RON/BIO N3
Toxic effects of Lithium
Severe diarrhea, vomiting, drowsiness, muscle weakness and lack of coordination. If untreated can lead to renal failure, coma and death. When the toxic signs occur the drug should be stopped immediately. If the levels exceed 3.0 the patient may be place on dialysis. Monitor for Thyroid disease, BUN/Creatinine (renal failure), Hypothyroidism. Patients with heart disease, renal disease, thyroid disease, pregnant or breastfeeding CANNOT TAKE LITHIUM
Blunted
Showing little or slow to respond facial expression.
Pain disorder
Somatoform disorder where a person suffers clinically important pain whose onset or severity seems significantly affected by psychological factors, the pain is not relieved by analgesics. Example: Chest pain, and nothing shows on EKG
Avoidant personality disorder
Someone who has avoidant personality disorder avoids intimate and social contact with others. Have social discomfort, low self-esteem, hypersensitive to negative criticism.
Accountability
State of being answerable for one's actions—a nurse answers to himself or herself, the patient, the profession, the employing institution such as a hospital, and society for the effectiveness of nursing care performed.
What Governs how we practice?
Students: Course objectives, DEC (Differentiated Essential Competencies). RN: NPA, Policy & Procedures, JCAHO, standards published by specialty organizations. Education & training- theory skills, documented knowledge base
Paranoid
Suspicious, mistrusts of others, is watchful and secretive
Electroconvulsive Therapy (ECT)
Teach the patient prior to the procedure Avoid the word "shock" Patient might get a muscle relaxant prior to ECT and general anesthesia A crash cart should be in the room The nurse will: Maintain a patent airway Check vitals every 5-10 minutes Re-orient the patient after ECT Patient might complain of h/a, muscle soreness, nausea, retrograde amnesia (might not remember the procedure).
Somatic symptom disorder
The patient is convinced something is happening Remember: The client is really experiencing the symptoms they describe, they cannot control how or what they feel. The person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning.
Which description by the nurse is a correct explanation of delegation?
The transfer of responsibility for the performance of an activity
The registered nurse is delegating a task for unlicensed assistive personnel l (UAP). Which client's care would be suitable for delegation to the UAP
The unlicensed assistive personnel (UAP) can monitor the temperature of client B every hour.
How many rights of delegation are there in the nursing practice?
There are five rights of delegation in nursing practice. They are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.
Schizoid
They may be emotionally cold and detached. Isolated and introverted, no close friends. Restricted range of emotion
What are the overall purposes of delegation? Select all that apply.
To achieve nursing goals To improve client outcomes
Dependent
Unable to make decisions for self, allows others to assume responsibility for his or her life. Excessive need to be taken care of.
Which care activities would be involved in a correct delegation process? Select all that apply.
Unlicensed assistive personnel (UAP) assist the client with oral feedings. Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature. Licensed practical nurse (LPN) cleans the client's body.
Catatonia
Unmoving
Benztropine (Cogentin) controlling the uncontrollable
Used in treatment for Parkinson's disease and drug induced extrapyramidal reactions Also watch for drowsiness, dry mouth, blurred vision, urinary retention, constipation, decreased sweating, and GI upset. Assess the elderly for confusion, disorientation, agitation and psychotic like symptoms.
Documentation
Written entry into the patient's medical record of all pertinent information about him or her. These entries validate the patient's problems and care and exist as a legal record.
Anticholinergic effects
dry mouth, blurred vision, constipation, urinary retention
Maslow's Hierarchy of Needs
•At the very base lie physiological needs, including the most elementary of human necessities: food, water, oxygen, sleep, and other simple bodily functions. •Next in the hierarchy come safety needs. These consist of bodily, financial, and health security. •After physiological and safety needs are met, humans search out love and belonging needs, including community, friendship, family, and romantic love, as well as sexual intimacy. •The last of the needs are esteem needs--the needs for recognition, respect, as well as self-esteem. The individual achieves these needs by engaging in intellectual and physical activities that give them a sense of worth and value in the eyes of others.
S B A R
•S- situation: patient name, age, sex diagnosis •B-background: history, allergies, attending MD, consults •A- assessment, current vital signs, heart rhythm, lung sounds, oxygen rate, skin, iv site, iv site change date, dressings, last BM, Foley, activity, diet, drains, fall risk •R- recommendation: current labs, pending labs, awaiting procedures, nursing concerns
Word Salad
"Get by for anyone just to answer fortune cookies."
The registered nurse is teaching a student nurse about delegating tasks to the unlicensed assistive personnel (UAP) while caring for a client with a skin disease. Which delegation statement made by the student nurse requires a need for further teaching?
"I will advise the UAP to reinforce the client teaching."
The registered nurse is teaching a newly hired nurse about active delegation. Which statement made by the newly hired nurse indicates the need for further teaching?
"I will instruct the licensed vocational nurse (LVN) to administer intravenous (IV) medications."
