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Tuesday, July 22, 2008

Nclex Review Materials 4 (Saunders Nclex Notes)

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This client is exhibiting signs of increasing intracranial pressure (ICP). The nurse would avoid activities that further increase the ICP, such as suctioning the client. The head of the bed is kept at 30 degrees and the neck is kept at midline to promote venous drainage from the cranium. The nurse administers osmotic diuretics as prescribed, and carefully monitors fluid intake to prevent fluid overload.

A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night light for safety. The client should be accompanied during activities such as bathing and walking, so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety.

Authority for task completion is given to the team member by not directing or participating, and allowing the team member to complete the task under his or her own responsibility. The team member then reports the results to the team leader.

Safety is the primary concern when the client is ambulating.

The most important infection control measure is prevention of the spread of infection, and this is accomplished by frequent hand washing.

Guilt is a common reaction of the parents of a child diagnosed with glomerulonephritis. They blame themselves for not responding more quickly to the child's initial symptoms or may believe they could have prevented the development of glomerular damage.

Magnesium sulfate is administered to suppress seizures resulting from hypomagnesemia (as in eclampsia). A secondary effect of magnesium sulfate is that it acts as a laxative by increasing the water content of feces. Magnesium sulfate decreases SA node impulse formation and decreases myocardial conduction time.

Culture and sensitivity results should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture.

Warm, moist heat is employed after the first 24 hours following a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. Ice is used the first 24 hours to reduce the edema and numb the tissue. Stimulation of peristalsis is better achieved by ambulation. A sitz bath may provide comfort for hemorrhoids but does not prevent them.

Lactating women will require at least 500 additional calories above that consumed during pregnancy to ensure an adequate milk supply. Women are encouraged to increase their normal fluid intake (6 to 8 eight ounce glasses per day). Folate and iron requirements are lower than during pregnancy.

Offering only one breast per feeding causes milk stasis, which is a risk factor for mastitis. The mother is encouraged to allow the infant to empty one breast completely; then continue feeding the infant on the opposite breast. Newborns frequently become fatigued and do not completely empty the second breast. The mother is instructed to express remaining milk manually and to offer the second breast first at the next feeding. A safety pin attached to the brassiere cup will allow the mother to remember which breast should be offered first each feeding. Breaking the infant’s suction before removing the infant from the breast will reduce nipple trauma (another risk factor for mastitis). Gentle pressure placed on the tissue will not influence the development of mastitis. It is recommended to allow the infant to breathe through the nose unobstructed while they nurse.

The effects of human touch via counterpressure and effleurage promote a positive effect during the labor process. O

As the fetus’ head moves through the vaginal canal (second stage, descent phase), the maternal behaviors noted include: grunting sounds or expiratory vocalization; increased urge to push; frequent position changes; and altered respiratory patterns. During the first stage, transition phase, the client becomes agitated and changes body positions frequently. During the second stage, latent phase, the fetus’ head is delivering. The third stage is the period when the placenta is delivered.

During the beginning of the interactions between the parents and the infant, the safety of the infant is the primary concern. Not all mothers will breastfeed. Not all families have siblings. Protection of the infant from infection is important but is not done by isolation of the infant.

For premature infants, a nurse needs to calculate the developmental age by deducting the time of prematurity from the age of the child until he or she reaches the age of 2 years. In this case, 2 months need to be subtracted from 1 year, equaling 10 months of age. A 10 month old can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of 3 blocks.

Keeping a child calm and quiet decreases blood flow. Laying the child down and applying a warm washcloth to the bridge of the nose will increase blood flow. Additionally, the child needs to sit up and lean forward, not lie down. Even though bleeding for a child with ALL can be an emergency, steps need to be taken immediately to resolve the nosebleed before calling 911.

Poverty of speech is speech that is restricted in amount and ranges from brief to monosyllabic one-word answers. Poverty of content of speech is speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. Blocking is when the client stops talking in the middle of a sentence and remains quiet.

It is not normal for an adolescent to become depressed. Adolescents are concerned about body image and their appearance. Being moody and acting out a lot is not a normal behavior of an adolescent. Adolescents like to stay up late.

According to Erik Erickson, preschoolers are in the initiative stage of development. They pretend, explore, and try out new roles. They primarily look for the fun in activities, not the reasoning behind the activity. The child would not be interested in or understand information or details. Parental involvement is usually important for all ages of children especially during the younger years.

The signs of respiratory distress are often accompanied by fear of suffocation. In addition to immediate interventions to improve the client’s respiratory status, the nurse’s presence can provide reassurance and ease the client’s anxiety. The vital signs would be monitored, but this action will not relieve the client’s anxiety. The client may receive medication if prescribed, but this is not the priority.

