Psychotic Disorder Practice Exam/Test (24-32)

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Situation: L., a 28 year old woman, has been hospitalized for most of the past 12 years. For the past 2 1/2 years, she has been on a unit for chronically mentally ill patients. Her psychiatric diagnosis is disorganized type schizophrenia. Her behavior is labile, fluctuating from childishness to incoherence to loud yelling to making growling noises to demonstrating slow but appropriate interaction. L., needs assistance with all her activities of daily living (ADLs). In the morning, she remains in her nightgown unless helped to dress

24. Which behavior is characteristic of a patient with disorganized type of schizophrenia?

a) extreme social impairment
b) suspicious delusions
c) waxy flexibility
d) appropriate affect

25. L. continues to be unable to complte her ADLs without staff direction ans assistance. The nurse formulates a nursing diagnosis of Dressing and grooming self-care deficit related to inability to function without assistance. An appropriate patient goal is that within 1 month, L. will be able to:

a) complete ADLs independently
b) complte ADLs with only verbal encouragement
c) complete ADLs with assistance in organizing her grooming items and clothing
d) complete ADLs with complete assistance

26. L. is seen sitting in the day room looking disheveled. Her slacks are stained and her blouse is incorrectly buttoned so that one side hangs several inches below the other. The nurse can help L. most by:

a) telling her that her slacks are soiled and her blouse needs to be rebuttoned
b) taking her to her room, selecting another pair of slacks, and fixing her blouse
c) reminding her that she should complete her ADLs before going to the dayroom
d) bringing her to a mirror and helping her identify what needs to be corrected

Situation: M., a 24 year old college student, is brought to the hospital by her boyfriend with whom she has been living for the past 6 months. He reports that M.'s behavior has become very strange over the past week. She has become more and more withdrawn to the point that yesterday she sat on a chair in her room with her eyes closed, not moving for 6 hours, until he carried her to bed. He says that at first he thought she was just depressed about the recent death of a friend, but now he thinks she's "flipped out." M. is admitted with a diagnosis of catatonic schizophrenia.

27. During the physical assessment, M.'s arm remains outstretched after her pulse and blood pressure are taken, and the nurse must reposition it for her. The patient is manifesting:

a) suggestibility
b) negativity
c) waxy flexibility
d) retardation

28. M. keeps her eyes closed and does not respond to questions from the nurse or the physician. The nurse keep in mind that:

a) the patient is aware of what is going on around her and could respond if she wanted
b) the patient may be able to hear what is happening around her even though she does not respond
c) the patient cannot hear or comprehend what is being said to her
d) the patient is in a regressed state and should be treated like a frightened child

29. M. remains in bed with her eyes closed. She continues to be unresponsive and does not eat or drink. The physician orders chlorpromazine (thorazine) 100 mg orally four times a day. Under these circumstances, the nurse should:

a) withhold the medication until the patient becomes more responsive and eats
b) administer the appropriate dose of chlorpromazine in a concentrate form
c) administer the chlorpromazine as needed
d) request an order for chlorpromazine to be administered intramuscularly

30. While M. remains is an unresponsive state, the nurse's highest priority is assess the patient's:

a) fluid intake and output
b) daily activity level
c) communication level
d) response to others

31. One evening, M. suddenly begins running up and down the hall. She strips off her clothing and strikes out wildly at anyone she passes. This incident of catatonic excitement is considered:

a) a response to increased activity on the unit
b) self-limiting episode that will subside as suddenly as it began
c) an occurrence related to internal not external stimuli
d) an indication of patient improvement

32. All of the following interventions would be appropriate for a patient experiencing catatonic excitement except:

a) clearing the area of other patients
b) calling for assistance of at least three other staff members
c) obtaining an order for and preparing an as-needed dose of chlorpromazine
d) restraining the patient and calling for help




ANSWERS AND RATIONALE

24) A
- Rationale: Disorganized type schizophrenia (formerly hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A patient with a paranoid disorder typically exhibits suspicious delusions (belefs that evil forces are after him). Waxy flexibility, a condition in which the patient's limbs remain fixed in uncomfortable positions for long periods, is characterized of catatonic schizophrenia.

25) C
- Rationale: L.'s history of hospitalization and her disorganized personality caused by schizophrenia have affected her ability to care for herself. Interventions should be directed at helping her complete her activities of daily living (ADLs) with the assistance of staff members, who can provide needed structure by helping her select her grooming items and clothing. This goal promotes realistic independence. As L. improves and attains the established goal, new goals can be set that are directed at the patien's completing. ADLs with only verbal encouragement and, ultimately, completing them independently. L.'s condition does not indicate a need for complete assistance, which would only foster dependence.

