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Wednesday, July 16, 2008

Nclex-Rn: Saunders Nursing Review 7 (Level of Cognitive Ability)

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The nurse would assess the client for a previous history of a positive purified protein derivative reaction. The test should not be administered if the client has such a history. The nurse would use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.

Postprocedural care following endoscopic retrograde cholangiopancreatography includes monitoring vital signs and maintaining an NPO status until the gag reflex returns. The client usually receives a sedative before the procedure, so lethargy is expected. A local anesthetic is sprayed into the client’s throat; therefore, it is possible that the gag and cough reflexes will not be present. The client should be monitored for signs of cholangitis or perforation, which will include fever, abdominal pain (especially on the right upper quadrant), hypotension, and tachycardia.

The earliest symptom presented in an HIV positive infant is hepatosplenomegaly because the liver and spleen are target areas for the virus and the increased activity in these organs increases their size

Respiratory distress is a fearful event and is likely to cause apprehension. Apprehensiveness can also occur as a result of hypoxia experienced during the respiratory distress. Lethargy may occur as the respiratory status deteriorates.

The apical heart rate is best assessed by placing the stethoscope in the mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. Erb's point is located in the third intercostal space just left of the sternum. The aortic area is located in the second intercostal space just right of the sternum. The pulmonic area is located in the second intercostal space just left of the sternum.

Terazosin hydrochloride is a sympatholytic that is used to treat hypertension. Therefore the nurse would ask the client about a history of hypertension.

Meperidine hydrochloride is a narcotic analgesic that is used to treat pain. Therefore the nurse would monitor the client’s pain level to determine medication effectiveness. Hypotension, decreased urinary output, and sedation are side effects of the medication. The nurse would monitor the client’s blood pressure, the client’s urinary output, and the client’s neurological status for side effects of the medication, not intended effects.

Uterine atony accounts for many of the cases of immediate postpartum bleeding. A soft or boggy uterus indicates that the uterus is flaccid and is a sign of potential bleeding.

Filgrastim is a biologic modifier that stimulates production, maturation, and activation of neutrophils. Therefore the nurse would monitor the client’s neutrophil count.

Hypothermia may result in hypoglycemia because of the increased demands on the newborn's metabolism to generate heat. A weak high-pitched cry is a neurological symptom of hypoglycemia and occurs because of the lack of glucose to the brain. Acrocyanosis and mongolian spots are normal findings in a one-hour old newborn. Dry cracked skin is a sign of postmaturity.

Disseminated intravascular coagulation (DIC) is a life-threatening defect in coagulation. Severe PIH is one complication of pregnancy that can lead to DIC. Other causes include missed abortion or retained dead fetus, abruptio placentae, amniotic fluid embolism, and sepsis. Petechiae or bleeding from any vulnerable area such as intravenous sites, incisions, or the gums or nose are signs of DIC.

The clinical manifestations of Pneumocystis carinii pneumonia include fever, tachycardia, and tachypnea.

Phenytoin sodium (Dilantin) is an anticonvulsant. Frequent side effects include drowsiness, lethargy, irritability, headache, restlessness, joint aches, vertigo, anorexia, nausea, gastric distress, and gingival hyperplasia. Gingival hyperplasia is indicated by bleeding, tenderness, or swelling of the gums. The urine may appear pink, red or red brown while taking this medication, but this is not a side effect of the medication. Constipation and difficulty swallowing are not side effects of the medication.

Life-threatening hypokalemia can occur with the administration of amphotericin B. Therefore, the nurse monitors the results of serum potassium levels, which should be prescribed at least biweekly during therapy. Magnesium levels should also be monitored.

Sulfonylureas are hypoglycemic agents that lower the blood glucose. Acetohexamide (Dymelor), chlorpropamide (Diabinese), glyburide (DiaBeta), and tolbutamide (Orinase) are sulfonylureas. If a sulfonylureas is administered with a sulfonamide, increased glycemic effects can occur.