Major Tranquilizers
-Chlorpromazine (Thorazine) is a powerful drug, it can cause drowsiness, blurred vision, hypotension, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Adverse reaction: PAD: Pseudoparkinsonism, akathisia and dystonia.
The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb since last night, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1)-Restrict fluids to 1500 mL/day. 2)-Weigh the client every morning. 3)-Administer furosemide (Lasix) 40 mg IV push. 4)-Maintain accurate intake and output records.
3)-Administer furosemide (Lasix) 40 mg IV push.
The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1)-Teaching family members to assist the client with fluid intake 2)-Administering IV fluids as prescribed by the physician 3)-Providing straws and offering fluids between meals 4)-Developing a plan for added fluid intake over 24 hours
3)-Providing straws and offering fluids between meals
Bipolar Disorder
A disorder associated with episodes of mood swings ranging from depressive lows to manic highs.
Hallucinations
A false or mistaken idea/perception of visual, auditory, tactile, olfactory, or gustatory experiences without an external stimulus and with a undeniable sense of their reality
Liability
A legal responsibility for one's acts (and failure to act); includes responsibility for financial restitution of harms resulting from negligent acts.
Illusion
A misinterpretation of reality.
When assigning a task, the delegator should understand the delegatee's personal values and align them with the organizational values. Which task can be achieved from this delegation
Affirming
Which interventions are in the scope of a licensed practical nurse (LPN)? Select all that apply.
Ambulating the client Assisting the client with bathing Administering intramuscular medications
Tricyclic Antidepressants
Amitriptyline (Elavil), Doxepin (Sinequan), Nortriptyline (Pamelor), Imipramine (Tofranil). Watch for signs of: Sedation, Orthostatic hypotension, decrease in sexually ability/desire, dry mouth, urinary retention, tachycardia. Tricyclic medications can cause sedation. ***If a dose is missed, take within 3 hours from the time it needed to be taken or if not able to take within 3 hours wait until next dose.
Can be lethal
An overdose of MAO Inhibitors and Tricyclic antidepressants (potentially lethal) Demerol with MAOI can cause a FATAL reaction
Gabapentin (Neurotonin).
Anticonvulsant also helps with neuropathic pain. Watch for confusion, depression, drowsiness, fatigue, somnolence, dizziness, ataxia, tremor, and diplopia. Abrupt withdrawal may cause increase seizure frequency. Overdose will give you slurred speech, drowsiness, lethargy, and diarrhea.
Depakote
Anticonvulsant used as a mood stabilizer. Check therapeutic levels, pt will have a base line and ongoing labs like liver function, ammonia level and PT and PTT. It can treat seizures and bipolar disorder. It can also help prevent migraine headaches.
Clozapine (Clozaril) and Olanzapine (Zyprexa)
Are the psych medication that cause the MOST Weight gain
Schizotypal personality disorder
Being a loner and lacking close friends outside of the immediate family. Flat emotions or limited or inappropriate emotional responses. Persistent and excessive social anxiety.
Which healthcare team member is responsible for the coordination and assignments of client care?
Charge nurse
Anatomy of maniac episode
DIG FAST: primary symptoms of a maniac attack D: distractibility I: indiscretion G: grandiosity F: flight of ideas A: activity increase S: sleep deficit T: talkativeness
Histrionic
Dramatic, excessive emotionality, flamboyant, needs to be the center of attention, always seeking attention.
Code of ethics.
Formal statement that delineates a profession's guidelines for ethical behavior. A code of ethics sets standards or expectations for the professional to achieve.
Olanzapine (Zyprexa)
IM Injection can cause patient to have delirium, or sedation. Patient has to be observed for 3 HOURS after receiving this injection
Which of these refers to the accountability element of the decision making process?
Individuals being answerable for their actions
Carbamazepine (Tegretol)
Is an anticonvulsant drug used prophylactically to protect a client with known seizures and also for relief of pain from neuralgia. Watch for drowsiness, nausea, vomiting, blurred vision/visual problems, ataxia, vertigo and h/a. DON'T GIVE MEDICATION WITH GRAPE FRUIT! Agranucytosis is a concern. Pt needs to have serum level checked: therapeutic level 4-12 mcg/mL and also check WBC. Tegretol is an anticonvulsant that is used as a mood stabilizer.
Tardive dyskinesia
It is permanent involuntary movement. Is a serious side effect that may occur with certain medications used to treat mental illness. TD may appear as repetitive, jerking movements that occur in the face, neck, and tongue. The symptoms of TD can be very troubling for patients and family members. IT IS NOT REVERSIBLE
Nurse Practice Act (NPA).
Law established to regulate nursing practice.
Regulatory agencies.
Local, state, provincial, or national agencies that inspect and certify health care agencies as meeting specified standards. These agencies can also determine the amount of reimbursement for health care delivered.