26) D
- Rationale: the nurse should help L. to recognize for herself what needs to be corrected. Taking her to a mirror encourages reality testing (determining objective reality) and helps develop self-perception with the nurse's support and guidance. Providing L. with an opportunity to attend to her appearance promotes mastery of ADL skills and is more therapeutic than telling her what is wrong or fixing her clothes for her.

27) C
- Rationale: Waxy flexibility - an ability to assume and maintain awkward or uncomfortable positions for long periods - is characteristic of catatonic schizophrenia. Patients often remain in these awkward positions until repositioned by someone else. Patients with dependency problems may demonstrate suggestibility, a response pattern in which the patient easily agrees to the ideas and suggestions of others rather than making his own independent judgments. Negativity (resistance, for example, to being moved or being asked to cooperate) and retardation (slowed movement) are also seen in catatonic patients.

28) B
- Rationale: the nurse should assume that a withdrawn, unresponsive patient may be able to hear what is being said and what is going on around her. She should address the patient by name, tell her what is being done, and orient her to person, place, and time. All staff members should be respectful of the patient's condition and careful when conversing in the patient's presence. The patient's withdrawal is an extreme defense mechanism that is not consciously controlled and therefore is not willful. Consistent and caring interventions can help the patient develop trust and eventually reduce the need for such extreme behavior. Although the patient may experience extreme and fear, treating her like a child is inappropriate and reinforces dependency.

29) D
- Rationale: because the physician has ordered chlorpromazine (Thorazine) to be administered orally and the patient is not eating or drinking, the nurse should request an order for IM administration instead. Giving oral forms of medication (including tablets and concentrates) while the patient is in this state would be unsafe and would not ensure that the proper dose is being received. After administering the IM dose,the nurse should closely monitor the patient's vital signs; postural hypotension is a possible side effect. The patient requires adequate doses of chlorpromazine, an antipsychotic, to relieve her symptoms; giving this drug on an as-needed basis would not ensure the proper dosage necessary for a therapeutic effect.

30) A
- Rationale: the nurse should monitor M.'s fluid intake and output closely. The patient's refusal to eat or drink and her limited mobility put her at high risk for severe fluid and electrolyte imbalance, dehydration, inadequate nutrition, constipation, and urine retention. Vital signs and skin assessment can also indicate fluid volume deficit. Assessing the patient's activity level, communication level, and response to others is of secondary importance.

31) C
- Rationale: Catatonic excitement, which is characterized by extreme purposeless motor activity, agitation, and striking out wildly, appears related to internal rather than external stimuli. It differs from manic excitement, which is escalated by environmental stimuli (and therefore is somewhat more predictable) and can be lessened by a quiet setting. Catatonic excitement is not self-limiting; it may not stop without intervention. A patient experiencing catatonic excitement needs immediate attention to protect herself and others from injury; it does not indicate improvement.

32) D
- Rationale: a patient experiencing catatonic excitement is extremely agitated and potentially dangerous to herself and others. The nurse should not attempt to restrain the patient without adequate assistance. At least three staff members should approach the patient and have a plan for restraint, if needed. While waiting for staff backup, the area should be cleared of other patients as well as chairs or objects that could be thrown or pose a safety hazard. The nurse should prepare an as-needed injection of chlorpromazine, if ordered, so that the patient ca be medicated once safely restrained.


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NCLEX Preparation Course - Critical Thinking Exercises I (Anwers 1-10)

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Here are the Questions to NCLEX Preparation Course - Critical thinking 1-10 -->

1) A
- Rationale: in pulmonary edema, the transfusion should be slowed down. For choices 2,3, and 4 the nurse should STOP the blood transfusion

2) A
- Rationale: focus on feelings and present reality. Hallucinations oftentimes are frightening to the client

3) D
- Rationale: safety should be given highest priority. A client who experiences postural hypotension is prone to falls

4) B
- Rationale: Placing the client in supine position will further cause bleeding and edema in the area. When bleeding occurs in a particular body part, it should be elevated.

5) D
- describes choice management:
Choice A - is functional nursing
Choice B - is total care nursing
Choice C - is team nursing

6) B
- positive variance indicates favorable outcome.
Negative variance indicates unfavorable outcome, like development of complications and the patient's hospital stay is prolonged.

7) B
- democratic leadership style is participative. Whereas, autocratic leadership is controlling and does not involve members in decision-making; Laissez-faire leadership delegates all responsibilities to members.

8) A
- in case of fire, priority actions are as follows:
R - escue the client
A- ctivate the fire alarm
C - onfine the fire
E- xtinguished the fire

9) A
- do not release information about patient's, unless he gives consent. Implement Principle of confidentiality/privacy. This is a patient's right.

10) B
- saw palmetto is "herbal catheter", and recommended for BPH. Ginseng is an energy-booster; Echinacea is immune-enhancer; Milk thistle is for liver diseases.


