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Sunday, November 30, 2008

Practical Nclex Questions You Should Already Know

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Incentive devices have many desired and positive effects. Incentive devices provide the stimulus for a spontaneous deep breath. Spontaneous deep breathing, using the sustained maximal inspiration concept, reduces atelectasis, opens airways, stimulates coughing, and actively encourages individual participation in recovery. Shallow breaths, wheezing, and unilateral chest expansion would indicate that the incentive spirometry was not effective. Wheezing indicates narrowing or obstruction of the airway and unilateral chest expansion could indicate atelectasis.

Prazosin (Minipress) is an alpha-adrenergic blocking agent. “First-dose hypotensive reaction” may occur during early therapy, which is characterized by dizziness, lightheadedness, and possible loss of consciousness. This can also occur when the dosage is increased. This effect usually disappears with continued use or when the dosage is decreased.

With an arterial ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing technique includes the use of Kling rolls on circumferential dressings.

The stools of a child with celiac disease are characteristically malodorous, pale, large (bulky), and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.

Pregnancy-induced hypertension is the most common hypertensive disorder in pregnancy. It is characterized by the development of hypertension, proteinuria, and edema. Glycosuria and ketonuria occur in diabetes mellitus.

The major postoperative complication following craniotomy (supratentorial surgery) is increased intracranial pressure (ICP) from cerebral edema, hemorrhage, or obstruction of the normal flow of cerebrospinal fluid (CSF). Symptoms of increased ICP include severe headache, deteriorating level of consciousness, restlessness, irritability, and dilated or pinpoint pupils that are slow to react or nonreactive to light. Without prompt recognition and treatment, herniation syndromes develop and death can occur.

Buck’s extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin.

Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects.

Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pigskin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client.

The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The client is logrolled when turned to avoid extreme hip flexion. The head of the bed is elevated 30 to 45 degrees. All of these measures are used to enhance venous drainage, which helps prevent increased intracranial pressure (ICP).

Esophageal atresia prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia.

Indications for suctioning include moist, wet respirations, restlessness, rhonchi on auscultation of the lungs, visible mucus bubbling in the ET tube, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.

PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP.

Following thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax.

Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.

Fractured ribs are treated with good pulmonary therapy techniques such as coughing and deep breathing, rapid mobilization, and adequate pain control. Strapping of the ribs is not a treatment measure because it restricts deep breathing and can increase the incidence of atelectasis and pneumonia.

A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration. The increased intrathoracic pressure would cause the blood pressure to fall, not rise.

Bronchial sounds are normally heard over the main bronchi. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation, because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Bronchovesicular sounds are normally heard over the main bronchi. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes.

Kaposi’s sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy, and cryotherapy.

Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.

Pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.

Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock. Clamping the tubing for 30 minutes allows for equilibration to prevent complications.

Amphotericin B (Fungizone) is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications.

Continuous bladder irrigation is done following TURP using sterile normal saline, which is isotonic.

The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end expiratory pressure (PEEP). Therefore, an intubation tray is necessary.

In a clietn with empyema whose going to have a thoracentesis performed at teh bedside. The nurse plans to have an chest tube and rainage system availabel in the event that the procedure is not effective. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion.

Aspiration of clear fluid of less than 1 mL is indicative of epidural catheter placement. More than 1 mL of clear fluid or bloody return means that the catheter may be in the subarachnoid space or in a vessel. Therefore, the nurse would not inject the medication and would notify the anesthesiologist.

If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube, or in this case, immersing the end of the chest tube in a bottle of sterile normal saline or water. The physician should be notified after taking corrective action. If the physician is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petrolatum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.

In the client with Cushing’s syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus.

If the client experiences air embolus, the nurse should clamp the catheter immediately and notify the physician. The client is placed in the lateral Trendelenburg position on the left side to trap the air in the right atrium.

Aldosteronism can lead to hypokalemia, which in turn can cause life-threatening dysrhythmias.

Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%.

Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is insufficient for the majority of pregnant women, and iron supplements are routinely prescribed.

When Cushing’s syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mental status changes, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention, producing edema and hypertension.

Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. The tongue cannot be moved back because it would occlude the airway. Swallowing cannot be done with the mirror in place.

The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy will need permanent replacement of adrenal hormones.

A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison’s crisis) that occurs as a result of the adrenalectomy. Aldactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.

Following treatment with radioactive iodine therapy, a decrease in thyroid hormone level should be noted, which would help alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse needs to reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates. Occasionally, a client may require a second or third dose, but treatments are not lifelong.

The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum.

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Saturday, November 29, 2008

Start Of The 2-Day November 2008 Nursing Board Exam Licensure Examination

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Today marks the start of the 2-day nursing board examination. They will be answering three sets today and the remaining two sets tomorrow. The nursing board exam this November will be “leakage-free,” according to officials of the Board of Nursing, amid reports that one of the review centers have released some items in the tests.

The BON is coordinating with the nursing schools, as well as the Commission on Higher Education (CHED), to implement strict measures to make sure that the country will have high quality nurses, Sto. Tomas said.

More or less the results for the November 2008 Nursing Licensure Examination (NLE) will be release around late January to early February of next year. List of passers for the Nov 2008 NLE will be posted here once it is available by the PRC.

Subscribe to get a copy of the results of the 2008 Nov NLE and get updated.

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Friday, November 28, 2008

Nclex Style Questions And Anwsers On Critical Thinking

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Antihypertensive medications, such as enalapril, are administered to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis.

The sigmoid and descending colon are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus.

Respiratory distress can occur following thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. SSKI is typically administered preoperatively to block thyroid hormone synthesis and release, as well as place the client in a euthyroid state. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem post-thyroidectomy.

Sodium nitroprusside becomes unstable when exposed to light and must be protected.

The use of an incisional splint such as a “cough pillow” can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated.

All stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual, which is determined in order to evaluate whether undigested formula from a previous feeding remains. It is important to assess gastric residual because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. Assessing residual does not confirm placement, determine patency, or assess fluid and electrolyte status.

Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen.

Breathing and relaxation techniques aid the client in coping with the discomfort of labor and in conserving energy. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous.

Autonomic dysreflexia (hyperreflexia) is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. A client with autonomic dysreflexia would be hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.

IV nitroglycerin is prepared only in glass bottles, using the administration sets provided. Standard plastic (polyvinyl chloride) tubing will adsorb the nitroglycerin, thus reducing the potency and reliability of the medication. It should also be protected from extremes of light and temperature. It should be remixed every 4 hours.

The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case the client’s symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion.

Procainamide (Pronestyl) is an antidysrhythmic medication. Before the medication is administered, the client’s blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 3 to 10 mcg/mL).

Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific physician’s order to do so.

After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) in order to maintain the client’s electrolyte balance. It does not need to be mixed with water, nor should it be discarded or mixed with formula.

Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring, administering oxygen at a rate of 2 to 4 liters per minute unless otherwise ordered, and ensuring an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. Thrombolytic therapy may or may not be prescribed by the physician. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event.