Dependent edema may occur when the casted extremity is in the dependent position or when there is prolonged hip flexion while the client is sitting. Dependent edema caused by sluggish venous return should decrease when the leg is elevated above the level of the heart. If the edema is related to the potentially serious complication of compartment syndrome, pressure in the compartment is not decreased by elevating the leg above the heart. In fact, the pressure and the swelling may increase with elevation. Therefore, swelling that does not resolve with the intervention of elevating the extremity should be reported to the physician. Blue skin color and persistent pain are not typical and could be signs of compartment syndrome. Foul odors, with or without drainage, may indicate infection and should be reported to the physician.

Holding the infant close so that body warmth can be felt initiates a positive experience for the parent. It is also self-quieting and consoles the infant. The use of a high-pitched voice and participating in infant care are other methods of promoting parental-infant attachment. Infants should not be allowed to sleep between the parents not only because of the danger of suffocation, but also because the parents will require meaningful rest and time to be alone as a couple.

A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeat test in 6 months is recommended because false-negative results can occur early in the infection.

Regular fetal movements have been determined to be a reliable indicator of fetal health. The procedure is easy to learn and is noninvasive. It also allows self-care and reporting, which is a major goal of health maintenance.

Negative statements about the baby’s features or gender may interfere with the mother’s ability to bond with and care for the infant. Positive statements and identification with family members help the mother in identifying with the infant, promoting attachment. Fatigue is an expected response and may cause the mother to request the staff to assume care of the infant temporarily; however, after a period of rest, she should begin to assume care for her infant.

Erythromycin (Ilotycin) is effective against both Neisseria gonorrhea andChlamydia. It is less irritating to the newborn’s eyes than silver nitrate, does not stain, and may be administered at any safe temperature.

It is most important that pregnant clients receive iron supplements because of the extra demands placed on maternal circulation by the fetus.

Radiation therapy is often a source of fear and misconceptions for clients and their families. Education by the nurse can eliminate the fear and misconceptions and support the client. Some of the most common fears and misconceptions include fear of being burned, fear of being radioactive, the radioactive treatment, treatment failure, and the adverse effects.

Lidocaine is classified as an antidysrhythmic and is used to treat cardiac dysrhythmias.

The client who has been raped is in the beginning stages of the grieving process. The acceptance phase does not occur immediately after the rape. The goal that the individual will not experience psychological trauma is negated by the fact that the victim has been raped. Clients use defense mechanisms to help control anxiety and some defense mechanisms, such as denial, have been described to be helpful to the individual, especially in the immediate post-traumatic period.

No more than a standard amount of food should be placed on the feeding utensil, which is roughly the equivalent of 15 mL. Food should be placed on the posterior part of the tongue to aid in swallowing. Foods that have a soft consistency are provided. Liquids are thickened and are given separate from solid foods to prevent choking.

Clients admitted from home into a long-term care facility are dealing with losses in control over their environment, independence, and privacy. Providing total care does not facilitate independence. Medicating for pain will keep the client comfortable, but this does not address psychosocial needs. Daily visits that allow for the client's expression of feelings is the best way to address psychosocial needs.

r effective communication, the nurse uses active listening and creates an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive and will not create an environment for verbal exchange from the client. Reactiveness and listening only for facts are examples of inactive listening.

Memory impairments in advanced Alzheimer’s disease are marked by loss of recent memory, loss in long-term memory, and forgetfulness of routines.

Giving away treasured possessions is a sign of a potential suicide intent. Social withdrawal and inability to make or act on decisions are signs of depression, not potential suicide. While there is an increased risk of suicide in alcoholics, alcohol dependency itself is not an indicator of suicidal intent.

It is important for clients with type 1 diabetes mellitus to correlate eating with insulin administration to prevent hypoglycemia. Insulin should be given at approximately the same time each day and meals should be eaten at approximately the same time each day. This will establish regular patterns of glucose availability that approximate glucose availability in a nondiabetic body.

An excess of insulin relative to the amount of blood glucose induces hypoglycemia. Depending on the length of action of the insulin administered, the risk of hypoglycemia may be greatest in the late afternoon. The nurse needs to collect more data to determine if the client is actually experiencing hypoglycemia. Asking the client to describe the sick feeling provides the nurse with more data.

Polydipsia, polyuria, and polyphagia are the classic signs and symptoms of diabetes mellitus. Dyspepsia, dysphagia, and dysphasia are associated with other body systems (gastric and neurological). Hyperglycemia also occurs.

Treatment for clients with hyperparathyroidism includes dietary modification to low calcium foods. Ice cream and yogurt are high in calcium and should be restricted. The nurse should respond by rephrasing the client's statement to ensure that the nurse understands exactly what the client is saying.

Pregnant adolescents are at risk for complications during pregnancy. Adolescents are often concerned about their body image. If weight is a major focus, the client is more likely to restrict calories to avoid weight gain.

The process of convalescence from hepatitis is long and slow. Physically, the client becomes easily fatigued and needs additional rest. However, as the client recovers, there is an equally important need for some diversion from the long days of bedrest.

Tuberculosis is a contagious disease that is spread through respiratory droplets. A primary consideration is that the nurse identifies the names of close friends and family members so that these individuals can be tested for exposure to the TB. The client may not know who the disease was contracted from. It is premature to determine knowledge regarding medications because the treatment measures may not have yet been prescribed.