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NCLEX Preparation Course - Critical Thinking Exercises I (Questions 1-10)

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Here are the Answers to NCLEX Preparation Course - Critical thinking I (1-10) -->

1. The nurse should slow down the transfusion of packed RBC when she has which of the following assessment findings?

a) bibasilar rales or crackles
b) anuria
c) low back pain
d) fever and skin rashes

2. The client experiences tactile hallucinations in delirium tremens (DTs). He states, "there are bugs crawling under my skin." The most appropriate response by the nurse would be:

a) I know, this is frightening to you. But I don't see any bugs crawling in your skin
b) this sensation is common among clients who undergo alcohol withdrawal, like you
c) that sensation is all in your imagination
d) it is not possible for bugs to crawl under your skin

3. The nurse had been given four clients. Who among these clients should she give highest priority?

a) the client with fever
b) the client with diabetic gangrene
c) the client with diarrhea
d) the client who feels dizzy when changing position from supine to standing position

4. A client has had radical neck dissection, and begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

a) applying manual pressure over the site
b) placing the client in supine position
c) monitoring the client's airway
d) calling the physician immediately

5. Case management nursing care delivery involves

a) division of tasks with each nurse assuming responsibility for certain tasks
b) taking responsibility for all aspects of one or more client's care within the shift
c) delivery of nursing care by the staff of various educational preparations such as RN, LVN, and CNA
d) care delivery that coordinates and links health care services to clients and their families from admission through and following discharge

6. Positive variance occurs in which of the following situations?

a) the elderly client who was admitted due to acute episode of emphysema developed pneumonia
b) the 52-year old client who had undergone laparoscopic cholesystectomy was discharged after 24 hours
c) the client with diabetes mellitus developed lumbosacral decubitus ulcer
d) the client who had undergone prostatectomy developed thrombophlebitis

7. The leadership style that is based on the belief that every member should have input into development of goals and problem solving is

a) autocratic leadership
b) democratic leadership
c) laissez-faire leadership
d) power leadership

8. A fire was detected in the client's room. Which of the following is the best initial nursing action?

a) rescue the client
b) activate the fire alarm
c) close the door of the room
d) use the fire extinguisher

9. A man telephones the nurse's station and asks, "How is Mr. Smith?" who he claims to be his personal friend. Which of these responses by the nurse who answers the phone would be correct?

a) I can't confirm or deny that he is a patient here
b) you'll have to call him on the patient's phone
c) what is your relationship with him?
d) he is doing well as can be expected

10. Which of the following herbal medicines is recommended for a client with benign prostatic hyperplasia (BPH)?

a) ginseng
b) saw palmetto
c) echinacea
d) milk thistle


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Psychotic Disorder Practice Exam/Test (13-23)

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Situation: J., a 32 year old man with a 5 year history of multiple psychiatric admissions, is brought to the emergency department by the police. He was found wondering the streets, disheveled, shoeless, and confused. Based on h is previous medical records and current behavior, he is diagnosed as having chronic undifferentiated schizophrenia.

13. J. is escorted to the psychiatric unit by an aide. The nurse observes him sitting in the hall looking frightened. He is curled ap in a corner of the bench with his arms over his head and covering his face. How should the nurse approach the patient?

a) walk over to the bench, sit beside him quietly, and place an arm around his shoulders; then say, "I'm the nurse," and wait for a response
b) allow him to remain alone on the bench, where he can observe the unit for a half hour or so until he is more comfortable
c) greet him warmly saying, "Hi, I'm the nurse. This is a very nice unit. I think you'll like it here. Let me show you around"
d) sit about 3 or 4 feet from him on the bench and say, "Hello, J. I'm a nurse on this unit. You appear frightened"; then wait for a response

14. J. responds to the nurse by curling up on the bench even tighter. His arms still cover his head, and his hands are clasped tightly over his ears. the nurse should:

a) show acceptance of J.'s behavior by remaining with him and reassuring him, gently stroking his arms and shoulders
b) tell J. that she will leave him for a while and will return later when he feels more relaxed
c) say gently, "J., I'll just sit here quietly with you for a while," then remain seated nearby
d) say "J., most people feel uncomfortable in hospitals. You shouldn't be afraid, I'm here to help you

15. Later that evening, the nurse finds J. crouched in the corner of his room, with a curtain covering him. His roommate is sitting on the bed laughing and saying, "This guy is really a nut. He should be in a padded cell." How should the nurse respond to the roommate?

a) say "I'm sure J.'s behavior is frightening to you. I understand that you are trying to cover up how you really feel by laughing."
b) say "I'd appreciate it if you'd step outside for a while. I'd like to talk with you after I help J"
c) say nothing and attend to J
d) say, in a neutral tone, "I think your laughing is making J. feel worse. How would you feel if you were J.?"