Standard ECG graph paper measurements are 0.04 seconds for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.

Anterior cord syndrome is a medical condition where the blood supply to the anterior portion of the spinal cord is interrupted. It is characterized by loss of motor function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord (pain and temperature), and preservation of sensations carried by the posterior columns (fine touch and proprioception).

Fluid volume during pregnancy peaks between 18 to 32 weeks’ gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or CHF in the pregnant client. By assessing lung sounds in the lower lobes, the nurse may identify early symptoms of diminished oxygen exchange and potential CHF

Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and the application of ice.

To treat hypotension during hemodialysis, the nurse raises the client’s feet and legs to enhance cardiac return. A normal saline bolus of up to 500 mL may be given to increase circulating volume. The nurse would check the client’s weight and reassess the blood pressure. Finally, the transmembrane hydrostatic pressure or the blood flow rate into the dialyzer may be decreased. All of these measures should improve the circulating volume and blood pressure.

Anterolateral paddle placement for external countershock involves placing one paddle at the right second intercostal space and the other at the fifth intercostal space at the anterior axillary line.

Venography is similar to arteriography, except it evaluates the venous system. A radiopaque dye is injected into selected veins to evaluate patency and blood flow characteristics. The client signs an informed consent because it is an invasive procedure. Allergies to shellfish or iodine must be noted. Peripheral pulses are assessed so comparisons can be made after the procedure. The client is usually given clear liquids for 3 to 4 hours before the procedure to help with dye excretion afterward.

Good contact between the skin and electrodes are necessary to obtain a clear 12-lead ECG tracing. Therefore, the electrodes are placed on the flat surfaces of the skin just above the ankles and wrists. Movement may cause a disruption in that contact. The client does not need to hold the breath or take a deep breath during the procedure. The client needs to be reassured that a shock will not be received.

Long, firm strokes in the direction of venous flow promote venous return when bathing the extremities. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and they do not promote venous return.

The Z-track variation of the standard intramuscular technique is used to administer intramuscular medications that are highly irritating to subcutaneous and skin tissues. The nurse selects an intramuscular site for injection, preferably in a large deep muscle such as the ventrogluteal muscle. A new sterile needle is attached because the new needle will not have any medication adhering to the outside that could be irritating to the tissues. Retracting the skin provides a seal over the injected medication to prevent tracking through the subcutaneous tissues. The medication is injected slowly after aspiration, if there is no blood return on aspiration. The needle remains inserted for 10 seconds to allow the medication to disperse evenly. The nurse then releases the skin after withdrawing the needle.

General recommendations for managing extravasation of a chemotherapeutic agent include stopping the infusion, leaving the needle in place and attempting to aspirate any residual medication from the site, administering an antidote if available, and assessing the site for complications. Direct pressure is not applied to the site because it could further injure tissues exposed to the chemotherapeutic agent.

Intravenous pyelography is a contrast study of the kidneys to determine a variety of disorders of the kidneys, ureters, and bladder. Normal sensations during injection of the iodine-based radiopaque dye include a warm, flushed feeling, salty taste in the mouth, and transient nausea. Difficulty breathing, wheezing, hives, or itching indicate an allergic response and should be reported immediately. This complication is prevented by inquiring about allergies to iodine or shellfish before the procedure.

Tetracycline use during pregnancy may lead to discoloration of the child’s teeth when they erupt. This treatment for acne is contraindicated during pregnancy.

When doing a indium imaging, a sample of the client’s blood is collected, and the leukocytes are tagged with indium. The leukocytes are then reinjected into the client. They accumulate in infected areas of bone and can be detected with scanning. No special preparation or after care is necessary.

Penicillin is frequently the medication of choice for treating endocarditis of bacterial origin. The standard duration of therapy is 4 to 6 weeks, with home care support after hospital discharge, which is usually in 7 to 10 days.

The use of wet-to-dry saline dressings provides a nonselective mechanical debridement, whereby both devitalized and viable tissue are removed. This method should not be used on a clean, granulating wound. Granulation tissue in a venous stasis ulcer is protected through the use of wet-to-wet saline dressings, Vaseline gauze, or moist occlusive dressings, such as hydrocolloid dressings.

Digoxin immune fab is an antidote for severe digitalis toxicity. It contains an antibody produced in sheep, which antigenically binds any unbound digitalis in the serum and removes it. As more digoxin reenters the bloodstream from the tissues, it binds that also for excretion by the kidneys.
The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jelly-like stools. Clinical manifestations of Hirschsprung’s disease include constipation, abdominal distention, and ribbon-like, foul-smelling stools. Peritonitis is a serious complication that may follow intestinal obstruction and perforation. The most common symptom of appendicitis is colicky, periumbilical or lower abdominal pain in the right quadrant.

The client in seclusion is assessed continuously or at least every 15 minutes, or according to agency protocol. Vital signs, food and fluid intake, and toileting needs are assessed.

In this situation, the nurse is performing one test of cerebellar function and is testing for ataxia. Alterations in the cerebellar function are noted by alterations in balance and coordination.

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Wednesday, November 26, 2008

Nclex Study Guide Questions Answers Quiz

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Droperidol (Inapsine) may be administered by the intramuscular (IM) or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed. The IM route may be used when the medication is used as an adjunct to anesthesia.

The purpose of Electrophysiology (EPS) is to study the heart’s electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias without the influence of medications. Because the client’s verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

The inhalation of heated vapor helps the client to cough productively because the vapor condenses on the tracheobronchial mucosa and stimulates the production of secretions and a cough reflex. The client is told to lightly cover the mouthpiece with the lips and not to form a tight seal. The client inhales vaporized saline until coughing results.

If the client experiences air embolism, the immediate action is to place the client on the left side with the feet higher than the head. This position traps air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.

Physical or emotional stress triggers a sympathetic nervous system response. Responses that are reflected in the vital signs include an increased pulse, increased blood pressure, and increased respiratory rate. Stress reduction, then, returns these parameters to baseline.

Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thus reducing preload, afterload, and myocardial work. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.

When collecting a 24-hour urine specimen. The nurse asks the client to void at the beginning of the collection period and discards this urine sample. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is labeled, placed on fresh ice, and sent to the laboratory immediately.

If a client’s nasogastric tube stops draining, the nurse would first check the functioning of the equipment. The nurse would ensure that there was an order for irrigating the tube and would then irrigate the tube with 30 to 60 mL of normal saline (or with another acceptable solution per agency procedure). There is no useful reason to clamp the tube because it is probably clogged. Pulling out the tube could displace the tube, placing the client at risk for aspiration. Replacement of the tube is the last step if other actions are unsuccessful.

Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic and contraindicated for tepid sponge or tub baths. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child’s body temperature. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results.

The TPN line is used only for the administration of the TPN solution. Any other IV medication must be administered though a separate IV access site

If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther in order to provide sufficient space to inflate the balloon. The catheter’s balloon is behind the opening at the catheter insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra.

Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same precautions that are used for a client receiving anticoagulant therapy. Thus, venipuncture sites should be held for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia, but not hyperglycemia.

Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler’s position. High-Fowler’s is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilatation.

In PTCA a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall.

The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck’s extension traction (which is applied to a leg), the foot of the bed is elevated.

As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to reduce the gag response. The tube may be advanced after the client relaxes.

The antidote to iron dextran is deferoxamine, which is a heavy metal antagonist. This medication chelates unbound iron in the circulation and forms a water-soluble complex that can be eliminated by the kidneys. Dirithromycin is a macrolide antiinfective. Ferrous sulfate and ferrous fumarate are forms of iron supplements.

An AV shunt is a less common form of access site, but carries a risk for bleeding when it is used. This is because two ends of a cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt should be checked at least every 4 hours.

Hypocalcemia is a potentially life-threatening complication following parathyroidectomy, and the nurse should ensure that intravenous calcium preparations are readily available.

Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance

Clients with low back pain are often more comfortable when placed in semi-Fowler’s position with the knees raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the bed flat with the knees raised would excessively stretch the lower back and would also put the client at risk for thrombophlebitis.

Ipecac is administered to induce vomiting in certain poisoning situations. In this situation, the child is conscious and the ingested substance (aspirin) will not damage the esophagus or lungs from vomiting. Activated charcoal may be prescribed as an antidote in some poisoning situations, but its action is to absorb ingested toxic substances.

Mestinon is an acetylcholinesterase inhibitor. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors.

Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after an x-ray is taken. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.

Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Tricep muscle spasms may occur as a result of increased muscle use, but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking.

A Tensilon test may be performed to determine whether increasing weakness in a previously diagnosed myasthenic client is a result of cholinergic crisis (overmedication with anticholinesterase drugs) or myasthenic crisis (under medication with cholinesterase inhibitors). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.

As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurred, the physician needs to be notified.

A sputum culture showing Mycobacterium tuberculosis confirms the diagnosis of tuberculosis. Usually three sputum samples are obtained for the acid-fast smear. After the initiation of medication therapy, sputum samples are obtained again to determine the effectiveness of therapy. A positive Tine or Mantoux test indicates exposure to tuberculosis but does not confirm the presence of Mycobacterium tuberculosis. A positive chest x-ray may indicate the presence of tuberculosis lesions, but again does not confirm active disease.

Up until the third trimester, the measurement of fundal height will, on average, correlate with the gestational age.

On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client into the Trendelenburg position while pushing the presenting part upward to relieve the cord compression. This position is maintained and the physician is notified. The nurse monitors the fetal heart rate. The client is transferred to the delivery room when prescribed by the physician.

Intravenous pentamidine (Pentam-300) is infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias.

The nurse monitors for postoperative complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client’s calf could also indicate this complication.

Normal respiratory rate varies from 30 to 80 breaths per minute when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn infant may be a periodic breather. Observing and palpating respirations while the infant is quiet promotes accurate assessment. Palpation aids observation in determining the respiratory rate.

Homans’ sign tests for venous thrombosis of the lower extremity. Pain in the calf during walking could indicate venous thrombosis.

When assessing an IV for signs and symptoms of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the vein or surrounding tissues, which could cause more tissue damage. Increasing the IV flow rate can further damage the tissues if the IV has infiltrated. The IV site will feel cool if the IV fluid has infiltrated into the surrounding tissues. Redness and warmth may indicate phlebitis.

In suspected neck injuries, the appropriate way to open the airway is the jaw-thrust maneuver. If a neck injury is present, this maneuver will prevent further injury.

Intracranial pressure and encephalopathy are major problems associated with Reye’s syndrome.

A complication of pneumococcus pneumonia is pleural effusion, so the respiratory status of the child needs to be monitored.

Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling places pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

The fasciotomy site is not sutured, but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. Additionally, Betadine can be irritating to normal tissues.

Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on rigorous activities.

If there is leakage at the IV site, the nurse should first locate the source. The nurse should assess the site further to be certain that all connections are secure. The nurse should not increase the flow rate. Although it may leak more, it may also cause tissue damage if the IV was infiltrating. The infusion most likely will need to be stopped, but the physician would not need to be notified. Slowing and discontinuing the IV is also premature. The IV must first be assessed for the cause of the leaking.

The client is instructed to perform the Valsalva maneuver (take a deep breath, exhale, and bear down) for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space.

Electroconvulsive therapy is an effective treatment for depression that has not responded to medication. Psychosurgery is invasive, rarely performed, and would not treat depression. Seculsion is not used to treat depression. Neuroleptics are not effective in the treatment of depression.

The person whose anxiety is assessed as severe is unable to solve problems and has difficulty focusing on what is happening in the environment. Somatic symptoms are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever.

Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxia and polycythemia.

The neurovascular status of the extremity of the client in Buck’s extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client’s temperature is monitored, it is not specific to the use of Buck’s extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck’s extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days at the most. Range of motion of the involved leg is contraindicated in hip fractures.

A significant advantage of an ultrasound is that it can differentiate a solid mass from a fluid-filled cyst. It is noninvasive, and does not require any special after care. Other diagnostic tests, such as magnetic resonance imaging and computed tomography scanning, are also noninvasive (unless contrast is used) and require no special after care either. However, the ultrasound can discriminate between solid and fluid masses most optimally.

The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses or parasites.

Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Therefore, the client’s results are compatible with new-onset MI.

The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. The client is placed in a sitting position.

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus.

Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (Borborygmi) indicate hyperperistalsis. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit.

The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client’s activity level is adjusted according to the amount of edema and water retention. As edema increases, the client’s activity level should be restricted.

The pain of ureteral colic is caused by movement of a stone through the ureter, and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of its abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a deep ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.

Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a “three-point” position while upright and use pillows to support the head and thorax at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.

The priority items in the management of sickle cell crisis are hydration therapy and pain relief. To achieve this goal, the client is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Narcotic analgesics may be given to relieve the pain that accompanies the crisis. Oxygen would be given based on individual need. Red blood cell transfusion may also be done in selected circumstances, such as aplastic crisis or when the episode is refractive to other therapy. Genetic counseling is recommended, but not during the acute phase of illness.

Classic signs of cardiogenic shock include increased pulse (weak and thready), decreased blood pressure, decreasing urinary output, signs of cerebral ischemia (confusion, agitation), and cool, clammy skin.

Chest tube drainage should not exceed 100 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after cardiac surgery. The nurse measures and records the drainage on an hourly basis. The drainage is initially dark red and becomes more serous over time.

The client undergoing radiation therapy should wash the site using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). The client should wear cotton clothing over the skin site and guard against irritation from tight or rough clothing such as belts or bras.

Iron is needed for RBC production. Otherwise, the body cannot produce sufficient erythrocytes. In either case, the client is not receiving the full benefit of epoetin alfa therapy if iron is not taken.

Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately in order to note any variation in the pulse rate or rhythm that may need to be reported to the physician. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the physician is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.