Bipolar Disorder Maniac vs Depressive
Maniac: -Onset before age 30 -Mood: elevated, expansive, irritable -Speech: Loud-rapid, punning, rhyming, clanging, vulgar. -Weight loss -Grandiose delusions -Distracted -Hyperactive -Decrease need for sleep -Inappropriate -Flight of ideas -Begins suddenly and escalates over several days Depressive: - -Previous manic episodes -Mood: anxious, depressed, hopelessness -Decreased interest in pleasure -Negative views -Fatigue -Decreased appetite -Constipation -Insomnia -Decreased libido -Suicidal Preoccupation -May be agitated or have movement retardation
Depressive
May have major depression
Obsessive-compulsive
Might have a pattern of perfectionist, mental or interpersonal control. Orderly, rigid, inflexible.
A professional organization that develops the criteria for Nursing Diagnosis
NANDA
A healthcare team is caring for a population according to the functional model of nursing. Which healthcare team member is most appropriate for the delegation of hygiene care?
Nursing assistant
Objective Data
Observed by someone other than the patient. Vital Signs, lab values, physical examination.
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply.
Planning for future safety Promoting access to community services Validating the experiences
Delegation
Process of assigning another member of the health care team to be responsible for aspects of patient care (e.g., assigning nurse assistants to bathe a patient).
Flight of ideas
Racing thoughts, often unconnected.
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?
Right communication
Medication Rights
Right person Right medication Right dose Right time Right route Right documentation Right reason Right response
Depression assessment SIG E CAPS
S: sleep disturbances I: interest decreased in pleasure, activities and sex G: guilty feelings E: energy decreased C: concentration A: appetite P: psychomotor function S: suicidal ideations
What professional responsibility does the nurse display as a client's advocate?
The nurse protects the client's human and legal rights and provides assistance in asserting said rights.
Ambivalence
Uncertainty or indecisiveness.
Clonazepam (Klonopin)
"Benzodiazepine and Anticonvulsant" -Two sides to the story Patient can build tolerance and dependence on this medication with long term use. Medication levels might have to be adjusted and increased. Can be used with Lithium or other mood stabilizers but not used by itself to treat bipolar disorder. PO route. Watch for drowsiness, ataxia, behavioral disturbances, aggression, irritability and agitation. Abrupt withdrawal may cause increase restlessness, irritability, insomnia, and hand tremors. Think SAFETY with the elderly, patient will be at risk for FALL!
A registered nurse teaches a student nurse about delegation. Which statement made by the student nurse indicates appropriate learning?
"Licensed practical nurses are accountable for the tasks they perform." XXX Licensed practical nurses can be expected to perform tasks with which they have experience." ???
Clozapine (Clozaril)
- Antipsychotic medication - Watch for tachycardia and seizures - May cause severe agranulocytosis ; WBC will be tested every 7-14 days for the first 6 months -This medication is dispense every 7-14 days only after having the WBC results of at least or above 3500. -After 6 months it will be done every 2 weeks Signs and symptoms of agranulocytosis: fever, malaise, chills, weakness, sore throat, ulcerated sores throat, bleeding gums, bone pain, low blood pressure, fast heartbeat, and trouble breathing, leukopenia. ***A reaction to this medication might happen immediately or it can take 18-24 weeks after initiating drug therapy. ***First stop the medication immediately, then make sure patient is stable and call provider with SBAR.
Homelessness
-Nurses may feel powerless and frustrated when caring for homeless patients. -These patients' frequent ED visits -The homeless patient's poor adherence to discharge instructions can contribute to burnout in nurses
Extrapyramidal Side Effects (EPS)
-Serious Side-Effects of Antipsychotic Medications -Acute Dystonia: involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx -Pseudoparkinsonism: Resting tremors, which are shaking that occurs when your muscles are relaxed. -Akathisia: a state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs. -Eyes might be rolled up to the back -Often collectively referred to as EPS ***This can be reverse with the proper medication
While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1)-33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV 2)-50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care 3)-19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today 4)-75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting today
1)-33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV
The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1)-Applying oxygen per nasal cannula as ordered 2)-Monitoring the respiratory status for the first 30 minutes 3)-Giving the ordered dose of Narcan and evaluating the response to therapy 4)-Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format
1)-Applying oxygen per nasal cannula as ordered
An experienced LPN/LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? (Select all that apply.) 1)-Checking oxygen saturation using pulse oximetry 2)-Completing in-depth admission assessment 3)-Auscultating breath sound 4)-Developing the nursing care plan 5)-Evaluating the patient's technique for using MDIs
1)-Checking oxygen saturation using pulse oximetry 3)-Auscultating breath sound
Which clients must be assigned to an experienced RN? (Select all that apply.) 1)-Client with chest pain who has a history of arteriosclerosis 2)-Client with abdominal cramps related to food poisoning 3)-Client who was in an automobile crash and sustained multiple injuries 4)-Client with a severe headache of unknown origin 5)-Client with chronic back pain related to a workplace injury 6)-Client who has returned from surgery and has a chest tube in place
1)-Client with chest pain who has a history of arteriosclerosis 3)-Client who was in an automobile crash and sustained multiple injuries 4)-Client with a severe headache of unknown origin 6)-Client who has returned from surgery and has a chest tube in place
An LPN/LVN is to administer rapid-acting insulin (Lispro) to a patient with type 1 diabetes. What essential information would you; the RN, be sure to tell the LPN/LVN? 1)-Give this insulin after the patient's food tray has been delivered and the patient is ready to eat. 2)-Rapid-acting insulin is the only insulin that can be given subcutaneously or IV. 3)-Only give this insulin if the patient's fingerstick glucose reading is above 200 mg/dL. 4)-This insulin mimics the basal glucose control of the pancreas.