16. What is the least threatening approach to J. while he sits huddled under the curtain?

a) sit next to him on the floor without speaking, and wait for him to acknowledge the nurse
b) gently remove the curtain and say, "J., this is the nurse. What happened?"
c) approach J. slowly and say, "J., this is the nurse. You appear to be very frightened. Can you tell me what you are experiencing?"
d) call for assistance and do not approach J. until at least two other staff members are present

17. Which is the priority nursing diagnostic category based on J.'s current behavior?

a) anxiety
b) impaired verbal communication
c) altered thought processes
d) dressing and grooming self-care deficit

18. Because J. has previously responded well to treatment with haloperidol (Haldod), the physician orders haloperidol 10 mg orally twice a day. Which adverse effects is most common with this medication?

a) extrapyramidal symptoms
b) hypotension
c) drowsiness
d) tardive dyskinesia

19. During the next several days, J. is observed laughing, yelling, and talking to himself. His behavior is characteristic of:

a) delusion
b) looseness of association
c) illusion
d) hallucination

20. J. tells the nurse, "The earth is doomed, you know. The ozone layer is being destroyed by hair spray. You should get away before you die." J. appears frightened as he says this. The most helpful response is to:

a) says, "J., I think you are overreacting. I know there is some concern about the earth's ozone later, but there is no immediate danger to anyone
b) say, "I've heard about the destruction of the ozone layer and its effect on the earth. Why don't you tell me more about it?"
c) ignore J.'s statement and redirect his attention to some activity or the unit
d) say, "J., are you saying you feel as though something bad will happen to you?"

21. After a half hour, J. continues to ramble about the ozone layer and being doomed to die. He paces in an increasingly agitated manner, and he begins to speak more loudly. At this time, the nurse should:

a) check to see whether the physician ordered haloperidol on an as-needed basis
b) allow J. to continue pacing but observe him closely
c) try to involve J. in a current events discussion group that is about to start
d) tell J. to go to his room for a while

22. The treatment team reviews J.'s behavior and decides to continue increasing his haloperidol dosage for the next few weeks. The nurse must closely observe the patient fro:

a) signs of haloperidol toxicity
b) evidence of the therapeutic window effect
c) increased incidence of orthostatic hypotension
d) indications of tardive dyskinesia

23. After several months, J. improves, and the physician decides to change the medication to haloperidol decanoate (haldol decanoate). Why is this change made?

a) haloperidol decanoate is more effective
b) haloperidol decanoate has fewer side effects
c) a change in medication produces a better response
d) haloperidol decanoate can be given monthly instead of daily




ANSWERS AND RATIONALE

13) d
- Rationale: In approaching J. for the first time, the nurse should keep in mind that schizophrenic patients fear closeness. Moving too close to the patient at first may be seen as invasion of his personal space, which could frighten him and cause him to strike out at the nurse. To avoid overwhelming J., the nurse should limit her introduction to who she is and acknowledge that the patient appears frightened. Touch can have unpredictable meanings to a frightened psychiatric patient, so it is best to avoid it, especially with someone new. Because J. is obviously in distress, the nurse should gently intervene rather than leave him alone or ignore his distress with false reassurance about how nice the unit is.

14) c
- Rationale: The nurse should attempt to establish trust by demonstrating acceptance of J.'s behavior and offering to remain with him. This lets J. know that he does not have to talk to get her attention. Touching or stroking the patient ignores the indications that he is trying to distance himself as a protective measure and would be viewed as intrusive and threatening. Because the patient's behavior results from his resistance to closeness, leaving him alone would reinforce this conduct and would add to his anxiety. Attempts to offer verbal reassurance are likely to be ineffective for a withdrawn and frightened patient such as J.

15) b
- Rationale: Because the nurse's first priority is to attend to J., the most appropriate action is to ask the roommate to step outside. The nurse should recognize the roommate's behavior as a probable sign of increased anxiety and should ask the roommate to leave without engaging him in a prolonged discussion. However, she should confront the roommate as soon as possible to discuss his reaction to J.'s behavior and to explore more appropriate responses. Any attempt to interpret the roommate's behavior at this time could escalate his anxiety about the situation and cause additional outbursts that could further increase J.'s anxiety.

16) c
- Rationale: J.'s behavior indicates that he is experiencing severe anxiety and panic. The nurse can avoid startling him by approaching him slowly while talking to him, yet maintaining a safe distance of 3' to 4' (about 1 to 1.5 m). Although sitting at the same level as the patient can facilitate communication, failing to maintain a safe distance may place the nurse at considerable risk should the patient suddenly become violent. The nurse should encourage J. to discuss his present experience by reflecting her observations of his behavior. She should not attempt to remove the curtain, which is being used to protect against intrusion. As j.'s anxiety decreases, he can be asked to remove it himself. Additional staff members should be called if the patient does not tolerate the nurse's approach and becomes agitated; however, initially, their presence would probably frighten him more.