The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living.

External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in jeopardy. Internal monitoring is contraindicated when there is vaginal bleeding of an unstated cause, especially in preterm labor. Because fetal distress has not been determined at this time, oxygen administration is premature. The amount of bleeding described is insufficient to require intravenous fluid replacement.

A consistent finding of abnormally high sodium and chloride concentrations in the sweat is a unique characteristic of CF. Normally, the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF.

The Cantor tube is an intestinal tube and is used for aspirating intestinal contents. For intestinal intubation the tube is threaded through the nose into the stomach and then through the pylorus, where peristaltic activity of the bowel carries it to the desired intestinal area. The nurse ensures intestinal placement by checking the pH of aspirate. A pH reading greater than 7 indicates intestinal contents; a reading less than 7 indicates gastric contents.

To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches, and then the pressure is released. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and further evaluation. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the physician should be notified.

Decerebrate posturing, which can occur with upper brain stem injury, is the extension of the extremities after a stimulus.

If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. The client should be positioned with the head in semi-Fowler’s position and the arm elevated on pillows to decrease edema. Edema is likely to occur because lymph drainage channels have been resected during the surgical procedure. Blood pressure measurement, venipuncture, and IV sites should not involve use of the operative arm.

Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, buttermilk, onions, peanut butter, and gelatin.

The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

Mild diverticular disease is treated with a high-fiber diet and prevention of constipation with bran and bulk laxatives. A diet high in fat should be avoided because high-fat foods tend to be low in fiber. A low-roughage diet is similar to a low-fiber diet.

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Monday, November 24, 2008

Mosby's Nclex RN 4th Edition Review For Nclex

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A decrease in Luteinizing hormone (LH) results in the loss of secondary sex characteristics. A decrease in Adrenocorticotropic hormone (ACTH) is seen in Addison’s disease. Prolactin (PRL) stimulates breast milk production by the mammary glands, and Growth hormone (GH) affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.

Amenorrhea or a decreased menstrual flow is common in the client with Graves’ disease. Dysmenorrhea, metrorrhagia, and menorrhagia are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves’ disease.

The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 5 cells). Protein (15 to 45 mg/dL) and glucose (45 to 80 mg/dL) are normally present in CSF.

The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

Intravenous diazepam is given by IV push directly into a large vein (reduces the risk of thrombophlebitis), at a rate no greater that 1 mg per minute. It should not be mixed with other medications or solutions and can be diluted only with normal saline.

The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. Noting a bulging fontanel when the infant cries is a normal finding that should be documented and monitored. It is not necessary to notify the physician.

The normal respiratory rate for a 3-year-old is approximately 20 to 30 breaths per minute.

Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.

Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods, and amenorrhea is the cessation of menstruation for a period of at least three cycles or 6 months in a woman who has established a pattern of menstruation and can result from a variety of causes.

In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests.

A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the neonate needs to receive the hepatitis vaccine and hepatitis B immune globulin within 12 hours after birth.

If a woman complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The appropriate nursing action would be to assess for Homans’ sign, which would assist in determining the presence of venous thrombosis. It is not appropriate to tell the mother that this is normal during pregnancy. Ambulation is an important exercise, and the woman should be encouraged to ambulate during pregnancy. Although it is important to elevate the legs during pregnancy, elevating the legs consistently is not an appropriate nursing action.

Before accessing an implanted vascular port, the nurse must palpate the port to locate the center of the septum. The port should then be anchored with the nondominant hand. Cool compresses over the site can help alleviate pain upon entry. The site should be cleansed with alcohol, working from the inside out to prevent introducing germs into the access site.

When measuring fundal height, the client lies in a supine position and the nurse should instruct the client to turn onto her left side, or the nurse can elevate the left buttock by placing a pillow under the area.

Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will correct or prevent the problem.

Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses.

Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase.

Following a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the biopsy site.

The Cantor tube is a single-lumen, mercury-weighted tube. The weight of the mercury tube carries the tube by gravity. Following insertion, to facilitate movement of the tube, the client is positioned on the right side.

Following supratentorial surgery (surgery above the brain’s tentorium), the client’s head is usually elevated 30 degrees to promote venous outflow through the jugular veins.

The term puerperal infection refers to a bacterial infection following childbirth.

The cord needs to be cleansed with alcohol thoroughly, and the cord and base should be cleaned two to three times per day with alcohol (or per agency protocol). The steps are (1) lift the cord, (2) wipe around the cord starting at the top, (3) clean the base of the cord, and (4) fold the diaper below the umbilical cord to allow the cord to air dry and to prevent contamination from urine. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. The infant does not feel pain in this area.

The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life.

Potassium chloride is very irritating to the vein and needs to be diluted to prevent phlebitis. Potassium chloride is never administered as a bolus injection

Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant’s passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X.

Meticulous skin care helps protect the HIV-infected newborn infant from secondary infections.

Stage II of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems in this stage include cardiac conduction defects and neurological disorders such as Bell’s palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy) and a rash appear in stage I.

A hallmark sign of pemphigus is Nikolsky’s sign, which is when the epidermis can be rubbed off by slight friction or injury. Other characteristics 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, 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 in the calf on forced dorsiflexion of the foot.

Following tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.

The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas). Asking the client to swallow assesses the swallow reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid.

The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.

The nursing care of a child with RMSF will include the administration of tetracycline. An alternative medication is chloramphenicol, a fluoroquinolone. Amphotericin B (Ketoconazole) is used for fungal infections. Ganciclovir (Foscarnet) is used to treat cytomegalovirus. Amantadine (Rimantadine) is used to treat influenza A virus.

The hallmark symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor without residual neurological damage. Before surgery, the child’s head will be shaved, although every effort is made to shave only as much hair as is necessary. Although chemotherapy may be needed, it is not the treatment of choice.

An MRI is a noninvasive diagnostic test that visualizes the body’s tissues, structure, and blood flow. The client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques or a sedative are used before the procedure to reduce claustrophobic effects. There is no useful purpose for administering an antihistamine, corticosteroid, or antibiotic.

Tretinoin (Retin-A) is prescribed for a client with acne. Decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel.

Dimercaprol (BAL) is a chelating agent that is used to treat lead poisoning. Sodium bicarbonate may be used in salicylate poisoning. Ipecac syrup may be prescribed by the physician to induce vomiting in certain poisoning situations. Activated charcoal is used to decrease absorption in certain poisoning situations.

A small amount of serous drainage may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and if this is noted, the physician should be notified.

A complete neurological assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices.

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Sunday, November 23, 2008

Listen to Heart Sounds

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Heart Sounds

1. aortic insufficiency heart sound
2. aortic stenosis heart sound
3. atrial septal defect heart sound
4. coarctation aorta heart sound
5. ebstein's disease heart sound
6. functional or innocent murmurs - venous heart sound
7. mitral prolapse syndrome heart sound
8. mitral stenosis heart sound
9. normal heart sound heart sound
10. patent ductus arteriosus heart sound
11. pulmonary stenosis heart sound
12 ventral septal defect heart sound

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Saturday, November 22, 2008

Room Assignment for November 2008 Nursing Examination

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Nurses 1108 Room Assignment

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November 2008 NLE Nursing Board Exam Results Release By the PRC

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More or less the November 2008 NLE Nursing Board Exam Results will be release a few months after the examination date.

