NCLEX RN EXAM QUESTIONS | ACCURATE AND VERIFIED FOR GUARANTEED PASS | GUARANTEED PASS, Exams of Nursing

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NCLEX RN EXAM QUESTIONS | ACCURATE

AND VERIFIED FOR GUARANTEED PASS |

GUARANTEED PASS| LATEST UPDATE|2024-

2025 WITH 100 QUESTIONS

Treat bronchial asthma. Used with caution impaired hepatic function. Liver function laboratory tests should be performed and monitored with treatment.

• ANSWER Zafirlukast (Accolate) administered empty stomach unless it causes GI upset, & then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently.
• ANSWER rifampin (Rifadin) causes optic neuritis, decreases visual acuity & ability discriminate between color red & green. - ANSWER Ethambutol (Myambutol) Single daily dose (bronchodilator) early in morning. Enables maximal benefit during daytime activities. Additionally, causes insomnia. Take in at least 2 L of fluid per day; decrease viscosity of secretions. Limit intake Coffee, cola, & chocolate
• ANSWER Theophylline (Theo-24) antiinflammatory for long-term control asthma. Anaphylactic reactions can occur with administration. Swelling lips & tongue are indication of adverse reaction
• ANSWER omalizumab (Xolair) Used treatment of pulseless ventricular tachycardia & ventricular fibrillation

• ANSWER Defibrillation Regular rhythm, with rate 60 to 100 beats/min. PR & QRS normal 0.12 to 0.20 second & 0.04 to 0.10 seconds.
• ANSWER Normal sinus rhythm Characterized absence P waves, wide QRS complexes (longer than 0.12 sec) & typically rate between 140-180 impulses/min. Rhythm is regular. Restorative coughing techniques sometimes used unstable V tachycardia. Cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply & coughing forcefully every 1-3 seconds. Cough CPR may terminate the dysrhythmia or sustain cerebral & coronary circulation for short time until other measures can be implemented.
• ANSWER Ventricular tachycardia Life-threatening dysrhythmia results from irritable ectopic focus that takes over pacemaker for heart. Low cardiac results can lead quickly to cerebral & myocardial ischemia. Feeling of impending doom.
• ANSWER Ventricular tachycardia Loss P waves & fibrillatory waves before each QRS complex. aia quiver, which can lead to thrombus formation
• ANSWER Atrial fibrillation energy level used defibrillation attempts is 360 joules.
• ANSWER monophasic defibrillator machine maintenance first patent airway, & then oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection.
• ANSWER Nursing responsibilities after cardioversion

Irregular chaotic undulations varying amplitudes. Ventricular fibrillation has no measurable rate & no visible P waves or QRS complexes & results from electrical chaos in ventricles.

• ANSWER Ventricular fibrillation Induced by exercise & relieved by rest or nitroglycerin tablets. Triggered by a predictable amount effort or emotion
• ANSWER Stable angina Prolonged & severe & occurs same time each day, most often at rest. Triggered by coronary artery spasm; attacks are of longer duration than in classic angina & tend to occur early in day & at rest.
• ANSWER Variant angina, or Prinzmetal's angin Chronic & incapacitating and is refractory to medical therapy
• ANSWER Intractable angina Occur lower level activity/rest less predictable, often precursor of myocardial infarction. Triggered by unpredictable amount exertion or emotion & may occur at night; attacks increase in number, duration, & severity over time.
• ANSWER Unstable angina Considered dangerous when frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on T wave.
• ANSWER Premature ventricular contractions (PVCs) Common lab range for APTT are 20-36 seconds. Should be 1.5 to 2.5 times normal value if heparin therapy is theraputic, considered therapeutic if 60 seconds
• ANSWER Activated partial thromboplastin Antidysrhythmic used treat ventricular dysrhythmias client allergic to lidocaine

• ANSWER Procainamide Monitor signs of bleeding. Hemorrhage is complication of any type of thrombolytic medication - ANSWER receiving tissue plasminogen activator, alteplase (Activase, tPA). Thiazide diuretics; sulfa-based, risk for allergic sulfa reaction. Also, Risk hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, & hyperuricemia.
• ANSWER hydrochlorothiazide Early sign toxicity GI: anorexia, nausea, vomiting, & diarrhea. Subsequent manifestation: headache, visual disturbances diplopia, blurred vision, yellow-green halos, & photophobia; drowsiness; fatigue; & weakness. Cardiac rhythm abnormalities can occur. Monitors digoxin level. Therapeutic level digoxin range from 0.5 to 2 ng/mL.
• ANSWER Digoxin toxicity Diuretic & expected outcome increased urine output, decreased crackles, & decreased weight. Can be used for client who needs diuresis.
• ANSWER Bumetanide Antidote is protamine sulfate; readily available to use if excessive bleeding or hemorrhage should occur.
• ANSWER Heparin Vitamin K is an antidote
• ANSWER Warfarin sodium Contraindicated number of preexisting conditions in which there is risk uncontrolled bleeding. Also contraindicated severe uncontrolled hypertension because risk cerebral hemorrhage. - ANSWER Thrombolytic therapy

Check patency fistula by palpating for presence of a thrill or auscultating for a bruit.