17) a
- Rationale: The priority nursing diagnostic category is Anxiety, severe to panic-level, as evidenced by J.'s extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce his anxiety and to protect the patient and others from possible injury. Impaired verbal communication, as evidenced by noncommunicativeness. Altered thought processes, as evidenced by an inability to understand the situation, and Dressing and grooming self-care deficit, as evidenced by a disheveled appearance, are all appropriate nursing diagnostic categories but are not the priority in this situation.

18) c
- Rationale: Extrapyramidal effects, including dystonia, akathisia, pseudoparkinsonism, and tremors, are the most common adverse reactions associated with haloperidol (Haldol), a high-potency antipsychotic drug. Haloperidol rarely causes tardive dyskinesia, a severe, irreversible extrapyramidal reaction. Hypotension and drowsiness are common side effects of low-potency antipsychotic agents, such as chlorpromazine and thioridazine.

19) d
- Rationale: Auditory hallucination, hearing voices when there are no external stimuli, is common in schizophrenic patients. The nurse can indirectly determine that J. is hallucinating by observing such behaviors as laughing, yelling, and talking to himself. Delusions, false beliefs or ideas that arise without external stimuli, also are common in patients with schizophrenia. For example, a delusional patient may believe that he is being controlled by the television in his room. Schizophrenic patients may exhibit looseness of association, a pattern of thinking and communicating in which ideas are not clearly linked to one another. For example, the patient may make statements that are disconnected and unclear to the listener. A less severe perceptual disturbance is illusion, wherein in the patient misinterprets actual external stimuli. For example, the patient may see a red exit sign and think that the wall is on fire. Illusions are not commonly associated with schizophrenia.

20) d
- Rationale: J.'s statement combines truth (the ozone layer is being destroyed), some exaggeration that may be delusional (the earth is doomed), and some projection of his own fears (the nurse should get away). By choosing to respond to the underlying message about J.'s fear of being destroyed, the nurse attempts to help him identify and express his feelings in a more direct and appropriate manner. Reflecting doubt about delusional statements can help the patient see that the nurse does not share his belief. However, such reflection should not be stated judgmentally ("You are Overacting"). Pursuing a discussion about the ozone layer or ignoring his comments completely are nontherapeutic approaches because they do not acknowledge his fear.

21) a
- Rationale: Because interpersonal interventions have failed to decrease J.'s anxiety level, medication is needed. If an as-needed order is unavailable, the nurse should ask the physician to write one. If the nurse does not intervene and allows J. to continue pacing, his anxiety and agitation may escalate, which may be dangerous to the patient and others. Involving J. in a discussion group would probably increase his anxiety level and cause him act out aggressively. Telling J. to go to his room after he receives his medication would be helpful; the combination of an antipsychotic agent and reduced stimuli will help to decrease his agitation.

22) b
- Rationale: The therapeutic window effect is the point at which an increase in dosage decreases a drug's therapeutic effect. Therefore, the nurse must closely observe the patient as the haloperidol dosage is increased. The toxic level of haloperidol has not been clearly established. Orthostatic hypotension is not common with this drug; tardive dyskinesia are rare. A patient receiving haloperidol is typically observed for therapeutic effects rather than intolerable side effects.

23) d
- Rationale: Haloperidol decanoate (Haldol Decanoate), given by depot injection, has a 4 week duration of action, which makes it appropriate for patients who require long-term drug therapy. Haloperidol decanoate is not more effective; nor is it useful for treating patients with acute psychotic episodes because a therapeutic level is not achieved for up to 3 months. Although this form of haloperidol rarely causes sedation or postural hypotension, it often produces extrapyramidal symptoms. Switching antipsychotic agents does not achieve a better response; high-potency antipsychotic drugs are equivalent in clinical effectiveness.


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NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 61-70)

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Here are the Answers to NCLEX Preparation Course - Critical Thinking VI (61-70) -->

Situation: Baby Nicole is born with myelomeningocele.

61. Antibiotic therapy is started, but Baby Nicole's condition worsens. Which is a later sign of meningitis that the nurse should report?

a) hypothermia
b) opisthotonus
c) sunset the sign of the eyes
d) depressed fontanels

62. Six months after surgery, baby Nicole develops fever and convulsion. Which observation by the nurse would help confirm a diagnosis of meningitis?

a) rigidity of the lower extremities
b) increased pulse rate
c) high pitch cry
d) severe constipation

63. The nurse explains to the parents of Baby Nicole that even if the surgery was successful. Nicole need a continued health supervision of a:

a) cardiologist
b) dental hygienist
c) urologist
d) speech therapist

64. When Baby Nicole was 1 day old she has surgery for reduction of myelomeningocele. Which nursing intervention is critical during the postoperative period?

a) passive range-of-motion exercises of the lower extremities
b) suprapubic manual expression of urine
c) observation of the frequency and character of the stools
d) daily measurement of the head circumference