Clients should be taught proper hand washing techniques and instructed to avoid persons who are ill, not to care for fish tanks or animal litter, and to avoid undercooked meat, raw eggs, and unpasteurized dairy products. An HIV-infected pregnant client may have a normal, spontaneous vaginal delivery; however this is not related to methods of preventing an opportunistic infection. It is also critical to limit trauma during delivery to avoid the risk of HIV transmission to the neonate. Attending a party with a number of preschool children may increase exposure to colds and opportunistic infections.

The most common response for the client newly diagnosed with HIV is shock and disbelief, which is followed by guilt, anger, and depression. A symptom complex resembling PTSD is also common in the first few weeks after learning about the diagnosis. The client may experience anxiety, hypervigilance, and malingering.

The client should be instructed to avoid lifting objects heavier than 20 pounds for at least 6 weeks. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and, if noticed, does not indicate a need to notify the physician. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A fluid intake of at least 2 to 2.5 liters per day should be maintained to limit clot formation and prevent infection.

The client should be instructed to limit upper arm ROM to the level of the shoulder only. After the axillary drain is removed, the client can begin full ROM exercise to the upper arm

Risk factors associated with cervical cancer include intercourse with uncircumcised males, early frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and/or a history of genital herpes or human papilloma virus infection.

Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes when the intraocular pressure has risen to 40 to 50 mm Hg or higher. Severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.

The principle of treatment for the client with glaucoma is to maintain intraocular pressure at a reduced level to prevent further damage to intraocular structures. Medications are used to create miosis (constriction of the pupil) and to reduce formation of the aqueous humor by the ciliary body.

Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume normal activities, including returning to work, within 1 to 2 days (not immediately). The treatment prevents further visual loss but the lost vision cannot be restored.

The goals of treatment for herpes zoster are to relieve pain, to prevent infection and scarring, and to reduce the possibility of postherpetic neuralgia. Oral analgesics are prescribed to reduce the incidence of persistent pain. The lesions may also be injected with corticosteroids. Acyclovir, if started early, may reduce the severity of herpes zoster.

Indomethacin (Indocim) is a nonsteroidal antiinflammatory medication.

Prescriptive glasses, contact lenses, or intraocular lenses correct aphakia (absence of the lens of the eye). Only central vision is corrected with prescriptive glasses and peripheral vision is distorted. There is approximately 30% magnification of central vision with prescriptive glasses. This requires adjustment of daily activities and use of safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car or sitting in a chair.

Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bed rest and bilateral eye patching or shielding for 2 to 5 days during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood.

Preoperative instructions for cataract surgery are the client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back slowly. Eye medications such as mydriatics, cycloplegics, or beta blockers may be administered before the surgical procedure.

The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients may complain of visual distortion that is usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk.

Hodgkin’s disease is a chronic, progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not significantly related to the disease.

Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary obstruction and constipation. As the disease progresses, ascites associated with dyspnea and ultimately general severe pain will occur. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

Hypercalcemia is a serum calcium level greater than 11 mg/dL or 5.5 mEq/L. It most often occurs in clients who have bone metastasis and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the blood stream. Hypercalcemia is an oncological emergency and the physician needs to be notified.

A hordeolum is commonly known as a sty. Therapeutic management includes application of a warm compress for 15 minutes 4 times daily and instillation of an ophthalmic antibiotic ointment prescribed by the physician (not over-the-counter antibiotic ointment) to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in rupture of the sty and drainage of purulent contents. If a sty does not rupture spontaneously, it can be incised by the physician with a small sterile instrument. The client should be told not to press on or squeeze the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain.

Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient’s eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists order a medication such as 2% pilocarpine to constrict the pupil (not dilate the pupil) before surgery.

Enucleation is removal of the eye, leaving the eye muscles and remaining orbital contents intact.

Discharge instruction for a client following keratoplasty includes telling client that sutures are usually left in place for as long as six months. After sutures are removed and complete healing has occurred, prescription glasses or contact lenses will be prescribed.