1)-Give this insulin after the patient's food tray has been delivered and the patient is ready to eat. The onset of action for rapid-acting insulin is within minutes, so it should be given only when the patient has food and is ready to eat.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADL's? Select all that apply. 1)-Use a soft-bristled toothbrush or tooth sponge for oral care. 2)-Use a lift sheet when moving and positioning the patient in bed. 3)-Use an electric razor when shaving the patient each day. 4)-Be sure the patient's footwear has a firm sole when the patient ambulates. 5)-Use a rectal thermometer to obtain a more accurate body temperature.
1)-Use a soft-bristled toothbrush or tooth sponge for oral care. 2)-Use a lift sheet when moving and positioning the patient in bed. 3)-Use an electric razor when shaving the patient each day. 4)-Be sure the patient's footwear has a firm sole when the patient ambulates.
There are 3 types of Bipolar Disorders
1- Bipolar: Mixed pt cycles alternate between mania, normal mood and depression. 2- Bipolar Type 1: Manic episode with at least 1 depressive episode 3-Bipolar 2: Recurrent depressive episodes, with at least 1 hypo-manic episode
3 parts of Nursing Diagnosis
1-Problem and Priority 2- Related to: R/T 3-As Evidence By: AEB
Benztropine (Cogentin) given IM and Diphenhydramine (Benadryl)given IM or IV
2 medications that can be given to stop Extrapyramidal Side Effects (EPS) (acute dystonia, pseudoparkinsonism, akathisia)
You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1)-62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 2)-5-year-old who has a new pruritic rash and a possible chickenpox infection 3)-3-year-old who has paroxysmal coughing and whose sibling has pertussis 4)-74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight
2)-5-year-old who has a new pruritic rash and a possible chickenpox infection. Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB.
Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1)-Anxious client with chronic pain who frequently uses the call button 2)-Client who is reporting pain at the site of a peripheral IV line 3)-Client on the second postoperative day who needs pain medication before dressing changes 4)-Client with a kidney stone who needs frequent PRN pain medication 5)-Client with chronic pain who is to be discharged with a new surgically-implanted catheter 6)-Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain
2)-Client who is reporting pain at the site of a peripheral IV line 3)-Client on the second postoperative day who needs pain medication before dressing changes 4)-Client with a kidney stone who needs frequent PRN pain medication
A client's potassium level is 6.7 mEq/L. (normal potassium level is 3.5 - 5.0 mEq/L at your hospital). Which intervention should you delegate to the first-year student nurse whom you are supervising? 1)-Administer potassium 10 mEq orally. 2)-Assess the electrocardiogram (ECG) strip for tall T waves. 3)-Administer spironolactone (Aldactone) 25 mg orally. 4)-Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally.
4)-Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. The client's potassium level is high (normal range is 3.5 to 5 mEq/L). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. The beginning nursing student does not have the skill to assess ECG strips. Focus: Delegation, supervision
In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1)-Evaluating relief after applying a cold compress 2)-Monitoring the client for signs of discomfort while ambulating 3)-Coaching the client to deep breathe during painful procedures 4)-Assisting the client with preparation of a sitz bath
4)-Assisting the client with preparation of a sitz bath
A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a UAP? 1)-Assessing the patient's insulin injection technique 2)-Typing in the ordered consult with the dietitian into the electronic health record 3)-Teaching the patient to use a glucometer to monitor glucose at home 4)-Reminding the patient to check glucose level before each meal
4)-Reminding the patient to check glucose level before each meal
HIPPA.
A US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.
Depersonalization
A feeling of being disconnected from yourself.
Drug Order
A full drug order must contain: 1-Patient's name 2-Date order is written 3-Name of medication 4-Dosage (includes size, frequency and number of doses) 5-Route of delivery 6-Signature of the describer
Hypochondria
A psychological disorder characterized by the illusory conviction that one is ill or in pain, or likely to become so. Clinical Picture of a patient with Hypochondriasis: -Preoccupation with the fear of having a serious disease -Lack of diagnostic findings on examination or laboratory tests -Failure to develop the feared disease -Duration for at least six month
Dystonic reaction
A state of abnormal tension or muscle tone, similar to dystonia, produced as a side effect of certain antipsychotic medication; a severe form, in which the eyes appear to roll up into the head, is called oculogyric crisis.