Providing psychosocial support means helping the client deal with their feelings. Goals for the client will focus on open expression of feelings and fears, and the development of coping skills in dealing with their illness and care.

When collecting data about the psychosocial needs of the client with HIV, the nurse should address the issue of client concerns or fears. Career choices are not the priority issue at this time.

An inactive older person may become disoriented due to lack of sensory stimulation. The family can help with orientation, but it is the nurse’s responsibility to help reorient the client. This client is in traction, so his or her understanding and cooperation is essential to the treatment.

When collecting data regarding the client’s psychosocial adjustment, the nurse would first address the client’s usual coping techniques.

The cause of the confusion in this situation is probably due to decreased sensory stimulation from being in a private room. Therefore, ambulating the client in the hall will increase sensory stimulation and may decrease confusion.

An environment that is conducive to sleep is one that simulates the client’s natural environment, including number of pillows, bedcovers, light, temperature, and noise. The nurse should plan to be flexible in care delivery times to allow the client rest periods as needed.

One of the problems for the parents of a high-risk neonate, such as a preterm SGA infant, is the risk for impaired parenting. The initial foci of intervention for parents of a preterm SGA infant are assessing and assisting parent-infant bonding. Failure of an SGA infant to exhibit normal newborn characteristics interferes with parent-infant bonding.

Because of client's incision is supratentorial, Craniectomy involves removal of a portion of the client’s cranium, and therefore, lying on the operative side is contraindicated, since the bony protection of the skull has been removed. The head of bed should be raised to 30 degrees to promote optimal venous drainage while maintaining arterial perfusion to the brain.

Anticipatory grieving is the intellectual and emotional responses and behaviors with which individuals and families work through the process of modifying self-concept with perception of potential loss. Defining characteristics include expressions of sorrow and distress at potential loss. Dysfunctional grieving or impaired adjustment is an abnormal response to changes in health status. Compromised family coping is identified when a usually supportive person is providing insufficient, ineffective or compromised support, comfort, assistance, or encouragement.

Medical management of hypoparathyroidism is aimed at correcting the hypocalcemia. This is accomplished with prescribed medications as well as lifelong compliance to dietary guidelines, which include consumption of foods high in calcium but low in phosphorus. Knowing that the interventions are lifelong can create some anxiety for the client, and this problem needs to be addressed before hospital discharge.

The normal values for the term infant being monitored for sepsis include: PO2 of 92% to 96%, temperature 97.8 to 99.0° F, and respiratory rate of less than 70 breaths per minute. A diastolic BP less than 40 mm Hg may be indicative of impending circulatory failure and should be reported immediately.

Post-term infants may experience meconium aspiration syndrome from the effects of anoxia in utero. Infants suffering from meconium aspiration may require mechanical ventilator support. Option 1 is absolute and incorrect and does not specifically respond to the mother’s question.

A clear liquid diet consists of foods that are relatively transparent to light, and are clear and liquid at room and body temperature. These foods include such items as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, popsicles, and either regular or decaffeinated coffee or tea.

MyPyramid, defined by the USDA, symbolizes a personal approach to healthy eating and physical activity. It has been developed to remind consumers to make healthy food choices every day. Foods from each of the 5 groups need to be consumed each day. A variety of fresh, frozen, canned, or dried fruits should be selected. The client should consume an increased intake of dark green vegetables.

If a client does not increase activity, the bones will experience a loss of calcium. Increasing calcium intake would only lead to elevated amounts in the blood, which could cause kidney stones.

Normal hemoglobin levels (11 to 18 g/dL) indicate that iron and protein intake is sufficient. Elevated creatinine levels indicate kidney problems.

Before the procedure, medication is given to prevent a gag reflex. Upon return from the procedure, the nurse must ensure that the gag reflex is present to prevent aspiration. After the procedure, the client must be placed in a side-lying or semi-Fowler’s position to prevent aspiration. Vital signs should be taken every 30 minutes for 2 hours to detect abnormalities. Saline gargles must only be administered when the presence of the gag reflex has been confirmed.

A high-protein, low-fat diet is recommended for a client with heartburn. This type of diet allows the lower esophageal sphincter to maintain its pressure and prevent reflux and heartburn. At least 2 hours should pass before the client lies down, which would allow enough time for the stomach acid to decrease. Fruit juices should be avoided due to their high level of acidity, which would aggravate symptoms. Clients should not be encouraged to overeat because it increases more production of acid and pressure within the stomach.

The client who has been having episodes of nausea and vomiting is likely to better tolerate food and liquids that are at room temperature or are cold. Hot items may increase the nausea because of the aromas emitted. Dry toast would be better tolerated by the client than toast with butter.

Daily weights are the most accurate way to monitor the client’s progress because it focuses on the outcome of therapy, weight gain. It is important to weigh the client at the same time each day, have the same amount of clothes on, urinate beforehand, and to use the same scale. It is also recommended that the client be weighed before breakfast.

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