Following enucleation, postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon because this finding could indicate hemorrhage.

Legal blindness implies that the person cannot perform work that requires visual ability. The person who is legally blind usually retains some perception of light and movement. Total blindness means the absence of all light perception. Low vision is a term that is used to refer to legally blind persons with severe vision impairment who still have some visual ability.

The immediate first aid treatment is irrigation of the eye with copious amounts of tap water for a minimum of 5 minutes. As soon as the initial irrigation is complete, the victim should be immediately brought to the nearest medical service. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is removed and the pH test with litmus paper is about 7.4. A quick test with litmus can be done before, during, and after irrigations to determine the pH and whether the substance was acid or alkaline.

Ménière’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is not entirely known. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches are not associated with this disorder.

The three characteristic symptoms of Ménière’s disease are tinnitus, sensorineural hearing loss on the involved side, and severe vertigo accompanied by nausea and vomiting.

The correct procedure for performing the otoscopic exam on an adult is to pull the pinna up and back and to visualize the external canal while slowly inserting the speculum. The nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. A small speculum may not provide adequate visualization of the ear canal and would be more appropriately used in a pediatric setting.

When performing a hearing tests on a client, The nurse should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately.

In the Weber tuning fork test, the examiner places the vibrating tuning fork in the middle of the client’s head at the midline of the forehead or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the opposite ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.

Insects that make their way into an ear are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil, lidocaine, or an ether-soaked cotton ball (not water) is instilled into the ear to kill or stupefy the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration, making the impaction worse.

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. It is not a conductive hearing loss nor is it specifically associated with nystagmus, dizziness, or ringing in the ears.

Nystagmus is a type of eye movement characterized by alternating smooth pursuit in one direction and saccadic movement in the other direction

Following mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse should monitor for signs of facial nerve injury to cranial nerve VII. The nurse should also monitor the client for pain, dizziness, or nausea. The head of the bed should be elevated and the client should lie on the unaffected side. The client will probably have sutures, an outer ear packing, and a bulky dressing that is removed on approximately the sixth postoperative day.

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

Tinnitus is the most common complaint of clients with otologic disorders, especially disorders involving the inner ear. Symptoms of tinnitus can range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span. Hearing loss can occur in some ear disorders but is not the most common complaint of an inner ear problem.

A hallmark sign of pemphigus is Nikolsky’s sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics of pemphigus include flaccid bullae that rupture easily and emit a foul smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, groin and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin.

Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign seen in tetany is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot.

Scabies can be identified by the presence of multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by a female mite, which burrows beneath the skin and lays its eggs.

Herpes zoster is caused by a reactivation of the varicella zoster virus, the cause of the virus for chicken pox. With classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skin’s surface to identify specific allergies. A biopsy will determine tissue type.

The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body’s midline.

Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas are highly metastatic, and a person’s survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed and although metastasis is rare, underlying tissue destruction can progress to include vital structures.

A melanoma is an irregularly shaped pigmented papule or plaque with a red, white or blue toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough, adherent yellow or brown scale.

A hydrocele is an abnormal collection of fluid within the layers of the tunica vaginalis that surrounds the testis. It may be unilateral or bilateral and can occur in an infant or adult. Hydrocelectomy is the excision of the fluid-filled sac in the tunica vaginalis. Increased fluid intake is encouraged.

A stage 4 pressure ulcer is a deep ulcer that extends into muscle and bone. It has a foul smell, and the eschar is brown or black. Purulent drainage is common. In a stage 1 ulcer, the skin is intact, but the area may appear pale when pressure is first removed. A stage 1 ulcer is also identified by a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief. A stage 2 ulcer is an area in which the top layer of skin is missing.

It is important to explain to the client with hepatitis that the majority of calories should be eaten in the morning hours, since nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories since energy is required for healing. Changes in bilirubin interfere with fat absorption so low fat diets are better tolerated.