Please enter you email address below so that you will get updates regarding the PRC Nov 2008 NLE Nursing Board Exam Results.


FYI: We are one of the few websites to post the results right after the PRC has released the successful NLE nursing examinees this November.

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Dawn Phenomenon & Somogyi Effect: Diabetic Talk

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Dawn Phenomenon
One of the most frustrating things that diabetics deal with is an unexpected rise in blood glucose overnight. You go to bed with a BG of 100 mg/dL (5.6 mmol/L), and wake up with a BG of 130 (7.2)! You didn't eat, so what happened?

This results from two distinctly different processes: Dawn Phenomenon and Somogyi Effect. Here are some basics.

Everyone, diabetic or not, exhibits some Dawn Phenomenon. It is a natural part of our bodies' circadian rhythms. Some have said it is the way our ancestors had the strength to rise and slay a wooly behemoth for breakfast.

Since most of us fast while sleeping, with teenagers a possible exception, our bodies use stored energy during sleep. If you have read our Nutrition Section, you know that the body uses all three macro-nutrients (carbohydrates, proteins, and fats) to store energy.

The most easily used is the storage medium of carbohydrates, called glycogen. Glycogen is made from glucose, and is stored in the liver and muscles. Since it is basically nothing more than a complex matrix of glucose, it is easy for the body to store and use, something the body does all day long. The technical term for the act of creating and storing glycogen is glycogenesis. When the body calls for the conversion of glycogen back to glucose it is called glycogenolysis.

Another macro-nutrient that is available to be converted to glucose is protein. Most of us think of our protein as being stored in muscle, but the body has protective mechanisms to make muscle wasting its last choice. One of the most useful and readily available sources of protein storage is in blood components, i.e., albumin (plasma). The body uses a process performed in the liver to convert amino acids, the building blocks of proteins, into glucose. The name for this process is gluconeogenesis, literally "the creation of new glucose".

So, what does all this have to do with a high fasting BG? Overnight, usually between 4am and 11am, your body releases some hormones. These are Growth Hormone (GH) from the anterior pituitary gland, cortisol from the adrenal cortex, glucagon from your pancreatic alpha-cells, and epinephrine (adrenalin). These hormones cause an increase in insulin resistance, raising your BG. In addition, these hormones trigger glycogenolysis and gluconeogenesis, adding stored or new glucose to your bloodstream

Read more (Dawn Phenomenon & Somogyi Effect)

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Nclex Study Guide - Nclex Excel Course-Drexel University Course Book

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Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Symptoms of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client’s thinking process and attention span.

Hydroxyzine (Vistaril) is an antiemetic and sedative/hypnotic that may be used in conjunction with narcotic analgesics for added effect. The injection can be extremely painful. Medications administered by the IM route generally take 20 to 30 minutes to become effective. Hydroxyzine causes dry mouth and drowsiness as side effects.

Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body utilize all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.

Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid, which is a potent acid in the body. Thus, this situation results in an alkalotic condition.

The client with late-stage salicylate poisoning is at risk for metabolic acidosis because of the effects of acetylsalicylic acid in the body. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul’s respirations, headache, nausea, vomiting, diarrhea, fruity smelling breath caused by improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia.

N-acetylcysteine (NAC) is the antidote for acetaminophen (Tylenol) overdose. It is administered orally with juice or soda or via a nasogastric tube. Vitamin K is the antidote for warfarin (Coumadin). Protamine sulfate is the antidote for heparin. Succimer (Chemet) is used in the treatment of lead poisoning.

Sodium chloride 0.9% (not sodium chloride 0.45%) is the same solution as normal saline 0.9%. This solution is isotonic (not hypertonic), and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.

Pulmonary edema from heart failure may first be manifested as a cough. The cough occurs in response to fluid filling the alveolar spaces. Pulmonary edema develops as a result of left ventricular failure or acute fluid overload. Orthopnea is an assessment finding. Increased rather than decreased blood volume occurs in heart failure. A nonproductive cough is a late manifestation of right-sided heart failure.

All IV solutions should be free of particles or precipitates. A tourniquet is applied above the chosen vein site. Cool compresses will cause vasoconstriction, making the vein less visible. Armboards are applied after the IV is started and are used only if necessary.

Acute respiratory distress syndrome usually develops within 24 to 48 hours after an initiating event, such as pulmonary trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations. Blood-tinged frothy sputum would present later, after the development of pulmonary edema. Breath sounds in the early stages of ARDS are usually clear but then may progress to bronchial breath sounds when pulmonary edema occurs. Chest x-ray findings may be normal during the early stages but will show infiltrates in the later stages.

Clinical manifestations of a Candida infection include pain, itching, and a thick, white vaginal discharge. Proteinuria, edema, and hypertension are signs of pregnancy-induced hypertension. Hematuria, proteinuria, and costovertebral angle pain are clinical manifestations associated with urinary tract infections.

When the hemoglobin level is below 11 mg/dL, iron deficiency is suspected. An indirect index of the oxygen-carrying capacity is the packed red blood cell volume or hematocrit level. Pathological anemia of pregnancy is primarily caused by iron deficiency.

Fever on the third or fourth day postpartum should raise concerns about possible endometritis until proven otherwise. A woman with endometritis normally presents with a temperature over 38° C. Lochia rubra on the second day postpartum is a normal finding. The white blood cell count of a postpartum woman is normally elevated. Thus, this method of detecting infection is not of great value in the puerperium.

The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 to 37 weeks of gestation) exhibits thick vernix covering the body, smooth soles without creases, and lanugo covering the entire body.

Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome, which can occur in post-term infants who have decreased amniotic fluid and are prone to cord compression. It develops when meconium in the amniotic fluid enters the lungs during fetal life or during labor. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section. Respiratory distress syndrome is a complication of preterm infants.

Deep vein thrombosis is a potentially serious complication of orthopedic injuries and surgery. Checking for a positive Homans’ sign assesses for this complication. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially serious complications.

Torsemide (Demedex) is a loop diuretic. The medication can produce acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse

Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph nodes, fever, malaise, and night sweats. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.

Increased urination is an early sign that the neonate’s respiratory condition is improving. Lung fluid, which occurs in RDS, moves from the lungs into the blood stream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress. Edema of the hands and feet occurs within the first 24 hours as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues.

Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and is absorbed into the circulatory system. A negative direct Coombs’ test result indicates that there are no maternal antibodies on fetal erythrocytes.

Clinical manifestations of cystitis usually include urinary frequency, urgency, dysuria, inability to void, or voiding only small amounts. The urine may be cloudy, with hematuria and bacteriuria. The client may complain of pain that is suprapubic or in the lower back.

