NCLEX (PassPoint)

DVT

Deep vein thrombosis is a complication of total joint replacement and manifestations include a red tender calf. Ecchymosis around the incision site is a normal finding. The client's diaphoresis, fluid volume deficit, and edema in the nonaffected leg should be further assessed; however, the priority is the red tender calf.

Which drug should a nurse choose as an antagonist for magnesium sulfate?

Calcium glutinate

A client, who was recently hospitalized, has constipation related to her medical regimen. Which medication may contribute to this problem?

Iron may cause constipation when supplements are taken at 100% of the recommended daily allowance (RDA). Folic acid, potassium, and vitamin E don't increase the likelihood of constipation.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?

Development of an increase in mobility Explanation: This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.

Heberden vs. Boucherd Nodes

Heberden's nodes appear on the distal interphalangeal joints. These bony and cartilaginous enlargements are usually hard and painless and typically occur in middle-age and elderly clients with osteoarthritis.

The nurse is working with a family in crisis. What should the nurse do in order of priority from first to last? All options must be used.

Identify the family member in crisis. Develop strategies to reduce symptoms. Assess the family's resources. Make a plan for managing the crisis.

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care?

In functional neurologic symptom disorder, the client represses and converts emotional conflicts into motor, sensory, or visceral symptoms that have no physiologic cause. All of these interventions are appropriate for this client. However, the client needs first to express feelings that can help to reduce anxiety and anger, and lead to understanding and insight into the situation. The other actions are necessary, but not immediately.

Lorazepam

Lorazepam is a benzodiazepine that is given for anxiety. It is addictive and clients can develop tolerance. If the client has severe or panic levels of anxiety, the client will be unable to learn new information that is needed to manage anxiety. Temporary use of lorazepam can allow the client to learn. It is not possible to completely eliminate anxiety. It is unknown if the client will always need to take medication for anxiety.

When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?

Pulling the ear pinna back, up, and out

The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest.

S1 is loudest at the mitral area, at the fifth intercostal space, left mid-clavicular line.

The ear canal of an infant or young child:

slants upward.

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped?

"What are you thinking about before you start to prepare supper?"

A nurse is caring for a client recently diagnosed with cancer and experiencing situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply.

- Maintain a calm, nonthreatening environment. - Encourage the client to verbalize concerns regarding the diagnosis. - Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Explanation: During periods of acute stress, interventions that help the client regain control will help master this new threat. Providing a calm, nonthreatening environment and encouraging verbalization of concerns will help the client face the unknown. Relaxation techniques have a physiologic and psychological effect in calming the client, which in turn allows further exploration of thoughts and feelings as well as problem solving. The ability to learn is limited during extreme stress, so teaching the client about grief and chemotherapy would not be effective at this stage. Providing distractions would be ineffective at this point in the grief process.

Psych Meds Differences (-lams/-pams, benztropine, chlorpromazine, buspirone)

Alprazolam's antianxiety properties make it the most appropriate medication for this client. It should only be given very short term because of its addictive apotential and the client should be weaned off from it. Benztropine is an antiparkinsonian agent used to control the extrapyramidal effects of such antipsychotic agents as chlorpromazine hydrochloride and thioridazine hydrochloride. Chlorpromazine is used to control the severe symptoms (hallucinations, thought disorders, and agitation) seen in clients with psychosis. Buspirone is an antianxiety agent but takes several weeks before it is effective in reducing anxiety. Thus it would not help this client who needs immediate assistance. Alprazolam provides immediate relief.

Social Isolation

For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse should provide simple, not detailed, explanations to the client and his family because stress may have diminished their comprehension. The nurse should encourage the family to visit as often as the client's condition permits.

A nurse in a psychiatric inpatient unit is caring for a client with generalized anxiety disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to:

Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium.

A woman has become increasingly afraid to ride in elevators. While in an elevator one morning, she experiences shortness of breath, palpitations, dizziness, and trembling. A physician can find no physiological basis for these symptoms and refers her to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which type of therapy is most likely to reduce the client's anxiety level?

Systematic desensitization. Phobias are commonly viewed as learned responses to anxiety that can be unlearned through certain techniques such as behavior modification. Systematic desensitization, a form of behavior modification, attempts to reduce anxiety, and thereby eradicate the phobia, through gradual exposure to anxiety-producing stimuli. Psychoanalytically oriented therapy also may be effective in this situation, but years of treatment are required to achieve results. Group psychotherapy could be used as an adjunct treatment to increase the client's self-esteem and reduce generalized anxiety. Electroconvulsive therapy is reserved primarily for clients with severe depression or psychosis who respond poorly to other treatments; it's rarely indicated for phobic disorders.