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Monday, September 1, 2008

Nclex Tips 15 (Review for Nclex)

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The clinical manifestations of a disulfiram-alcohol reaction include flushing, throbbing in the head and neck, difficulty breathing, nausea, vomiting, sweating, dizziness, and weakness. This type of reaction can occur in a client taking disulfiram (Antabuse). The reaction can occur even if only one-half ounce of alcohol is absorbed into the body (whether ingested by mouth or applied to the skin).

Clients who are depressed often suffer insomnia, and relaxation measures are recommended to induce sleeping. The nurse might also give the client a back rub and use soft, dim lighting.

Responsible assertiveness provides clients with the skill to stand up for their personal and professional rights and to express their thoughts and beliefs directly, honestly, and appropriately in a manner that will not violate the rights of other.

Benztropine mesylate is an anticholinergic agent that is used in the treatment of Parkinson’s disease and the extrapyramidal symptoms (except tardive dyskinesia) that result from the use of neuroleptic or antipsychotic medication. The medication increases and prolongs the dopamine activity in the CNS, thereby correcting neurotransmitter imbalances and minimizing involuntary movements.

Buspirone hydrochloride (Buspar) is used in the management of anxiety disorders. It is contraindicated in clients with severe renal or hepatic impairment and in clients taking monoamine oxidase inhibitors. The nurse would notify the physician if the client had a history of renal impairment.

A therapeutic serum level for the use of carbamazepine is a level between 3 mcg/mL to 12 mcg/mL.

Neuroleptic malignant syndrome is a rare, life-threatening syndrome that is an adverse reaction of the use of chlorpromazine. Its signs include severe rigidity, fever, increased white blood cell count, unstable blood pressure, tachycardia, tachypnea, and renal failure. Signs of acute dystonias include painful neck spasms, torticollis, oculogyric crisis, and convulsions. Tardive dyskinesia includes choreiform movements of the tongue, face, mouth, jaw, and possibly the extremities.

Common side effects experienced during the first 2 weeks of therapy with disulfiram include mild drowsiness, fatigue, headaches, metallic or garlic aftertaste, allergic dermatitis, and acne eruptions. Symptoms disappear spontaneously with continued therapy or reduced dosage.

Donepezil hydrochloride is a cholinergic medication and is to be taken in the evening before bedtime. The medication should be taken with food; therefore, a snack should be provided to the client when the medication is administered.

Fluoxetine hydrochloride (Prozac) takes 2 to 5 weeks to produce an elevation of mood. Advantages of the medication are few anticholinergic side effects and a low incidence of cardiovascular effects. It may, however, impair judgment, thinking, and motor skills. The client should be instructed that it will take more time for the medication to produce the desired effect.

Lithium should be administered with meals. The client should be instructed to maintain a regular diet and an average salt intake to keep the serum lithium level in the therapeutic range. The client is instructed to avoid alcohol and to drink 2 to 3 liters of liquids per day during initial therapy, and 1 to 1.5 liters per day during the remainder of therapy.

Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI) antidepressant. The client needs to be instructed to avoid foods that require bacteria or mold for their preparation or preservation or those that contain tyramine. These food items include cheese, sour cream, beer, wine, pickles herring, liver, figs, raisins, bananas, avocados, soy sauce, yeast extracts, yogurt, papaya, broad beans, meat tenderizers, or excessive amounts of caffeine such as in coffee, tea, or chocolate. The client is also instructed to avoid over-the-counter preparations used for hay fever, colds, or for weight reduction. The client should also avoid alcohol.

When a client is experiencing an auditory hallucination, it is important initially to understand what the voices are saying or telling the client to do. Suicidal or homicidal messages, if heard by the client, necessitate implementing priority measures.

The therapeutic maintenance range of lithium is 0.6 to 1.2 mEq/L. Early signs of lithium toxicity include nausea and vomiting, slurred speech, muscle weakness, thirst, and polyuria. Advanced signs of toxicity (1.5 to 2.0 mEq/L) would include hand tremors and muscle incoordination (option 4). Severe toxicity (greater than 2.0 mEq/L) is present if the client exhibits ataxia, hypotension, oliguria, and confusion (options 2 and 3). Seizures, coma, and death can also result.

Levels of mania may be labeled as hypomania, acute mania, and delirious mania. The client in the acute state experiences relative sleeplessness, which over time decreases cognitive functioning, concentration, and judgment. The client is continuously active and does not take time to eat. The client’s mood may alternate rapidly between periods of good humor and irritability. In hypomania, the client experiences feelings of euphoria and sociability. Judgment is often poor in this level. In delirious mania, the client is out of touch with reality.

Blood levels are drawn weekly in many cases when a client is beginning lithium therapy. The literature varies somewhat and states that blood levels may be drawn initially from 3 times a week to biweekly during this phase. After therapeutic levels are achieved, blood level draws may be reduced to monthly. If levels are stable after 6 to 12 months, the frequency may be further reduced to every 3 months.