65. Which is the best position of Nicole before surgery?

a) trendelenburg's in the prone position
b) flat, on her side
c) semi fowler's on her side
d) prone position on her side

66. An internal fire drill is scheduled to be done in the hospital. To make beds available for the fire drill, who among these clients may be discharged?

a) the client with oral simplex virus whose culture is negative, temperature is 37.4C
b) the client with pneumonia, WBC is level 12,000/cu.mm.
c) the client with anemia whose hemoglobin level is 7.5g/dL
d) the client with renal failure with serum potassium level of 3 mEq/L

67. A nurse is caring for a client with a burn injury to the lower legs. Nitrofurazone (furacin) is prescribed to be applied to the site of injury. The nurse documents which of the following in the plan of care as the appropriate method to apply this medication?

a) apply dressings soaked with saline solution over the medication
b) apply 1-inch film directly to the burn sites
c) apply 1/16-inch film directly to the burn sites
d) apply 1/2-inch film directly to the burn sites

68. The nurse would expect to find which of the following:

a) abdominal rigidity
b) distended abdominal and umbilical veins
c) visible waves of peristalsis
d) rectal prolapse

69. Following surgery for Pyloric Stenosis, Hannah is started on glucose water. Infant formula is held until:

a) bowel sounds are detected
b) vital signs are stable
c) the infants is able to retain clear liquids
d) diarrhea is absent


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    NCLEX Secrets - Neurology Board Review (1-5)

    3:46 PM    

    NCLEX Secrets - Neurology Board Review

    Situation: Warren was admitted to the hospital with a diagnosis of hypertension.

    1. The nurse should carefully evaluate the pulse prior to administering which medication?

    a) clonidine (catapres)
    b) propanolol (inderal)
    c) atorvastitin calcium (lipitor)
    d) lovastatin (mevinolin)

    2. At the time of Warren's physical examination, which finding was indicative of hypertension?

    a) pupil changes an opthalmoscopic exam
    b) presence of the second heart sound
    c) sinus rhythm on auscultation
    d) cardiac electrocardiogram

    3. When teaching Warren on precautions to take while on antihypertensive medication, the nurse should advice him to:

    a) avoid changing position suddenly
    b) observe for black and blue marks
    c) learn to take his blood pressure TID
    d) take the drugs always on empty stomach

    4. Warren has renal damage related to his hypertensive condition. When teaching him about his diet the nurse should advice him to:

    a) replace whole milk with milk products
    b) use salt substitute such as potassium chloride
    c) eliminate protein from his diet
    d) limit processed foods to fruits and juices

    5. Which test should you order for Warren before treatment is indicated?

    a) creatinine clearance
    b) serum uric acid
    c) serum creatinine
    d) resting electrocardiogram




    NCLEX Secrets - Neurology Board Review:
    ANSWERS AND RATIONALE

    1) B
    - Propanolol is a drug that is used for angina pectoris, MI, arrythmias, hypertension, migraine, essential tremor, pheochromocytoma. Its main effect is to block catecholamine effect in heart and blood pressure, thereby, lowering BP and heart rate. The main potential adverse effect of the drug is bradycardia, heart failure, and hypotension. Thus it is very important to always check the patient's apical pulse and blood pressure before administering the drug. If the patient has bradycardia (below 60), withhold giving the drug and notify physician.
    • always give with food to increase absorption
    • advise not to discontinue abruptly as it can exacerbate angina and precipitate MI
    • advise to continue taking the drug even he is already feeling well
    • this drug should not be given to patients with asthma
    • do not discontinue before surgery for pheochromocytoma
    Clonidine (Catapres) is an antihypertensive drug. Although it affects both blood pressure and pulse rate so that these vital signs must be checked before administering catapres, its effect on heart rate is not as much as that of propanolol. If the patient has hypotension and bradycardia, the drug should not be given and the doctor notified.
    • clonidene may cause a weakly positive Coomb's test and decreases excretion of vanilymandelic acid
    • avoid giving with propanolol and betablockers as it results in rebound hypertension
    • avoid giving with Verapamil as it may cause AV block and severe hypotension
    • avoid giving with herbal supplement capsicum as it may reduce antihypertensive effect of catapres
    • avoid orthostatic hypotension by rising slowly and changing position slowly
    • side effect drowsiness will diminish after 4 to 6 weeks
    • the last dose should be taken immediately before going to bed
    • advise not to discontinue drug abruptly as it may cause rebound hypertension
    Lipitor and lovastatin are drugs used to lower LDL and total cholesterol and triglyceride levels.

