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Friday, August 22, 2008

Nclex Tips 7 (Nclex Answers)

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Aneurysm precautions include placing the client on bed rest in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure (BP) or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides all physical care to minimize increases in BP. For the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used.

Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution.

Nimodipine is a calcium channel-blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding of the aneurysm. It is typically ordered for 3 weeks duration.

Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition during the seizure, and postictal status.

Generalized seizures are seizures that are bilaterally symmetric and have no focal point of onset. Partial seizures are seizures that begin locally and include simple partial seizures (without impaired level of consciousness), complex partial seizures (with impaired level of consciousness), and partial seizures secondarily generalized.

Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitate drainage of secretions, which could help prevent aspiration. The nurse would also remove restrictive clothing and the pillow and raise the padded side rails, but these would not decrease the risk of aspiration. Rather they are just general safety measures to use during seizure activity. The nurse would not raise the client’s head of bed.

Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic CVA, the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic CVA vary, but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with CVA experience signs and symptoms similar to cerebral embolism or intracranial hemorrhage. In addition, most clients do not have repeated episodes of loss of consciousness. The client does not complain of difficulty with night vision as part of this clinical problem.

After CVA, the client often experiences periods of emotional lability, which is characterized by sudden bouts of laughing or crying, or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture for the client with this health problem, although it may be difficult for health care personnel and family members to deal with

Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach

Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed, and food is placed on the unaffected side of the mouth. The client is given ample time to chew and swallow and should not eat quickly because this could cause choking. Liquids are thickened to avoid aspiration.

Homonymous hemianopsia is loss of one half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision.

The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, crackles or rhonchi, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty in managing own saliva, or coughing or choking while eating. Because this is a medical complication, the most appropriate action is to notify the physician, who will then order definitive therapy.

Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client’s risk for injury. The nurse’s role is to refocus the client’s attention to the affected side. Personal care items, belongings, bedside chair, and commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and staff as well.

Clients with aphasia after CVA often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include: speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse also suggests to avoid shouting (because the client is not deaf), appearing rushed for a response, and allowing family members to give all the responses for the client.

Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes.

The client with myasthenia gravis has weakness after periods of exertion and near the end of the day, and medication is prescribed to alleviate weakness, particularly at these times. The nurse works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client also is instructed to take medication as prescribed.

The client with myasthenia gravis experiences dysphagia and a nasal quality to speech when the muscles of chewing and swallowing are involved. The nurse listens attentively and verbally verifies what the client has said. Other helpful techniques are to ask questions requiring a yes or no response and to develop alternative communication methods (letter board, picture board, pen and paper, flash cards).

Plasmapheresis is a process that separates the plasma from the blood elements, so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually three to five treatments are required. T

Myasthenic crisis is often caused by undermedication and responds to the administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to the withholding of medications.

Signs and symptoms of cholinergic crisis in a client with myasthenia gravis include general weakness and difficulty chewing, swallowing, speaking, and breathing. Nausea and vomiting, abdominal cramping, diarrhea, and increased production of body secretions also occur. It is due to overmedication and is treated by withholding all medications and supporting the client’s respiratory function until symptoms improve.

Inadequate or inappropriate medication therapy can result in either myasthenic or cholinergic crisis. It is very important for the client to take medications correctly to maintain blood levels that are within the therapeutic range. Clients with myasthenia gravis are taught to space activities over the day to conserve energy and restore muscle strength. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

Discharge instructions to a client with myasthenia gravis includes the client avoids swallowing any type of food or drink with the head lifted upward. This action could cause aspiration because it opens the glottis. The client should also refrain from talking with food in the mouth (glottis is open). The client should sit bolt upright while eating, cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.

The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed, and has difficulty starting and stopping. An ataxic gait is staggering and unsteady. A dystrophic gait is broad-based and waddling. A festinating gait is accelerating with walking on the toes.

The client with Parkinson’s disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an active participant in his or her own care. The family also should give the client encouragement and praise for perseverance in these efforts. The family should plan activities intermittently throughout the day to inhibit daytime sleeping and boredom.

The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses.

Home modifications to reduce the risk for falls includes use of sturdy and secure railings on all staircases and ample lighting. Bathroom safety equipment includes the use of a shower chair, handrails in the shower and near the toilet, and keeping a mat in the tub to prevent slipping.

Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.

A radiograph is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. The radiograph itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply, and then hold the breath while the chest radiograph is taken. The client is not required to void before the procedure, but may do so to enhance comfort during the procedure.

No activity or dietary restrictions must be followed after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. No hazards to the client or staff exist from the minimal amount of radioactivity of the isotope. The client would not experience nausea or flushing because contrast dye is not used for this procedure. In addition, those sensations would likely be experienced at the time of dye injection, not after it.

A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent.

When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is outside a hospital, and a physician is called if the client is hospitalized. The nurse should remain with the client and provide realistic reassurance.

The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smooth ed as needed with a special cast knife. A plaster cast gives off heat as it dries and may feel warm to the client. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The traction setup is checked routinely to assure that the ropes are in the grooves of the pulleys; ropes are not frayed; knots are tied securely; and weights are hanging freely from the ropes. Problems with any of these can interfere with maintenance of proper traction. If any problems are noted, they should be fixed immediately.

Buck’s extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. It reduces muscle spasms and helps to immobilize the fracture. It does not completely immobilize the fracture. It does not lengthen the leg to prevent blood vessel damage. It also does not allow bony healing to begin.

Purulent drainage can indicate infection at the pin insertion site, and the nurse would reassess the client’s temperature as another indication of the presence of infection. A small amount of serous oozing is expected at pin-insertion sites. Serosanguineous drainage may be present in small amounts initially, but does not indicate infection. Sanguineous drainage also is of concern and should be brought to the attention of the physician.

Self-Care Deficit applies when the client is unable to perform activities of daily living (ADLs) independently. A major defining characteristic of Deficient Diversional Activity is expression of boredom by the client. Activity Intolerance applies when the client has a decreased tolerance for activity or exercise, which is reflected by excessive fatigue or change in vital signs with activity. Impaired Physical Mobility is present when the client has difficulty with coordination, range of motion, or muscle strength.

Buck’s extension traction is a type of skin traction. The nurse should inspect the skin of the limb in traction at least once every 8 hours for irritation or inflammation.

Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client should not, however, do active ROM to the involved joints, because it would disrupt the pull of the traction force. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client may also flex and extend the feet.

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 of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired arterial circulation in the distal limb include coolness and pallor of the skin and diminished arterial pulse. Edema indicates impaired venous return in the extremity.

A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage.

Standard management of the client with deep vein thrombosis includes bed rest for a period as prescribed; limb elevation; relief of discomfort with warm moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated, because the tail of the thrombus could dislodge and travel to the lungs as a pulmonary embolus. This is most likely to occur in the first 24 to 48 hours after clot formation.

Clients with chronic venous insufficiency are advised to avoid crossing the legs, sitting in chairs where the feet do not touch the floor, wearing garters or sources of pressure above the legs (such as girdles), and to avoid prolonged standing or sitting. The client should wear elastic hose for 6 to 8 weeks, and perhaps for life. The client should sleep with the foot of the bed elevated to promote venous return during sleep.

Successful resolution of the deep vein thrombosis is marked by the absence of original symptoms used to diagnose the problem (unilateral leg warmth, redness, edema, tenderness, enlarged calf).

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

Tonometry is an effective screen for the early detection of glaucoma. The normal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 20 mm Hg is a normal finding.

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