Akathisia
A syndrome characterized by an inability to remain in a sitting posture, with motor restlessness and a feeling of muscular quivering; may appear as a side effect of antipsychotic and neuroleptic medication.
Pseudoparkinsonism
A syndrome similar to parkinsonism appearing as a side effect of certain antipsychotic drugscharacterized by rhythmic muscular tremors, rigidity of movement, droopy posture, and masklike facies.
5 Steps to the Nursing Process
ADPIE Assessment Diagnosis Planning Implementation Evaluation
Akinesia
Absence or loss of the power of voluntary movement, due to an extrapyramidal disorder.
Confidentiality
Act of keeping information private or secret; in health care the nurse only shares information about a patient with other nurses or health care providers who need to know private information about a patient to provide care for him or her; information can only be shared with the patient's consent.
The charge nurse is identifying tasks for staff caring for clients using functional nursing. Which tasks should be assigned to the licensed practical/licensed vocational nurse (LPN/LVN)? Select all that apply.
Administering topical and oral medications Measuring capillary blood glucose level for five clients
Negative (Soft) Symptoms
Alogia: "poverty of speech" Anhedonia: inability to feel pleasure Apathy: lack of interest, enthusiasm, or concern Asociality: not social -rejecting or lacking the capacity for social interaction Blunted affect: difficulty in expressing their emotions, prominent symptom of schizophrenia. Catatonia: inability to move normally -associated with schizophrenia Flat affect: people do not express emotions in the way other people might. No facial effects. Avolition or lack of volition: lack of motivation, absence of will Inattention: lack of attention; distraction.
Positive (hard) Symptoms
Ambivalence: mixed feelings about something/someone Loose associations: characterized by loose or odd connections between ideas. Delusions: altered reality/not base on reality. Echopraxia/echolalia: involuntary imitation of movement of another person/repetition of another person's spoken words. Flight of ideas: when someone talks quickly and erratically, jumping rapidly between ideas and thoughts. Hallucinations: perception of having seen, heard, touched, tasted, or smelled something that's not there. Ideas of reference: false belief Preservation: when someone "gets stuck" on a topic or idea Bizarre behavior: behavior that is odd, strange, or unexpected, particularly if it is out of the ordinary for a given person
What entity outlined the principles of delegation for registered nurses?
American Nurses Association (ANA)
Agranulocytosis
An acute condition characterized by pronounced leukopenia with great reduction in the number of polymorphonuclear leukocytes, infected ulcers are likely to develop in the throat, intestinal tract, and other mucous membranes, as well as in the skin.
Sentinel event.
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
What cannot be delegated?
Assessment, planning, teaching, evaluation and nursing judgment cannot be delegated. Do not delegate to LVNs: IVs, teaching, discharge, analyzing data, unstable patients, unexpected outcomes.
What to avoid when taking MAOIs
Avoid: Wine, aged cheeses, yogurt, cured meats, preserved/process meats (hot dog, bologna, bacon, smoked meats), fermented sausages such as pepperoni, salami, and bologna. Beef or chicken liver, anchovies, caviar, corned beef or smoked fish. Pickled or fermented foods, such as sauerkraut, kimchi, caviar, tofu or pickles. Sauces, such as soy sauce, shrimp sauce, fish sauce, miso and teriyaki sauce. NO: Barbiturates, tricyclic antidepressants, antihistamines, central nervous systems depressants, antihypertensives, over-the-counter cold medications.
Individual or Group Therapy
Beneficial for various personality disorders, Goal is to build trust and help with basic living skills. Provides support and assistance with decreasing some of the stressful symptoms
How does a nurse adopt the element of right circumstances during a task delegation?
By considering the appropriate client setting, available resources, and other relevant factors
How should a student nurse be trained for implementing delegation in practice?
By interacting with highly qualified, clinically experienced nursing mentors
Clinical Reasoning
Collect know facts--> Consider options--> Consider NPA rule--> Take action--> Outcomes (reflection & evaluation).
Lithium therapeutic range 0.6 - 1.2 mmol/L.
Contraindicated for Reno patients and patients taking diuretics. It crosses placenta barriers, not recommended in pregnancy. Symptoms of lithium toxicity include severe nausea and vomiting, severe hand tremors, confusion, and vision changes. Immediate medical attention to check lithium levels L: level of lithium 0.6 to 1.2 mmol/L I: increased urination (check kidney function) T: tremors H: hydration I: increased H2O intake U: u will lose water M: mouth is dry
The registered nurse is assessing four members of the health care team before assigning a task. Which person is best suited for delegation of the task?
Delegatee D is best suited for delegation of the task because he of she has an established relationship and expertise and can perform the task with little guidance from the delegator.
The registered nurse is teaching the student nurse about the concepts of delegation. Which response given by the student nurse indicates the need for further teaching?