    2) A
    - letters b,c,d are examinations and findings that are more often carried out and associated with disease conditions of the heart.
    Hypertension is a persistent systolic blood pressure greater than 140 mmHg and a diastolic pressure greater than 90 mmHg. It is characterized by elevated peripheral vascular resistance from constriction of arterioles, which may be caused by sympathetic responses and stimulation of the renin angiotensin mechanism.
    It is classified as primary or essential hypertension in which there is no known etiology, and secondary, which develops as a result of some other condition.
    On Physical Examination:
    • opthalmoscopic exam: the eyes will usually reveal narrowed arterioles, hemorrhage, exudates and papilledema or swelling of the optic nerve
    • apical and peripheral pulses
    • vital signs and BP
    • edema of extremities
    Patients may complain of:
    • headache at the back of the head and neck
    • nocturia
    • confusion
    • nausea and vomiting
    • visual disturbances
    3) A
    - the most common side effect of antihypertensive drugs is orthostatic hypotension. To prevent it, instruct the patient to avoid changing position suddenly and standing for prolonged periods of time. Advise patient to sit down if he feels dizzy.

    4) D
    - hypertensive patients without renal damage are often placed on a fat/cholesterol, low sodium and low calorie diet.
    Processed, preserved and fast foods are often high in sodium and must be avoided in a low sodium diet
    Proteins are not eliminated in the diet but its intake is limited to the recommended daily allowance to prevent overloading the kidney, adding calories and weight gain.
    Using salt substitutes that contain potassium may interact with the antihypertensive drugs being taken by the patient, especially when patient is taking ACE inhibitors as it may result in hyperkalemia.

    5) C
    - the purpose of the diagnostic tests is to identify possible causes of hypertension and to identify the organs already affected by the disorder in order to institute the most effective treatment regimen for the patient. The routine laboratory tests conducted before initiating treatment include CBC, urinalysis and blood chemistry including glucose, electrolytes, cholesterol, serum creatinine and blood urea nitrogen.
    Serum creatinine and blood urea nitrogen reflect renal function. Hypertension can significantly decrease blood supply to the kidney which can damage the renal system and impair kidney function resulting in fluid retention and inability of the kidney to regulate electrolytes balance and excrete metabolic waste products such as urea. Hematocrit and hemoglobin are monitored as they reflect changes in fluid volume.



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    NCLEX Secrets about Musculoskeletal Injuries (1-8)

    12:28 AM    

    NCLEX Secrets about Musculoskeletal Injuries

    Situation: Mr. Janno Alcasid, overweight, 61 years old, was admitted and diagnosed with osteoarthritis.

    1. Mr. Alcasid asks the nurse, "What is osteoarthritis?" Which response from the nurse is correct?

    a) your bones are inflamed
    b) your weight bearing joints are inflamed
    c) you have inflammation in your joints
    d) there is shortening of your long bones

    2. Which of the following guidelines should a nurse include in the teaching plan for a patient who has osteoarthritis?

    a) achieve ideal body weight
    b) increase daily calcium intake to 1500 mg
    c) maintain a high fiber diet
    d) sleep at least 10 hours each day

    Situation: Maco, a newly registered nurse, works as a private duty nurse of a 55 year old female Canadian national who has gout.

    3. Which of the following nursing diagnoses is a priority for a patient with gout?

    a) pain
    b) fatigue
    c) risk for infection
    d) risk for peripheral neurovascular dysfunction

    4. The nurse would instruct the patient which of the following to minimize complications?

    a) drinking a minimum of 3000 ml of fluid per day
    b) eating a minimum of 2500 calories per day
    c) walking at least three miles per day
    d) resting at least three hours per day

    5. Foods allowed in the diet of gout patient include:

    a) cheese
    b) beef
    c) sardines
    d) liver

    6. The patient is placed on allopurinol (Zyloprim) therapy. To monitor effectiveness of the therapy, the nurse will monitor which the following serum laboratory values?

    a) uric acid
    b) fasting blood glucose
    c) serum calcium
    d) alkaline phosphatase

    7. A patient with rheumatoid arthritis asks the nurse why she is taking Prednisone (Deltasone) the nurse best response would be that it:

    a) enhance the immune system
    b) increase bone density
    c) decrease inflammation
    d) reduce peripheral edema

    8. A patient under steroid therapy should be advised by the nurse to:

    a) limit carbohydrates in the diet
    b) take the medication on an empty stomach
    c) avoid individuals who have infections
    d) stop the medication when symptoms have subsided





    NCLEX Secrets about Musculoskeletal Injuries:
    ANSWERS AND RATIONALE

    1) B
    - Osteoarthritis    , also known as hypertrophic arthritis, osteoarthritis, senescent arthritis and degenerative joint disease is characterized by destruction of the articular cartilage, which becomes opaque, yellow, soft, weak and deteriorated. It is followed by thickening of bone under the cartilage and formation of osteophytes or bone spurs. Unlike RH, osteoarthritis is not a systemic disease and affects only the joint and its surrounding tissue. This disorder commonly occurs in the 50-70 year age group but women are more severely affected.