Amitriptyline is a tricyclic antidepressant used to treat the client experiencing a mood disorder. It takes an average of 10 to 14 days for the client to begin feeling medication effects. The nurse should give the client information about the medication, and should encourage the client to continue the medication as prescribed.

Memory loss is an expected temporary effect of ECT. The client should be told that this might occur, and that memory usually returns within a few weeks. Occasionally clients have memory loss that lasts up to 6 months. The nurse uses therapeutic communication techniques that will focus on the client’s concerns and do not block further communication.

Fluoxetine (Prozac) is a selective serotonin uptake inhibitor used in the treatment of depression. The medication is effective if the client experiences relief of symptoms of depression.

The client taking a MAOI medication should be advised to avoid eating foods that are high in tyramine. The tyramine in foods reacts with the medication, causing a hypertensive crisis, which could prove to be fatal. Most fruits and vegetables are naturally low in tyramine, with the exception of figs, bananas (in large amounts), avocados, soybeans, and sauerkraut.

Clients with a histrionic personality disorder are overly concerned with impressing others, and they are often preoccupied with their appearance. Their emotional responses are often shallow and changeable, although they are also intense. Clients who have a borderline personality tend to have intense needs that they seek to fulfill in relationships. Clients with a narcissistic personality disorder have a great need for admiration, exploit others to meet their own needs and desires, and have a lack of empathy for others. The client with an avoidant personality disorder is often preoccupied with a fear of rejection and criticism.

Clients with cluster A personality disorders often behave in a manner that is odd or eccentric. Suspicion of others is particularly typical in paranoid personality disorder, a cluster A disorder. Manipulative and dramatic behaviors are typical of some of the cluster B disorders. Anger, anxiety, and fearfulness are typical of clients with cluster C disorders.

The nurse should avoid getting into power struggles with the manipulative client, such as arguing with the client or making accusations.

The client with a dependent personality disorder exhibits an unusually strong need to be cared for, and has difficulty making personal choices and making everyday decisions. An appropriate goal would be for the client to use the problem-solving process effectively in everyday situations.

The nurse who is preparing a treatment plan for a client in prison must employ a framework that integrates the built-in realities and limitations of the correctional setting and the compulsory regimen that has been created for the offender. The incidence of suicide in correctional settings is higher among inmates than it is in the general population. The prison nurse’s ability to assess for self-violence and suicide is critical.

One of the criteria that the Parole Board will investigate is the client’s ability to engage in strategic planning. The fact that the client has plans for employment and regaining custody of the children will be viewed in a positive way as an example of changed behavior.

Codependence involves overly responsible behavior, that is, doing for another person what that person could be doing for himself or herself.

The least helpful strategy by the nurse is to demand that the client stop taking drugs. This blocks further communication, and does not affect behavior change on the part of the client. If client health maintenance is the goal, it is helpful for the nurse to instruct the client about aseptic conditions for drug use to reduce the risk of human immunodeficiency virus and hepatitis. It is also useful to educate the client about the short- and long-term effects of the substance being abused. Since many clients who use drugs are malnourished, it is also helpful to teach the client the elements of basic nutrition.

In larger organizations such as hospitals, there are often employee assistance programs that offer services such as information, counseling, and referral for employees who experience a wide variety of problems, including substance abuse.

Bradykinesia is described as decreased speed and spontaneity of movement. The client appears to slow down.

Hypertensive crisis, a potentially fatal problem that occurs when the norepinephrine levels are excessively elevated, produces severe occipital headache, stiff or sore neck, palpitations, increase or decrease in heart rate, nausea, vomiting, hypertension, and an increase in temperature.

Tricyclic antidepressant agents produce an enhanced mood, an increase in activity level, and an improvement in appetite. In addition, sleep patterns become more like that of the client’s baseline normal sleeping pattern

Employing a hopeful attitude that is not excessively cheery will combat the negative and gloomy affect that is intrinsic to depression. The client can interpret an excessively cheerful approach as belittling. A matter-of-fact approach will be more reassuring to the client and avoid any regressive struggles that might emerge.

In addition to the 4 weeks required to establish maximum therapeutic effects, tricyclic antidepressants have significant adverse effects. Most notable are their effects on the heart. The use of TCAs in individuals with second-degree and third-degree heart block can be fatal. Therefore, the nurse is responsible to ensure that the psychiatrist orders a baseline ECG before treating the client with TCAs. This will enable the psychiatrist to determine if there are any preexisting cardiac abnormalities, which would necessitate eliminating this group of medications from the treatment protocol.

Establishment of a trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder.

Alprazolam is an antianxiety agent (benzodiazepine) used in the short-term management of panic disorder. Central nervous system side effects include disorientation, drowsiness, and clumsiness, among others.

BuSpar is classified as a nonbenzodiazepine antianxiety agent. It does not appear to cause either physical or psychological dependence in clients who use it. Clonazepam, oxazepam, and lorazepam are benzodiazepines that may cause dependence.

The client with post-traumatic stress disorder is not treated with behavior therapy. It may be treated with psychotherapy, family or group therapy, relaxation techniques, and vocational rehabilitation as needed.

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