Delegation is the transfer of accountability while retaining responsibility.
Malingering
Deliberate faking of a physical or psychological disorder motivated by gain. Over-exaggerating pain or other symptoms to get away from work or other responsibilities.
NCLEX traps
Do not ask Why? Do not leave the patient Do not persuade the patient Do not say, "Don't worry!" Do not pass the buck Do not read into the question
Therapeutic Communication Tips
Do respond to feeling tone Do provide information Do focus on the clients Do use silence Do use presence DO NOT: Do not ask "why" questions Do not as "yes/no" questions, except in case of possible self-harm Do not focus on the nurse Do not explore
The unlicensed assistive personnel (UAP) assigned to the 7:00 AM shift has not been coming to work until 8:00 AM. Nursing care is delayed, and assignments are started late. What is the most effective action by the charge nurse/team leader?
Document the information and discuss it with the UAP. Documentation is the best initial response; documentation should include both the missed time and the effect on client care. Discussing the issue with a friend from another unit is not a professional response to the problem. Reminding the unlicensed assistive personnel (UAP) of the expected start time may be helpful, but will not effectively address the issue if the problem continues. Reporting the event to the Human Resources department may be a later response to the problem.
First-Generation Antipsychotics
Dopamine Antagonist. They work by inhibiting dopaminergic neurotransmission. Chlorpromazine (Thorazine) Perphenazine (Trilafon) Fluphenazine (Prolixin) Thioridazine (Mellaril) Mesoridazine (Serentil) Thiothixene (Navane) Haloperidol (Haldol) Loxapine (Loxitane) Molindone (Moban) Perphenazine (Etrafon) Trifluoperazine (Stelazine)
Second-Generation Antipsychotics
Dopamine and Serotonin antagonist. They work by blocking D2 dopamine receptors as well as serotonin receptor antagonist action. Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Paliperidone (Invega) Iloperidone (Fanapt) Asenapine (Saphris) Lurasidone (Latuda)
While caring for a client with diabetes, the registered nurse delegates the task of administering oral medications to the licensed practitioner nurse (LPN), but the LPN is reluctant to take the assignment. What should be the most appropriate response of the registered nurse in this situation?
Evaluate the reason for the behavior. The registered nurse (RN) should first evaluate the reason for the behavior of the LPN and try to determine if the LPN has insufficient knowledge, a psychomotor deficit, or any other reason for the reluctance.
Patient-Centered Care Clinical Reasoning
Evidence-based practice outcomes as a basis for decision making in nursing practice
Delusions
False beliefs
The registered nurse delegates the care of a client in the immediate postoperative period to the patient care associate (PCA). Which tasks performed are in the scope of practice of the PCA? Select all that apply.
Feeding the client is basic care provided by the PCA. Assisting the client with bathing is the basic hygiene provided by the PCA. Primary ambulation of a postoperative client should be done by the registered nurse or another licensed practitioner. The PCA can monitor vital signs for stable clients but would not be delegated the task of monitoring vital signs for a postoperative client. Primary teaching of leg exercises to the client should be done by the registered nurse.
Narcissistic
Feelings of self-importance and entitlement; may exploit others to get own needs met. They need to be admired, pervasive pattern of grandiosity
A client with diabetic neuropathy reports a burning type pain in the lower extremities that is worse at night and not responding to non-steroidal anti-inflammatory drugs. Which medication will you advocate for first?
Gabapentin (Neurontin)
Haldol (haloperidol)
Given to a patient that is extremely manic. Watch for: extrapyramidal reactions, tardive dyskenisia, akathisia, acute dystonia, constipation, blurred vision, dry mouth.
You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action?
Have a conference with the nurses responsible for the care of this client. As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary.
Anhedonia
Having no pleasure or joy in life.
Which interventions are considered within the scope of practice for the basic psychiatric nurse? Select all that apply.
Holding a weekly therapy group that focuses on stress management Role modeling appropriate social boundaries for schizophrenic clients Performing case management for a group of clients with newly diagnosed bipolar disorder
Other side effects of antipsychotics
Hyperprolactinemia is a condition characterized by excess prolactin, the hormone responsible for milk production in a woman's breasts. gynecomastia -over development or enlargement of the breast tissue in men or boys secretion of milk decrease libido, problems with ejaculation increase risk for breast cancer weight gain
Neuroleptic Malignant Syndrome
Hyperthermia with extrapyramidal and autonomic disturbances which may result in death, following the use of neuroleptic agents. Adverse reaction to antipsychotics with severe "lead pipe" rigidity, FEVER, and mental status changes
Serotonin Syndrome
If a patient is taking a MAOI and SSRI together they are at risk for serotonin syndrome. Patient should not take MAOI and SSRI together. If patient is taking MAOI and stops to start taking SSRI, they need to wait for a "wash out" period. Mental status changes: confusion, agitation, lethargy, coma. Autonomic Instability: hyperthermia, tachycardia, mydriasis (dilation of the pupil of the eye), diaphoresis, nausea, vomiting, diarrhea. Neuromuscular hyperactivity: hyperkinesia, hyperreflexia, trismus. Come, death. Similar symptoms to SSRI overdose. Onset in 6 hours Treatment: "Ciproheptadine"
Antisocial
Impulsivity, tendency to disregard rights, boundaries of others. Violates the rights of others. Unable to conform to social norms. Lack of remorse. They may display false emotions to obtain what they want. Unable to empathise with others. Nurse: Has to SET LIMITS. Teach how to solve problems and manage emotions of anger and frustration. Egocentric, the world evolves around them. They avoid personal emotions. They manipulate and exploit those around them. They view relationships as serving their needs, and pursue others only for personal gain, and never think of the precautions of their actions to others. Cannot sustain long term commitment..
