SOURCE: http://www.nursereview.

org

NCLEX/CGFNS REVIEW BULLETS 2

In the immediate postoperative period following a radical neck dissection, the nurse assesses for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea). This finding is reported immediately, because it indicates airway obstruction. Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early, so that appropriate action can be taken In functional nursing, a task approach method is used to provide care to clients. The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are deep and nonlabored. They occur as the body tries to eliminate carbon dioxide to compensate for lactic acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the clients respiratory status as part of the clients overall status. The client is likely to have tachycardia due to efforts by the body to compensate for the effects of anemia. The client with anemia is likely to complain of fatigue, because of decreased ability of the body to carry oxygen to tissues to meet metabolic demands. Increased respiratory rate is not an associated finding, although some clients may have shortness of breath. Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression is an oncological emergency, and the physician should be notified. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole, not chewed. Because the client

might experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. For most hematological laboratory studies, including CBC, no special care is needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat prior to the laboratory test being drawn. Before bone marrow aspiration, the site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin, and decreases the risk of infection from the procedure. When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, a bed bath, ambulate a client with a walker, take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member. After ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid moving the head rapidly, bouncing, and bending over for 3 weeks. Exacerbation of Mnires disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure, since the client is at high risk. Acetaminophen may be given for discomfort, and aspirin should be avoided because it could aggravate bleeding The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. 2

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. The RN would plan to care for the client who is scheduled for surgery at 1:00 p.m. first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, many times the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared. Clozapine is an antipsychotic medication with no demonstrated extrapyramidal side effects. The risk of extrapyramidal effects with the other medications listed is moderate (chlorpromazine) to high (haloperidol, loxapine). Denial is a response by the rape victim. It is described as an adaptive and protective reaction. Projection is blaming or scapegoating. Rationalization is justifying the unacceptable attributes about himself or herself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation in which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on a specific situation, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed in spaces. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Appropriate nursing diagnosis for a client scheduled to have electroconvulsive theraphy (ECT) is Risk for aspiration. Aspiration is safeguarded against by keeping the client NPO for 6 to 8 hours before the procedure, removing dentures, and administering glycopyrrolate (Robinul) or atropine sulfate as prescribed. When analyzing data obtained from a client suspected of family violence, the physiological well-being of the client is always considered first.

During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. All of the symptoms noted in the question indicate a normal reaction to a very intensely difficult crisis event. Although the clients initial reactions may be predictive of later problems, they do not indicate an abnormal initial response. Finding the right drug at the right dose that provides the least side effects for the client, providing clients with the injectable, long-acting form of the medication, and including the family in the medication planning process are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen due to a short half-life of some medications. Lithium carbonate is an example of one such medication that must be taken throughout the day to maintain steady serum drug levels. Obsessions are defined as persistent thoughts that are intrusive and that the person tries to ignore or suppress. This client wants to snap out of this daily review, but the thoughts continue for hours. Compulsions are defined as repetitive behaviors that the client feels driven to perform, such as changing clothes frequently until he gets it just right. Al-Anon support groups provide a supportive opportunity for spouses and significant others to learn what to expect about successful behavioral changes. Any clear threats by psychiatric clients to harm specific people must be reported to the authorities (law enforcement) and the intended victims by mental health care providers and psychotherapists. Major depression occurs twice as frequently in females as in males. Reacting to loss by experiencing altered sleep for 1 week is a normal grief response. While depression is often associated with substance abuse, it would not, in and of itself, constitute a major depression. A conversion disorder is an alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a persons mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the persons capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

Ego defense mechanisms are operations outside of a persons awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less dangerous than those who initially aroused the emotion. In this scenario, the nurse manager reprimands the unit secretary for overusing clerical supplies. The secretary lashes out at the temporary secretary and student nurses for wasting supplies. These are much safer targets to become angry with than the nurse manager. Denial is the blocking out of painful or anxiety-inducing events or feelings. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Repression is unconsciously keeping unacceptable feelings out of awareness. Taking time to discuss the clients concerns is as important a nursing action in many instances as any intervention for physical care. Therapeutic communication should focus on the clients nonverbal cues and encourage the client to express feelings or concerns about surgery. When a client harms himself, immediate 1:1 nursing supervision is instituted. This meets the safety needs of the client. After doing this, the psychiatrist is notified of the incident. The client should not be restrained or placed in seclusion. Tardive dyskinesia, the involuntary movements of the tongue, jaw, lips, and facial muscles, is a manifestation of EPS. Flaccid muscles are not a characteristic of EPS. Agraphia, the inability to read or write, is not a characteristic of EPS. Dystonia is characterized by acute spasms of the tongue, neck, face, and back, laryngospasms, torticollis, and eyes locked upwards. The dosage of lithium carbonate needs to remain constant to maintain blood levels between 0.6 mEq/L and 1.2 mEq/L. There is a narrow margin between therapeutic and toxic levels. Blood levels are necessary to assess this narrow range. Adequate salt and fluids are necessary to prevent toxicity. Vomiting and diarrhea could be signs of toxicity and need to be reported. Dosages should never be adjusted. Amitriptyline (Elavil) has a sedative effect, and a single maintenance dose should be taken at bedtime. This also precludes the need for insomnia medication. Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs should report any headache to the physician, because it may signal an impending hypertensive crisis. A low tyramine diet needs to be consumed. Dry crackers can be eaten if the client gets nauseated. Chewing sugarless gum is appropriate. 5