The most accurate measurement of weight loss is daily weighing of the client at the same time of the day, in the same clothes, and using the same scale.

Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness.

Extracorporeal shock wave lithotripsy is done with conscious sedation or general anesthesia. The client must sign an informed consent form for the procedure and must be NPO for the procedure. The client needs an IV line for the procedure as well. A Foley catheter is not needed.

The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

Unresponsiveness may be an indication that the child is experiencing hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss.

Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure.

Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast, or the presence of “hot spots,” which are areas on the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal extremity include coolness and pallor of the skin, diminished arterial pulse, and edema.

Side effects of chlorpromazine (Thorazine) can include hypotension, dizziness and fainting especially with parenteral use, drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention.

Following a renal transplant. Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years post-transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is immediately begun with corticosteroids and possibly also with monoclonal antibodies and antilymphocyte agents.

Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances.

Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (succinylcholine and inhalation agents such as halothanes) trigger uncontrolled skeletal muscle contractions. This quickly leads to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a possibility for the client.

The meninges, three membranes that envelope the brain and spinal cord, are predominantly for protection. Each layer (pia mater, arachnoid, and dura mater) is a separate membrane. The basal ganglia consist of subcortical gray matter buried deep in the cerebral hemispheres. The basal ganglia, along with the corticospinal tract, are important in controlling complex motor activity.

Methyldopa (Aldomet) is an antihypertensive medication. During the second or third month of therapy with methyldopa, drug tolerance can develop, which is evident by rising blood pressure levels. The physician should be notified, who may then increase the medication dosage or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy.

Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.

When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks including circulation, sensation, and motion should be checked at least every 2 hours. Level of pain is an important postoperative assessment, but circulatory status is most important.

A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest x-ray is one of the best methods to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation would not likely occur immediately after placement. Although BP assessment is always important in assessing a client’s status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important but is not the priority.

The most accurate means of confirming the diagnosis of tuberculosis is by sputum culture. Establishing the presence of Mycobacterium tuberculosis is essential for a definitive diagnosis. Hemoptysis is not a common finding and is usually associated with more advanced cases of tuberculosis. A positive PPD indicates exposure to tuberculosis. A chest x-ray does not confirm the diagnosis of tuberculosis. Lung lesions may be indicative of diseases other than tuberculosis.

The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and to correct a bowel obstruction. The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic and the pH of the intestinal fluid is alkaline (7 or higher). Location of the tube can also be determined by x-ray.

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Friday, November 21, 2008

Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008)

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1. Mental health is defined as:
A. The ability to distinguish what is real from what is not.
B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation
D. Absence of mental illness

Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness.

2. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client
C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.

Answer: (A) Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher.

3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego

Answer: (A) Subconscious
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.

4. The superego is that part of the psyche that:
A. Uses defensive function for protection.
B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.

Answer: (D) The censoring portion of the mind.
The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego.

5. Primary level of prevention is exemplified by:
A. Helping the client resume self care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community

Answer: (C) Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.

6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse.

Which of the following is the most appropriate for the nurse to ask?
A. “Are you being threatened or hurt by your partner?
B. “Are you frightened of you partner”
C. “Is something bothering you?”
D. “What happens when you and your partner argue?”

Answer: (A) “Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.

7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal Disorder
C. Orgasm Disorder
D. Sexual Pain Disorder

Answer: (A) Sexual desire disorder
Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.

8. What would be the best approach for a wife who is still living with her abusive husband?
A. “Here’s the number of a crisis center that you can call for help .”
B. “Its best to leave your husband.”
C. “Did you discuss this with your family?”
D. “ Why do you allow yourself to be treated this way”

Answer: (A) “Here’s the number of a crisis center that you can call for help .”
Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault.

9. Which comment about a 3 year old child if made by the parent may indicate child abuse?
A. “Once my child is toilet trained, I can still expect her to have some"
B. “When I tell my child to do something once, I don’t expect to have to tell"
C. “My child is expected to try to do things such as, dress and feed.”
D. “My 3 year old loves to say NO.”

Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell"
Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.

10. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills

Answer: (C) Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later.

11. Situation: A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results.

The client has which somatoform disorder?
A. Somatization Disorder
B. Hypochondriaisis
C. Conversion Disorder
D. Somatoform Pain Disorder

Answer: (D) Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict.

12. Freud explains anxiety as:
A. Strives to gratify the needs for satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal reaction to stress
D. A conditioned response to stressors

Answer: (B) Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model.

13. The following are appropriate nursing diagnosis for the client EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction

Answer: (D) Impaired social interaction
The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain.

14. The following statements describe somatoform disorders:
A. Physical symptoms are explained by organic causes
B. It is a voluntary expression of psychological conflicts
C. Expression of conflicts through bodily symptoms
D. Management entails a specific medical treatment

Answer: (C) Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis.

15. What would be the best response to the client’s repeated complaints of pain:
A. “I know the feeling is real tests revealed negative results.”
B. . “I think you’re exaggerating things a little bit.”
C. “Try to forget this feeling and have activities to take it off your mind”
D. “So tell me more about the pain”

Answer: (A) “I know the feeling is real tests revealed negative results.”
Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint.

16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital.

When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to:
A. provide as much structure as possible for the child
B. ignore the child’s overactivity.
C. encourage the child to engage in any play activity to dissipate energy
D. remove the child from the classroom when disruptive behavior occurs

Answer: (A) provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.

17. The child with conduct disorder will likely demonstrate:
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors
C. Preference for inanimate objects.
D. Serious violations of age related norms.

Answer: (D) Serious violations of age related norms.
This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder.

18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following may be noted:
A. increased attention span and concentration
B. increase in appetite
C. sleepiness and lethargy
D. bradycardia and diarrhea

Answer: (A) increased attention span and concentration
The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.

19. School phobia is usually treated by:
A. Returning the child to the school immediately with family support.
B. Calmly explaining why attendance in school is necessary
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom

Answer: (A) Returning the child to the school immediately with family support.
Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear

20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe

Answer: (C) Moderate
The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35.

21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:
A. overprotection of the child
B. patience, routine and repetition
C. assisting the parents set realistic goals
D. giving reasonable compliments

Answer: (A) overprotection of the child
The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability.

22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis:
A. hopelessness
B. altered parenting role
C. altered family process
D. ineffective coping

Answer: (B) altered parenting role
Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources

23. A 5 year old boy is diagnosed to have autistic disorder.
Which of the following manifestations may be noted in a client with autistic disorder?

A. argumentativeness, disobedience, angry outburst
B. intolerance to change, disturbed relatedness, stereotypes
C. distractibility, impulsiveness and overactivity
D. aggression, truancy, stealing, lying

Answer: (B) intolerance to change, disturbed relatedness, stereotypes
These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder

24. The therapeutic approach in the care of an autistic child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child

Answer: (D) Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.