Erikson's Stages of Development
Infancy (Birth-18 months) - At this stage, we as human beings are completely dependent, helpless. We rely on an external source for everything, from food to affection •Early Childhood (18 months-3 years) - When we have overcome our Infancy crisis, we begin to move into Early Childhood. In this stage of development, we begin to do things for ourselves, such as communicate with others verbally, walk without assistance, and become pottytrained. Our crisis shifts to Autonomy vs. Shame. This can be a fragile stage, particularly due to our attempt to master skills •Play Age (3-5 years) - When we have resolved our Early Childhood crisis, we begin to move into Play Age. In this stage of development, we begin to mirror or mimic behavior around us. •School Age (5-12 years)This stage of life is all about expansion of one's social circle and beginning school. Students are influenced by their new surroundings as well as their peers. •Adolescence (12-18 years)According to Erikson, this is the first stage in our development that is determined directly by what we do as opposed to what we have had done to us. It is a phase of exploration in which we endeavor to determine our identity (ego identity) and what we want our lives to look like (career, education, etc). We are increasingly more independent, withdrawing from our peers and parents. •Young Adulthood (18-40 years)At this stage of psychosocial development, a person begins to search for a partner. It becomes the main focus or new struggle once a person has resolved their adolescent identity crisis. The most important event in this stage is a romantic attachment or relationship.. •Middle Adulthood (40-65 years)Erikson believed that much of our lives are spent preparing for this stage. Once we have successfully resolved the conflict of young adulthood, we approach a new conflict in middle adulthood. At this stage, work is most crucial to our lives and we tend to be concerned with productivity as well as personal growth. •Late Adulthood (65-Death)Once we have resolved our mid-life crisis or the crises of middle adulthood, we enter late adulthood. This stage is one that Erikson believed was a recovery from middle adulthood. In this final stage, people tend to reflect on their lives and accomplishments or lack thereof, regrets, and reflect on their demise.
Malpractice
Injurious or unprofessional actions that harm another.
Which delegation actions may be performed by unlicensed nursing personnel while caring for a client? Select all that apply.
Instructing the client to wear footwear while walking Asking the client to wash the hands before meals
Echolalia
Involuntary parrotlike repetition of a word or sentence just spoken by another person.
Tardive Dyskinesia
Irreversible involuntary movements of the facial muscles and tongue that develop as a late complication of some neuroleptic therapy, more likely with typical antipsychotics.
Conversion disorder
Is a disorder in which a person experiences blindness, paralysis, or other symptoms affecting the nervous system that cannot be explained solely by a physical illness or injury. Symptoms usually begin suddenly after a period of emotional or physical distress or psychological conflict.
Incident Report
It is a legal document You complete a incident report You DO NOT document in the patients medical record that an incident report was completed
Rules for Delegation
LPN/LVN Assignment: Assign stable patients with expected outcomes. UAP Assignment: Delegate standard, unchanging procedures. RN Assignment: Cannot delegate assessment, teaching, or nursing judgment.
Different Lithium Levels
Level from 1.5-2 they may start having symptoms of nausea, vomiting, diarrhea, decrease coordination, drowsiness, slurred speech and muscle weakness. Level of 2-3 will show symptoms of ataxia, agitation, poor vision, tinnitus, confusion, slurred speech, pruritus, increase urine output or bowel and bladder incontinence, vertigo. Level of 3 signs and symptoms are cardiac arrhythmia, hypotension, peripheral vascular collapse, seizures, decrease level of consciousness, stupor, coma, myoclonic jerks, and death.
Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply.
Licensed vocational nurses and licensed practical nurses are authorized to administer drugs through oral and intramuscular routes. Analyzing vital signs should be performed by the registered nurse. Hygiene maintenance can be delegated to unlicensed nursing practitioners (UNP) but a LVN can also do as well. Administering intravenous drugs should be done by the registered nurse.
MAO Inhibitors
Monoamine oxidase inhibitors (MAOIs) are a class of medication used to treat depression. Nardil (phenelzine), Parnate (tranylcypromine sulfate), Marplan (Isocarboxazid). No popular Meds Side Effects: drowsiness, dry mouth, insomnia, nausea, anorexia, constipation, urinary retention and orthostatic hypotension.