The client needs to be able to put the trauma into a new context. The client needs to realize that the trauma did not occur because he or she did something wrong, used poor judgment, or somehow deserved it. The client will often express feelings of guilt, but the goal will be to assist to put it in perspective and eventually to be able to work through the feelings of guilt. A situational crisis arises from external rather than internal sources. External situations that could precipitate crisis include loss of or change of a job, the death of a loved one, abortion, a change in financial status, divorce, the addition of new family members, pregnancy, and severe illness. An adventitious crisis is not a part of every day life, is unplanned, and accidental. As with all loss experienced by individuals and families, opening up the communication channels is a key factor in successful grieving and surviving. Often, estrangement occurs in families because well-meaning relatives and friends do not know how to respond. This uncertainty and fear causes relatives and friends to isolate when communication and an opportunity to grieve with support are crucial. Joining a survivor-victim group is a positive outcome, but if the client is not talking with his or her family members, it is likely that maximum benefit from the group will not be achieved. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. Counselors will not be available for all anxiety-producing situations. Sertraline hydrochloride (zoloft), a selective serotonin reuptake inhibitor, can cause a dry mouth that is alleviated by sucking on sugarless hard candy and chewing gum. Foods such as cheese, wine, and chocolate contain an amino acid, tyramine that reacts with monoamine oxidase inhibitors. Monthly blood levels are usually required for clients who are receiving lithium carbonate (Eskalith) therapy. Sertraline is usually taken with meals. Central nervous system depressants such as alcohol will produce an addictive effect if taken with diazepam, which can be lethal. Diazepam can cause initial drowsiness. It should not be discontinued abruptly, because the client may develop withdrawal symptoms. Many of the over-the-counter medications used to treat the flu contain medication that should not be taken when a client is taking diazepam. Clients who are taking monoamine oxidase inhibitors (MAOIs) must maintain a low tyramine diet and receive health teaching regarding the foods, beverages, and medications that must be avoided. Foods with aged cheese can cause a hypertensive crisis if taken with MAOIs. 6

Fluoxetine hydrochloride (Prozac) tends to improve the energy level, and if it is taken late in the day, insomnia may occur. Many clients suffer from sexual dysfunction throughout treatment, such as decreased libido. Side effects can be expected to some degree with any medication. The lag time from the time the medication is started until therapeutic effects are achieved is anywhere from 2 to 4 weeks or longer. This is true with any antidepressant. Sodium depletion will decrease renal excretion of lithium, thereby causing the medication to accumulate and potentiating toxicity. Clients need to be instructed to maintain a normal sodium intake. Diuretics promote sodium loss, and these medications need to be used with caution in the client taking lithium. Sodium loss secondary to diarrhea can cause lithium accumulation, and the client should be forewarned of this possibility. Chlorpromazine blocks dopamine neurotransmission at postsynaptic dopamine receptor sites, reversing psychotic symptoms. Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. Neuroleptic malignant syndrome is a serious and potentially fatal reaction to antipsychotics. The classic symptoms include hyperthermia; severe extrapyramidal symptoms, such as muscular rigidity; and autonomic dysfunction, such as hypertension and tachycardia. The first priority in planning care for a client with dysfunctional grieving is to assess the risk for violence toward self and others. The plan will include efforts to work toward resolving the grief through emotional, cognitive, and behavioral means. Ensuring safety is a major aspect in the plan of care for the abused elder. The nurse may need to contact the social worker to plan care for the client, but this is not the priority action. In all child abuse cases, the primary concern is the health and safety of the child. Adventitious crises are the unpredictable tragedies that occur without warning. A maturational crisis involves the normal life transition that creates changes with individuals and how they perceive themselves, their role, and their status. A situational crisis occurs when a specific, external event disturbs an individuals psychological equilibrium. An individual may experience a crisis; however, there is no formal type of crisis known as individual crisis. 7