25. According to Piaget a 5 year old is in what stage of development:
A. Sensory motor stage
B. Concrete operations
C. Pre-operational
D. Formal operation

Answer: (C) Pre-operational
Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop.

26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.

A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence

Answer: (B) tolerance
tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome

Answer: (A) delirium tremens
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.

28. The care for the client places priority to which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered

Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.

29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. cocaine
D. marijuana

Answer: (B) cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.

30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)

Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine

31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.

The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia

Answer: (C) agnosia
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.

32. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
A. ”Don’t take it personally. Your mother does not mean it.”
B. “Have you tried discussing this with your mother?”
C. “This must be difficult for you and your mother.”
D. “Next time ask your mother where her things were last seen.”

Answer: (C) “This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.

33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
A. receives adequate nutrition and hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure environment
D. independently performs self care

Answer: (C) remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently

34. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
A. “Your husband is dead. Let me serve you your breakfast.”
B. “I’ve told you several times that he is dead. It’s time to eat.”
C. “You’re going to have to wait a long time.”
D. “What made you say that your husband is alive?

Answer: (A) “Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.

35. Dementia unlike delirium is characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change

Answer: (B) insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.

36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation.

Which of the following nursing diagnoses will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body requirements
D. altered family process

Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.

37. What is the best intervention to teach the client when she feels the need to starve?
A. Allow her to starve to relieve her anxiety
B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels

Answer: (C) Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.

38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.

Answer: (B) Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.

39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem

Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders

40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.

Answer: (A) Patient will learn problem solving skills
if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.

41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa

Answer: (B) Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship

42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies

The client is suffering from:

A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia

Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.

43. Initial intervention for the client should be to:
A. Encourage to verbalize his fears as much as he wants.
B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.

Answer: (D) Accept her fears without criticizing.
The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.

44. The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal behavior
D. The client feels angry towards the nurse who resembles his mother.

Answer: (A) Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.

45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.

Answer: (D) The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.

46. Which of the following should be included in the health teachings among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken

Answer: (A) Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.

47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint.

The nurse plans intervention based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience high level of anxiety in response to the paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.

Answer: (C) The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.

48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
A. “I can refer you to a spiritual counselor if you like.”
B. “You shouldn’t allow anyone to pressure you into sex.”
C. “It sounds like this problem is related to your paralysis.”
D. “How do you feel about being pressured into sex by your boyfriend?”

Answer: (D) “How do you feel about being pressured into sex by your boyfriend?”
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.

49. Malingering is different from somatoform disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
C. Gratification from the environment are obtained.
D. Stress is expressed through physical symptoms.

Answer: (B) It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.
50. Unlike psychophysiologic disorder Linda may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy

Answer: (C) stress management techniques
Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.

51. Which is the best indicator of success in the long term management of the client?
A. His symptoms are replaced by indifference to his feelings
B. He participates in diversionary activities.
C. He learns to verbalize his feelings and concerns
D. He states that his behavior is irrational.

Answer: (C) He learns to verbalize his feelings and concerns
C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.

52. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident.

The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is:

A. “I feel envious of mothers who have toddlers”
B. “I haven’t been able to open the door and go into my baby’s room “
C. “I watch other toddlers and think about their play activities and I cry.”
D. “I often find myself thinking of how I could have prevented the death.

Answer: (B) “I haven’t been able to open the door and go into my baby’s room “
This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning.

53. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate nursing diagnosis?
A. Ineffective individual coping related to loss.
B. Impaired verbal communication related to inadequate social skills.
C. Low esteem related to failure in role performance
D. Impaired social interaction related to repressed anger.

Answer: (C) Low esteem related to failure in role performance
This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange

54. The following medications will likely be prescribed for the client EXCEPT:
A. Prozac
B. Tofranil
C. Parnate
D. Zyprexa

Answer: (D) Zyprexa
This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant.

55. Which is the highest priority in the post ECT care?
A. Observe for confusion
B. Monitor respiratory status
C. Reorient to time, place and person
D. Document the client’s response to the treatment

Answer: (B) Monitor respiratory status
A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.

56. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant talked fast and hyperactive.

Initially the nurse should plan this for a manic client:

A. set realistic limits to the client’s behavior
B. repeat verbal instructions as often as needed
C. allow the client to get out feelings to relieve tension
D. assign a staff to be with the client at all times to help maintain control

Answer: (A) set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.

57. An activity appropriate for the client is:
A. table tennis
B. painting
C. chess
D. cleaning

Answer: (D) cleaning
The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client.

58. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following:
A. Agree on a consistent approach among the staff assigned to the client.
B. Suggest that the client take a leading role in the social activities
C. Provide the client with extra time for one on one sessions
D. Allow the client to negotiate the plan of care

Answer: (A) Agree on a consistent approach among the staff assigned to the client.
A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior.

59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints

Answer: (A) Taking a directive role in verbalizing feelings
The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.

60. A client on Lithium has diarrhea and vomiting. What should the nurse do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium therapy
D. Hold the next dose and obtain an order for a stat serum lithium level

Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.

61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that she has AIDS.

Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of:
A. Depression
B. Denial
C. anger
D. bargaining

Answer: (C) anger
Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…”

62. The nurse’s therapeutic response is:
A. “I will refer you to a clergy who can help you understand what is happening to you.”
B. “ It isn’t fair that an innocent like you will suffer from AIDS.”
C. “That is a negative attitude.”
D. ”It must really be frustrating for you. How can I best help you?”

Answer: (D) ”It must really be frustrating for you. How can I best help you?”
This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client.

63. One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is:
A. focusing
B. validating
C. reflecting
D. giving broad opening

Answer: (D) giving broad opening
Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement.

64. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following:
A. anxiety
B. suicidal ideation
C. Major depression
D. Hopelessness

Answer: (B) suicidal ideation
The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide.

65. Which of the following interventions should be prioritized in the care of the suicidal client?
A. Remove all potentially harmful items from the client’s room.
B. Allow the client to express feelings of hopelessness.
C. Note the client’s capabilities to increase self esteem.
D. Set a “no suicide” contract with the client.

Answer: (A) Remove all potentially harmful items from the client’s room.
Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide.

66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.K. to work as nurse.

The client has which of the following developmental focus:
A. Establishing relationship with the opposite sex and career planning.
B. Parental and societal responsibilities.
C. Establishing ones sense of competence in school.
D. Developing initial commitments and collaboration in work

Answer: (A) Establishing relationship with the opposite sex and career planning.
The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework.

67. The personality type of Ryan is:
A. conforming
B. dependent
C. perfectionist
D. masochistic

Answer: (B) dependent
A client with dependent personality is predisposed to develop asthma. A. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis.

68. The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment

Answer: (C) A living, learning or working environment.
A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu.

69. Included as priority of care for the client will be:
A. Encourage verbalization of concerns instead of demonstrating them through the body
B. Divert attention to ward activities
C. Place in semi-fowlers position and render O2 inhalation as ordered
D. Help her recognize that her physical condition has an emotional component

Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered
Since psychopysiologic disorder has organic basis, priority intervention is directed towards disease-specific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready.