Since tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or facemasks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and dispose of tissues carefully.

Dietary instructions to the client with a uric acid type of stone include increasing legumes, green vegetables, and fruits (except prunes, grapes, cranberries and citrus fruits) to increase the alkalinity of the urine. The client should also decrease foods high in purines, such as organ meats, gravies, red wines, goose, venison, and seafood.

In Bell’s palsy, the client experiences weakness on an entire half of the affected side of the face. The client is unable to close the eye on the affected side and experiences paralysis of the ipsilateral facial muscles. The client also experiences pain, drooling, decreased ability to taste, and increased tearing. Tinnitus, vertigo, and deafness are not associated with Bell’s palsy but may be seen in Ménière’s disease. Muscle spasms in the jaw and cheek area are associated with trigeminal neuralgia.

Therapeutic management for the client with Bell’s palsy includes providing moist heat packs to the affected area. The client is instructed to eat small amounts of soft foods frequently and to protect the affected eye by using an eye patch. The client is also instructed to use artificial tears 4 times daily and to manually close the affected eye from time to time.

For the first 24 hours postoperatively, the nurse should elevate the limb as prescribed to decrease swelling and promote comfort. Stumps with compromised circulation should not be elevated. Elevation is then done at intervals because elevation for longer periods of time may cause flexion contractures of the hip. To prevent hip contractures, the client should be placed prone for 20 to 30 minutes twice a day. A high-Fowler’s position will promote flexion contractures.

In general, only the area in the treatment field is affected by the radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the larynx is most likely to experience a sore throat.

Pallor is best seen in the buccal mucosa or conjunctivae, particularly in dark- skinned clients. Cyanosis is best seen in the nail beds, conjunctivae, or oral mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.

Raynaud’s disease is a disorder in which the small arteries and arterioles constrict in response to stimuli. This disorder is managed by avoiding activities that promote vasoconstriction. The hands and feet should be kept dry; gloves and warm fabrics should be used in cold weather; and the client should avoid exposure to nicotine and caffeine. Avoidance of situations that trigger stress is also helpful. A high protein diet is of no use in managing the effects of this disorder.

A diagnosis of gout is made on the basis of clinical manifestations, hyperuricemia, and the presence of uric acid crystals in the synovial fluid of the inflamed joint. Blood studies show an increased serum uric acid level of more than 7 mg/100 mL. The ESR and the WBC count may be elevated during an acute episode. The BUN is unrelated to the diagnosis of gout.

Probenecid is a uricosuric medication. The client should be instructed to avoid alcohol and to avoid medications that contain aspirin because it increases the urate levels. Increased fluid intake is encouraged to maintain an adequate urine output and prevent stone development, hematuria, and renal colic. The client is instructed to take the medication with milk or meals to prevent gastric distress.

Calcium supplements should not be taken with fiber-containing foods because these foods decrease the absorption of the calcium. The client should be instructed to drink water while taking the supplements to prevent renal stones. Side effects include constipation, gastric irritation, a chalky taste, nausea, and gastric bleeding.

Osteomalacia is the general term for the softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets.

In psychomotor agitation, it is best to provide activities that involve the use of the hands and gross motor movements. These activities include Ping-Pong, volleyball, finger painting, drawing, and working with clay. These activities give the client a more appropriate way of discharging motor tension than pacing or wringing the hands.

In a depress client that has a nursing diagnosis of impaired nurtrition, The client should be asked which foods or drinks he or she likes and consultation with a dietician may also be done. The client is more likely to eat if the client has selected the foods and is given foods that he or she likes.

When the client is manic, the best activities initially are solitary activities requiring short attention span or mild physical exertion, such as writing, painting, finger painting, woodworking, or walks with the staff. Solitary activities minimize stimuli and mild physical activities release tension constructively. When less manic, the client may join one or two other clients in quiet, nonstimulating activities. Competitive games should be avoided because they can stimulate aggression and cause increased psychomotor activity.