In the ECT suite, blood pressure, cardiac, and electroencephalographic monitors are placed on the client to assess vital functions. Whenever ECT is administered, emergency equipment, including oxygen, suction, and a cardiac arrest cart, must also be available. In the norming stage, members express intimate personal opinions and feelings around personal tasks. In the forming or initial stage, the members are identifying tasks and boundaries. Storming involves responding emotionally to tasks. In the performing stage, members direct group energy toward the completion of tasks. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. Reminders of the clients recent accomplishments or personal successes are ways to interrupt the clients negative self-talk and distorted cognitive view of self. In a client with a diagnosis of delirium. It is important to provide a consistent daily routine and a low stimulating environment when the client is disorientated. Noise, including radio and television, can add to the confusion and disorientation. A well-lit room will increase stimulation. In the immediate post-disaster period, it is important that a nurse go to places where victims are likely to gather, such as morgues, hospitals, and shelters. Rather than waiting for people to publicly identify themselves as being unable to cope with stress, it is suggested that nurses work with the American Red Cross. The nurse should talk to people waiting to receive assistance, go door to door, or go to a relocation site. The nurse should ask people how they are managing their affairs and explore their reactions to stress. If a client is in the act of preparing to commit suicide, the most appropriate nursing activity is to communicate with the client and attempt to develop a therapeutic relationship. The nurse should communicate hope, and hope is most often the most therapeutic element in any nursing intervention with a suicidal patient. Identification is the process by which a person tries to become like someone he or she admires by taking on thoughts, mannerisms, or tastes of that person. Intellectualization is excessive reasoning or logic used to avoid experiencing disturbed feelings. Projection is attributing ones thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development.

Direct expressions of self-hate or low self-esteem can include the clients expression of self-criticism. The client will exhibit negative thinking and believe that he is doomed to failure. The underlying goal of the client is to demoralize himself or herself. The client may describe himself as stupid, no good, or a born loser. The client will view the normal stressors of life as impossible barriers and become preoccupied with self-pity. It is the nurses responsibility to tell a client that secrets cannot be kept and also that any disclosures that reveal behavior that may be harmful to the client will need to be communicated to the appropriate professionals in the health care team. To de-escalate aggressive behavior, the nurse should manage the environment by persuading the client to move to another area. This will help prevent anxiety contagion and protect others. The nurse should also give the client clear instructions that are brief and assertive and should also negotiate options with the client. This shows the nurses confidence and leadership and also avoids misunderstandings in regard to not knowing what to do. Negotiating options allows the client to feel that he or she has some room in exercising the options. The nurse must allow the client body space and should not stand closer than about 8 feet to the client. Standing close to the client will convey a threat. Recreational therapy helps clients with personality disorders explore ways to enjoy themselves without the use of self-destructive behaviors, such as abusing alcohol or drugs. This modality is helpful to clients who have difficulty socializing, because recreation strengthens social skills. Movement therapy may be helpful for clients who become numb when experiencing intense feelings. Art therapy may be helpful for the client who is angry. The client who is exhibiting violent behavior may require medication therapy. Concentration and memory are poor in severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or activities that require minimal decision making minimize opportunities for clients to put themselves down. When the client demonstrates calm behavior and communicates that he or she is no longer a threat to self or others, the nurse would gather additional assessment data to determine if the client is safe to come out of seclusion. Social phobia focuses on a specific situation, such as the fear of speaking, performing, or eating in public. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. 9

Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. It is most therapeutic for the nurse to empathize with the clients experience. Disagreeing with delusions may make the client more defensive and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. If a client with severe anxiety is left alone, he or she may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. It is not possible to teach the client deep breathing exercises until the anxiety decreases. Encouraging the client to discuss the accident would not take place until the anxiety has decreased. Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, exposure is increased, until the anxiety about or fear of the object or situation has ceased. If a client is monopolizing the group, it is important that the nurse be direct and decisive. The best action is to suggest that the client stop talking and try listening to others. Using therapeutic communication techniques, the nurse acknowledges the husbands concerns and conveys that the clients symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal within 2 weeks. When a nurse delegates aspects of a clients care to another staff member, the nurse assigning the tasks is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Noninvasive interventions can be assigned to a nursing assistant. A drop in blood pressure and rise in pulse rate could indicate postoperative bleeding, which is a complication of a parathyroidectomy. Because bleeding might not be observed on the front of the dressing due to the effects of gravity, the nurse must check underneath it as well. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. In autocratic leadership, the leader retains all authority and is primarily concerned with task accomplishment. Situational leadership is a comprehensive approach 10

that incorporates the leaders style, the maturity of the work group, and the situation at hand. Laissez faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group. To promote adequate healing and to meet continued high metabolic needs, the client with a major burn should eat a diet that is high in calories, protein, and carbohydrate. This type of diet also keeps the client in positive nitrogen balance. Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, making all of the decisions alone. Situational leadership is a comprehensive approach that incorporates the leaders style, the maturity of the work group, and the situation at hand. Laissez faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. 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 Parkinsons 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

11

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.

12