Lithium
Mood stabilizing drug. Lithium is a salt. It affects the CNS. It treats bipolar disorder by stabilizing the patient mood, and preventing or minimizing the highs and lows of bipolar illness It is the MOST Established Mood Stabilizer. Levels are checked every 2-3 days, while checking for a therapeutic dose to be determined. Levels should be around 1.0, levels less than 0.5 are considered not therapeutic and above 1.5 is toxic. Once they have a therapeutic dose they are usually monitor weekly and once patient is stable might be monitor once a month or more frequently. patient is stable Toxic Level 2.0
Common Side effects of Lithium
Nausea, diarrhea, anorexia, hand tremors, polydipsia, polyuria, metallic taste, fatigue, lethargy, weight gain, acne.
Borderline
Needy, always in a crisis, recurrent self-mutilating, unable to sustain relationships, suicidal gestures, splitting behavior. Fear of abandonment. Problems with self imagine, they may have problems with sexual, social or occupational roles as well. Unable to problem solve or learn from an experience. Self critical, demanding, winy, manipulative, argumentatively and verbally abusive.
In which role does the nurse oversee the budget of a specific nursing unit or agency?
Nurse manager
A registered nurse who has limited clinical experience must delegate in collaboration with a nursing assistant. Which communication method used by the registered nurse while supervising may affect the working performance of the nursing assistant?
Occasionally offering derogatory comments
Advocate
On behalf of the client with other members of the interdisciplinary healthcare team to procure resources for client care.
Which statement is true regarding delegation? Select all that apply.
Open lines of communication must occur between delegator and delegatee Delegation occurs only when at least two people are involved in a mutual work situation. Delegation involves sharing activities with other appropriate authority to accomplish the work.
Affect
Outward expression of the client's emotional state.
Subjective Data
Perceived by the client. Given by the "subject" Patient states "I have a pain o 9/10", I have nausea and diarrhea
Negligence
Performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do.
Antizeisure/Anticonvulsant
Phenytoin (Dilantin): given PO or IV. Watch for gingival hyperplasia (causes your gums to overgrow), bradycardia. Therapeutic level: 10-20 mcg/mL Carbamazepine (Tegretol): Watch for visual problems, ataxia, vertigo. Agranucytosis is a concern. Pt needs to have serum level checked: therapeutic level 4-12 mcg/mL and also check WBC. Tegretol is an anticonvulsant that is used as a mood stabilizer. Phenobarbital (Luminal): Watch for drowsiness, dependence. Can cause confusion, excitement, restlessness, and is habit forming. Drug levels need to be done for this drugs.
Accreditation
Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria.
The nurse is caring for four different clients with different health conditions. Which client care task delegated to the licensed vocational nurse (LVN) would be appropriate to develop a suitable care outcome?
Providing oral medication to the client who has undergone hysterectomy can be done by the licensed vocational nurse (LVN).
You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. __Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a headache that is partially relieved by medication. __Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. __Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. __Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility later that day. __Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. He reports chest pain of 9/10 on pain scale.
Rationale: All of the clients are in relatively stable condition. 1-The client with the pneumothorax has priority, because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated. 2-The woman who will be undergoing diagnostic testing should be assessed and medicated before she leaves for the procedure. 3-In a client with meningitis, a headache is not an unexpected complaint, but neurologic status and pain should be assessed. 4-The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. 5-Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; checking on her last prevents delaying care for all the others.
What does appropriate delegation do to a healthcare organization? Select all that apply.
Reduces stress Improves treatment outcomes Delegation requires empowerment of the delegatee to accomplish the task and, therefore, sharing functions reduces stress. As functions are distributed, it improves treatment outcomes. Appropriate delegation increases trust between the delegator and the delegates, increases client care, and increases time efficiency.
The team leader is making client assignments. Which team member should be assigned a client with a tracheostomy, chest tube, and blood transfusion?
Registered nurse (RN)
Passive aggressive disorder
Resentment and opposition to the demands of others. Procrastination and intentional mistakes in response to others' demands.
Extrapyramidal symptoms
Reversible movement disorders induced by neuroleptic medications. They include dystonic reactions, parkinsonism, and akathisia.
The registered nurse (RN) is teaching a newly hired nurse about delegating tasks to the healthcare team. When asked what the rights of delegation are, which right listed by the hired nurse indicates the need for further teaching?
Right drug name
SSRIs
Selective serotonin reuptake inhibitors Should be taken first thing in the morning If they forget a dose they have up to 8 hours to take the missing dose Watch for: h/a, nausea (teach to take with food), lethargy, fatigue, insomnia, sexual dysfunction, weight gain. DO NOT take with MAOI's or abruptly stop taking medication. The FDA put a warning about the increase in suicidal risk for children and adolescents taking SSRIs
Never event
Serious but preventable surgical errors (that should never occur).