70. The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse?
A. “You are much better than when you were admitted so there’s no reason to worry.”
B. “What would you like to do now that you’re about to go home?”
C. “You seem to have concerns about going home.”
D. “Aren’t you glad that you’re going home soon?”

Answer: (C) “You seem to have concerns about going home.”
. This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings.

71. Situation: The nurse may encounter clients with concerns on sexuality.

The most basic factor in the intervention with clients in the area of sexuality is:
A. Knowledge about sexuality.
B. Experience in dealing with clients with sexual problems
C. Comfort with one’s sexuality
D. Ability to communicate effectively

Answer: (C) Comfort with one’s sexuality
The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.

72. Which of the following statements is true for gender identity disorder?
A. It is the sexual pleasure derived from inanimate objects.
B. It is the pleasure derived from being humiliated and made to suffer
C. It is the pleasure of shocking the victim with exposure of the genitalia
D. It is the desire to live or involve in reactions of the opposite sex

Answer: (D) It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.

73. The sexual response cycle in which the sexual interest continues to build:
A. Sexual Desire
B. Sexual arousal
C. Orgasm
D. Resolution

Answer: (B) Sexual arousal
Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.

74. The inability to maintain the physiologic requirements in sexual intercourse is:
A. Sexual Desire Disorder
B. Sexual Arousal Disorder
C. Orgasm Disorder
D. Sexual Pain disorder

Answer: (B) Sexual Arousal Disorder
This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.

75. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
A. “You’re attractive but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”

Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.

76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks.

Which of the following statements is most appropriate to make to this patient?
A. What is causing you to become agitated?
B. You need to stop that behavior now.
C. You will need to be restrained if you do not change your behavior.
D. You will need to be placed in seclusion.

Answer: (A) What is causing you to become agitated?
In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.

77. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client’s anger is escalating. Which approach is least helpful for the client at this time?
A. Acknowledge the client’s behavior
B. Maintain a safe distance from the client
C. Assist the client to an area that is quiet
D. Initiate confinement measures

Answer: (D) Initiate confinement measures
The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.

78. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following:
A. A timid nurse
B. A mature experienced nurse
C. an inexperienced nurse
D. a soft spoken nurse

Answer: (B) A mature experienced nurse
The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.

79. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints

Answer: (A) Taking a directive role in verbalizing feelings
Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.

80. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights?
A. There was a doctor’s order for restraints/seclusion
B. The patient’s rights were explained to him.
C. The staff observed confidentiality
D. The staff carried out less restrictive measures but were unsuccessful.

Answer: (D) The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.

81. Situation: Clients with personality disorders have difficulties in their social and occupational functions.

Clients with personality disorder will most likely:
A. recover with therapeutic intervention
B. respond to antianxiety medication
C. manifest enduring patterns of inflexible behaviors
D. Seek treatment willingly from some personally distressing symptoms

Answer: (C) manifest enduring patterns of inflexible behaviors
Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality disorders.

82. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have?
A. Narcissistic
B. Paranoid
C. Histrionic
D. Antisocial

Answer: (D) Antisocial
These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors.

83. The client joins a support group and frequently preaches against abuse, is demonstrating the use of:
A. denial
B. reaction formation
C. rationalization
D. projection

Answer: (B) reaction formation
Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person.

84. A teenage girl is diagnosed to have borderline personality disorder. Which manifestations support the diagnosis?
A. Lack of self esteem, strong dependency needs and impulsive behavior
B. social withdrawal, inadequacy, sensitivity to rejection and criticism
C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness and need for control

Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior
These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality

85. The plan of care for clients with borderline personality should include:
A. Limit setting and flexibility in schedule
B. Giving medications to prevent acting out
C. Restricting her from other clients
D. Ensuring she adheres to certain restrictions

Answer: (D) Ensuring she adheres to certain restrictions
The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others.

86. Situation: A 42 year old male client, is admitted in the ward because of bizarre behaviors. He is given a diagnosis of schizophrenia paranoid type.

The client should have achieved the developmental task of:
A. Trust vs. mistrust
B. Industry vs. inferiority
C. Generativity vs. stagnation
D. Ego integrity vs. despair

Answer: (D) Ego integrity vs. despair
The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.

87. Clients who are suspicious primarily use projection for which purpose:

A. deny reality
B. to deal with feelings and thoughts that are not acceptable
C. to show resentment towards others
D. manipulate others

Answer: (B) to deal with feelings and thoughts that are not acceptable
Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others

88. The client says “ the NBI is out to get me.” The nurse’s best response is:
A. “The NBI is not out to catch you.”
B. “I don’t believe that.”
C. “I don’t know anything about that. You are afraid of being harmed.”
D. “ What made you think of that.”

Answer: (C) “I don’t know anything about that. You are afraid of being harmed.”
This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false

89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
A. tardive dyskinesia
B. Pseudoparkinsonism
C. akinesia
D. dystonia

Answer: (B) Pseudoparkinsonism
Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes

90. The client is very hostile toward one of the staff for no apparent reason. The client is manifesting:
A. Splitting
B. Transference
C. Countertransference
D. Resistance

Answer: (B) Transference
Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse

91. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother.

Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal

Answer: (B) Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life

92. During the initial care of rape victims the following are to be considered EXCEPT:
A. Assure privacy.
B. Touch the client to show acceptance and empathy
C. Accompany the client in the examination room.
D. Maintain a non-judgmental approach.

Answer: (B) Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.

93. The nurse acts as a patient advocate when she does one of the following:
A. She encourages the client to express her feeling regarding her experience.
B. She assesses the client for injuries.
C. She postpones the physical assessment until the client is calm
D. Explains to the client that her reactions are normal

Answer: (C) She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher

94. Crisis intervention carried out to the client has this primary goal:
A. Assist the client to express her feelings
B. Help her identify her resources
C. Support her adaptive coping skills
D. Help her return to her pre-rape level of function

Answer: (D) Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal

95. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:
A. Adjustment disorder
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder

Answer: (D) Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

96. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying.

The nurse assesses the level of anxiety as:
A. Mild
B. Moderate
C. Severe
D. Panic

Answer: (C) Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

97. Anxiety is caused by:
A. an objective threat
B. a subjectively perceived threat
C. hostility turned to the self
D. masked depression

Answer: (B) a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

98. It would be most helpful for the nurse to deal with a client with severe anxiety by:
A. Give specific instructions using speak in concise statements.
B. Ask the client to identify the cause of her anxiety.
C. Explain in detail the plan of care developed
D. Urge the client to focus on what the nurse is saying

Answer: (A) Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.

99. Which of the following medications will likely be ordered for the client?”
A. Prozac
B. Valium
C. Risperdal
D. Lithium

Answer: (B) Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic

100. Which of the following is included in the health teachings among clients receiving Valium?:
A. Avoid foods rich in tyramine.
B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.
D. Double up the dose if the client forgets her medication.

Answer: (B) Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

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