will be placed on the infant’s eyes. Feedings will be provided every 2 to 3 hours. Phototherapy can be performed at home.

Postmature infants are at risk for inadequate oxygen in utero, which in turn predisposes the infant to polycythemia. Polycythemia then makes the infant prone to hyperbilirubinemia. In this infant, the priority is to monitor the bilirubin level.

Total bilirubin levels in a term infant that rise above 12 mg/dL in less than 24 hours after birth is considered pathologic. Pathologic jaundice is of concern because of its association with kernicterus. Breast milk jaundice is usually associated with insufficient intake due to a sleepy infant, one who has a poor suck reflex, or is nursing on an infrequent schedule. This prevents the infant from receiving enough colostrum, which acts like a natural laxative, thus facilitating the passage of meconium stools that contain high levels of bilirubin. The cause of true breast milk jaundice is different from inadequate intake. The exact cause is not known but seems to be the combination of several factors that cause the bilirubin level to rise.

Anticholinergics dry up secretions and thereby help to prevent aspiration.

Furosemide (Lasix) = potassium wasting diuretics

Fresh fruits and vegetables are a good source of potassium.

One of the rights in medication administration is the “right client,” which can only be accurately verified by checking the identification bracelet. The client may be also asked their name but this action may not be reliable particularly if the client has periods of confusion.

A disoriented client must be offered fluid by the caregiver in order to increase fluid intake and prevent dehydration.

A client with dehydration has an increased depth and rate of respirations. The decreased fluid volume is perceived by the body as decreased oxygen levels (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings of deficient fluid volume are increased pulse, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness.

The vastus lateralis muscle is a large muscle and is large enough to handle an intramuscular injection in a toddler.

Pain expression varies by developmental stage. There are different pain scales utilized for different age groups.

Duodenal ulcers are associated with H. pylori infection. It is believed that these bacteria colonize the mucous cells and impair their function. Antibiotics are given to control this infection.

Exogenously administered corticosteroids have profound systemic effects because they “mimic” naturally occurring adrenal hormones. Hyperglycemia occurs because of the stimulation of gluconeogenesis and the decreased use of glucose by the cells.

Acetaminophen (Tylenol) is the only medication listed in the options that is a pain reliever that will not cause gastric irritation.

Centering is the tendency to concentrate on a single outstanding characteristic of an object while excluding its other features. Egocentrism is described as a type of thinking in which children have difficulty seeing any other point of view other than their own. Artificialism is the idea that people create the world and everything in it. Symbolic functioning is creating a mental image to stand for something that is not there.

A voiding cystourethrogram involves instillation of a radiopaque material into the bladder by means of a urethral catheter. The catheter is then removed and the client is asked to void while films are being taken. This helps to visualize obstructions or lesions in the bladder or urethra. It may be embarrassing or difficult for the client to void in front of others, and requires emotional support on the part of the nurse.

The developmental task in this stage includes moving toward heterosexuality, selecting a vocation, beginning separation from the family, and integrating personality.

A key advantage to CAPD is that it does not interfere with the client’s routine, since it does not require machinery, electricity, or a water source. Another advantage, unrelated to this question, is that there are fewer dietary and fluid restrictions, since this mode of dialysis closely resembles the (continuous) normal renal function. CCPD and IPD are two forms of automated peritoneal dialysis (APD). These require the use of an automatic cycling device, which limits client mobility and freedom. Hemodialysis is also disruptive to the client’s normal routine, since it usually involves a three to four hour hemodialysis session three times a week.

Gloves and a mask should be worn during connection and disconnection of peritoneal dialysis circuits. This prevents transmission of microorganisms by contact and via the airborne route.

Allergic rhinitis is called “hay fever,” and is an allergic response to an allergen. Sinusitis is inflammation of the sinuses, and coryza is a nasal discharge. An aspirin allergy is an allergic response to the medication. The combination of these three conditions (nasal polyps, asthma, and an aspirin allergy) is termed triad disease.

The primary symptom of a nasal polyp is nasal obstruction.

Milk contains both calcium and high quality proteins. Calcium supplements can replace the calcium provided by milk products; however, protein must also be provided. Lactose enzymes may help clients with lactose intolerance but they may not eliminate the client’s problems. An individual generally does not consume enough leafy green vegetables daily to obtain sufficient calcium.

Celiac disease is also known as gluten-induced enteropathy. It causes diseased intestinal villi, which results in decreased absorptive surfaces and malabsorption syndrome. Clients with celiac disease must maintain a gluten-free diet, which eliminates all products, made from wheat, rye, oats, and barley. Beer, pasta, crackers, cereals, and many more substances contain gluten. It is most important to determine the client’s understanding of the disease in order to plan care.

The pancreas makes digestive enzymes that aid in absorption. Chronic pancreatitis interferes with absorption of nutrients. Fat absorption is limited due to the lack of pancreatic lipase. Steatorrhea by definition means fatty stools often due to malabsorption problems.

The client is recovering from serious burns. The burn client is prone to several complications such as infection, dehydration, and sepsis. A temperature of 102.8° F is significant. On the fourth hospital day, infection may be the problem. The source of the infection may be the burns, the TPN infusion or TPN site, or other sources. As an initial action, the nurse needs to check the client for signs of infection and then notify the physician

TPN delivers high concentrations of glucose (25% to 70%). Due to the high concentrations of glucose and the possible addition of insulin to the solution, standard protocol for a client on TPN is to monitor blood glucose levels. The client may become hypoglycemic due to too much insulin in the TPN solution, or hyperglycemic and need supplemental insulin.

Frequently, TPN is given to clients at home who have severe malnutrition, gastrointestinal abnormalities, surgery, burns, or trauma. It is best to initiate the infusion in the evening in order to allow the client maximal daytime freedom.

To determine the client’s nutritional status, it is best to keep a record (journal) of all foods and fluids for several days before discontinuing the TPN. If the caloric and nutritional intake is adequate, the TPN may be weaned down before being discontinued. A journal kept by the client or caregiver will offer the physician or dietitian the most accurate information. A one-day record does not provide a sufficient amount of information. It may be difficult for the client to keep track of calorie intake. Additionally a calorie count is often inaccurate and does not provide information regarding nutrient status.

A complication of a subclavian central line can be an embolism due to air or thrombus. A sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The infusion is clamped (do not discontinue the line) and the physician is notified immediately.

Mitten splints are useful for the client with a head injury because the client cannot pull against them and create resistance, which could lead to increased intracranial pressure. Wrist restraints create resistance. Vest and waist restraints prevent the client from getting up or falling out of bed, but do nothing to limit hand movement.

Zalcitabine slows the progression of human immunodeficiency virus (HIV) disease by improving the CD4 cell count. The ELISA and Western blot are done to diagnose HIV initially. A CBC with differential may be done as part of an ongoing monitoring of the status of the client with HIV or acquired immunodeficiency syndrome and to detect adverse effects of other medications.


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