An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response and expresses the client’s outward affect. It may not coincide with the client’s inner emotions. A bizarre affect such as grimacing, giggling, and mumbling to one’s self is marked when the client is unable to relate logically to the environment.

Tranylcypromine, an antidepressant medication, can cause serious and potentially fatal adverse effects if used with other antidepressants. Therefore, the sertraline would need to be discontinued for two weeks before starting tranylcypromine. Sertraline (Zoloft) takes 14 days to 4 weeks for its antidepressant effect to occur. Alcohol should be avoided with the use of antidepressants.

When caring for a paranoid client, the nurse must avoid any physical contact and should not touch the client. The nurse should ask the client’s permission if touch is necessary because touch may be interpreted as a physical or sexual assault. The nurse would use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse’s intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. A matter-of-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a nondefensive stand. The anger that a paranoid client expresses is often displaced, and when the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and nonjudgmental attitude provides an attitude in which feelings can be explored more easily.

A client with paranoid personality disorder fears that others will exploit, harm, or deceive them, to the point of endangering their lives. The nurse should plan solitary noncompetitive activities that take some concentration, such as crossword puzzles, picture puzzles, photography, and typing. When the client feels less threatened, games such as bridge, chess, or playing cards with another client may be appropriate, since they require increased concentration. When the client is extremely distrustful of others, solitary activities are best and activities that demand concentration keep the client’s attention on reality and minimize hallucinatory and delusional preoccupation.

Delirium is an acute and relatively sudden (developing over hours to days) decline in attention-focus, perception, and cognition.

If the client’s behavior becomes physically abusive, the nurse first sets limits on the behavior by saying, “You are not to hit me or anyone else. Tell me how you feel.”

As anorexia nervosa develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons are likely to become very emaciated and will not maintain their near-normal body weight.

Nursing interventions related to imbalanced nutrition include determining the client’s eating patterns and food preferences and concern about eating. Determining previous and current coping skills is most appropriately related to a nursing diagnosis of ineffective coping. Determining client’s feelings about self and body is most appropriately related to a disturbed body image. Determining client’s lack of control about treatment plans is most closely related to the nursing diagnosis of powerlessness.

Repetition of words or phrases that are similar only in sound (rhyming) is evidence of one disturbed thought and language pattern seen in schizophrenia. Clang associations often take the form of rhyming. Echolalia is the pathological repeating of another’s word by imitation and is often seen in people with catatonia. Word salad is a term used to identify a mixture of phrases that are meaningless to the listener and perhaps to the speaker as well. Thought broadcasting is the belief that personal thoughts can be heard by others.

A social phobia is characterized by a fear of appearing inadequate or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious when attention is focused on him or her.

Signs of elder abuse include fear and confusion. The presence of bruises on the client also assists in validating the presence of elder abuse.

Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from ever occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. A precrisis level of prevention is similar to primary prevention.

Thioridazine hydrochloride (Mellaril), an antipsychotic medication, has a higher likelihood of producing impotence than other neuroleptics. Its incidence of EPS is relatively lower than many neuroleptics.

Agranulocytosis including leukopenia is an adverse effect of fluphenazine decanoate. Leukopenia places the client at risk for infection. Therefore, the nurse instructs the client to immediately report signs of infection such as a sore throat or fever.

Rifampin (Rifadin) is an antitubercular medication and can cause the client's urine to turn a harmless red-orange color. This condition disappears when the medication is discontinued.

A stage 3 ulcer is a deep ulcer that extends into the dermis and the subcutaneous tissue. White, gray, or yellow eschar usually is present at the bottom of the ulcer, and the ulcer crater may have a lip or edge. Purulent drainage is common. A stage 4 ulcer is a deep ulcer that extends into muscle and bone. A stage 2 ulcer is an area in which the top layer of skin is missing. A stage 1 ulcer is a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief.

The most commonly occurring side effects of antipsychotic agents include dry mouth, blurred vision, nasal stuffiness, and weight gain.




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