    The Signs and Symptoms of Osteoarthritis include:
    • pain - worse with weight bearing, improves with rest may occur with paresthesia
    • joint swelling and enlargement - may be from inflammatory exudates entering joint capsule causing an increase in synovial fluid or from fragments of osteophytes entering synovial cavity
    • decreased ROM - depends on the amount of destroyed cartilage
    • muscular atrophy - from disuse, joint instability and deformity
    • crepitus - must be present on movement of the joint
    • joint stiffness - worse in the morning and after a period of rest and disuse
    • heberden's nodes - bony protuberances occurring on the dorsal surface of the distal interphalangeal joints of the fingers
    • bouchard's nodes - bony protruberances occurring on the proximal interphalangeal joints of fingers
    • coxaarthrosis - pain in the hip on weight bearing with pain progressing to include the groin and medial knee pain and limited range of motion
    • varus (bowlegs) or valgus (knock kneed)
    2) A
    - the primary cause of arthritis is not yet known but it is often-associated with obesity, aging, trauma, fractures, and infections. Osteoarthritis is a wear and tear disease of the joints. The more pressure it takes the more severe and the faster is the progression of the disease. Thus, one of the important aspects of management if the patient is obese is to lose weight to lessen the pressure on the joints

    3) A
    - Gouty arthritis     is a metabolic disorder characterized by accumulation and deposition of uric acid crystals, called tophi, in tissues especially in joints that results in inflammatory response. It is caused by prolonged hyperuricemia due to problems in synthesizing purines or by poor excretion of uric acid by the kidney. This disorder is more common in men, with onset around age 50.

    The immediate problem of patient suffering from gout is the acute pain experienced on affected joints such as the great toe, feet, ankles, or knees.

    Other signs and symptoms include:
    • malaise
    • pruritus
    • headache
    • elevated serum uric acid
    • presence of tophi
    • positive monsodium urate crystals in synovial fluid
    • inflammation of affected joint
    Nursing care during the acute phase when severe joint pain afflicts the patient includes:
    • provide bed rest
    • use bed cradle to support bed sheets and keep pressures of sheets off joint
    • perform range of motion exercise gently
    • carefully align joints so they are slightly flexed
    • administer medications
    4) A
    - renal urate lithiasis (kidney stones) may result from precipitation of uric acid in the presence of low urinary pH. This can be avoided by allowing the patient liberal fluid intake to promote urinary excretion of uric acid.

    5) A
    - preventive measures for gout:
    • uric acid is formed from metabolism of purine. To prevent further formation and accumulation of uric acid, the patient must be advised to stick on a low purine diet. This means that the patient must avoid: sweet breads, yeast, heart, herring, sardines, anchovies, shellfish, heavy alcohol intake
    • avoidance of excessive weight gain
    • alkaline ash diet to increase the pH of urine to discourage precipitation of uric acid and enhance the action of drugs such as probenicid (Benemid)
    6) A
    - preventive therapy - prevention of future gout attacks is by placing the patient on daily medication that either promote uric acid excretion or prevent uric acid formation. To evaluate the effectiveness of the therapy, serum uric acid level of the patient must be monitored. The medication is effective when uric acid goes down to normal level below 6.9 mg/dl.

    7) C
    - the main effect of corticosteroids is to supress inflammation. However, this same effect is also one of the main setback of corticosteroid therapy suppression of the inflammatory response also decreases the immune response making the patient susceptible to infection.

    8) C
    - Long Term Side Effects of Prednisone Therapy
    • causes GI irritation so it must be taken with food. Patient may need antacid (must not contain sodium) to prevent ulcer. Give once-daily dose in the morning to lessen toxicity. Maybe diluted in juice or semi-solid food such as apple sauce
    • causes sodium and water retention that results in cushinghoid appearance: moon face, buffalo hump, thinning of hair, hypertension and edema. Advise patient on low sodium diet that's high in potassium and protein
    • avoid discontinuing abruptly as it can cause adrenal insufficiency and rebound inflammation. Reduce dosage gradually
    • can cause glaucoma and cataract so monitor patient for visual disturbances and advise to have annual eye exam if on long term therapy
    • increases cholesterol and glucose levels so diabetics must increase insulin dosage
    • skin tests will be false-negative because it suppresses immune response
    • avoid active immunization while under therapy because patient is immunosuppressed
    • causes hypocalcemia and hypokalemia and increased urine calcium levels, causes osteoporosis so patient needs Vitamin D and calcium supplement
    • will decrease iodine uptake and protein-bound iodine levels in thyroid function test
    • tell patient to report: slow healing, exposure to infection, depression, insomnia, psychotic symptoms, weakness and fatigue, dizziness, joint pain, fever, anorexia and fainting
    • always give by deep IM in gluteal muscle to prevent sterile abscess if given by subcutaneous and rotate injection sites route to prevent tissue atrophy
    • always give the lowest dose to minimize toxicity


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