• ANSWER arteriovenous fistula for hemodialysis Symptoms: Dysuria & penile discharge. In male often results from chlamydial infection & characterized: dysuria accompanied by clear to mucopurulent discharge. Because disorder often coexists with gonorrhea, diagnostic tests done for both & include culture & rapid assays - ANSWER Urethritis Symptoms: scrotal pain & edema, accompanied by fever, nausea & vomiting, chills. Often caused by infection, although sometimes by trauma. Common interventions; bed rest with bathroom privileges, elevation scrotum, ice packs, sitz baths, analgesics, & antibiotics. - ANSWER Epididymitis Signs: Pallor, diminished pulse, & pain in left hand
• ANSWER Arterial steal syndrome from left arm fistula Creatinine level frequently used laboratory test determine renal function. Increases when at least 50% of renal function is lost.
• ANSWER Renal function disorder often occurs first 2 weeks after transplantation. Manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, & deteriorating renal function. - ANSWER Acute rejection occurs gradually over period of months to years.
• ANSWER Chronic rejection characterized headache, mental confusion, decreased LOC, nausea, vomiting, twitching, & possible seizure activity. Disequilibrium syndrome is caused by rapid removal solutes from body during hemodialysis.
• ANSWER Disequilibrium syndrome

urinary retention can be triggered by decongestants, anticholinergics, & antidepressants. Should be questioned about use of these medications if has urinary retention. Retention also precipitated by other factors, such as alcoholic beverages, infection, bed rest, & becoming chilled.

• ANSWER history of benign prostatic hyperplasia with an inability to void Administered with full glass of water; maintain high fluid intake. Medication is more soluble in alkaline urine.
  • ANSWER Sulfamethoxazole May be administered IV infusion; not mixed with any other medications or solutions. Infused over 60-90 minutes, & bolus infusion or rapid infusions must be avoided. Early sign/symptom blood disorders that can occur; sore throat, fever, pallor, & instructed notify (HCP) if these occur.
• ANSWER Trimethoprim-sulfamethoxazole Because risk anaphylaxis during administration IV route, epinephrine & oxygen must be immediately available for use. Nephrotoxicity evaluated by monitoring elevated BUN & serum creatinine levels. Adverse effects; are nephrotoxicity, infection, hypertension, tremors, & hirsutism. Nephrotoxicity & infection are most serious.
  • ANSWER Cyclosporine (Sandimmune) grapefruit juice inhibits metabolism. As result, consumption grapefruit juice can raise cyclosporine levels by 50% to 100%, greatly increasing risk of toxicity.
  • ANSWER Cyclosporine (Sandimmune) Used for urinary tract infection. Imparts harmless brown color to urine
  • ANSWER Nitrofurantoin (Furadantin)

Reverse anemia associated with chronic kidney disease. Therapeutic effect seen hematocrit between 30% & 33% (Treat anemia) Medication administer subcutaneously or intravenously as prescribed.

• ANSWER Epoetin alfa (Epogen) Severe pain or pain accompanied by nausea is indicator increased intraocular pressure & should be reported to HCP immediately – ANSWER Cataract extraction Reveals red, dull, thick, immobile tympanic membrane, with/without perforation. Postauricular lymph nodes tender & enlarged. Low-grade fever, malaise, anorexia, swelling behind ear, pain with minimal movement of head.
• ANSWER Otoscopic examination with mastoiditis Painless blurring central vision is chief clinical manifestation. Early symptom include slightly blurred vision & decrease in color perception.
• ANSWER early stages of cataract formation Surgical removal eyeball. Presence bright red drainage on dressing,reported to HCP, indicates hemorrhage.
• ANSWER enucleation Sensorineural hearing loss that occurs with aging.
• ANSWER Presbycusis Right eye tested, then left eye, & then both eyes tested. Visual acuity measured with or without corrective lenses & at distance 20 feet from chart.
• ANSWER Snellen chart

Vision 20/20 normal; client able read from 20 feet what person with normal vision can read from 20 feet. Visual acuity 20/60 can read distance of 20 feet what person with normal vision can read at 60 feet. - ANSWER Snellen chart Wash hands & put gloves on. Tilt head backward, open eyes, & look up. Nurse pulls lower lid down against cheekbone & holds bottle like pencil with tip downward. Nurse gently rests wrist of hand on cheek & squeezes bottle gently to allow drop to fall into conjunctival sac. Instructed close eyes gently & not to squeeze eyes shut to prevent loss of medication. - ANSWER Administer eye medications Steps Contraindicated for gastrointestinal bleeding & potentially ototoxic. Mild intoxication with acetylsalicylic acid (aspirin) called salicylism. Tinnitus (ringing in the ears) is most frequent effect noted with intoxication - ANSWER Acetylsalicylic acid (aspirin) Nail bed pressure tests - ANSWER Unconscious patient test client's peripheral response to pain Tested using sternal rub, placing upward pressure orbital rim, or squeezing clavicle or sternocleidomastoid muscle. - ANSWER Unconscious patient Cerebral responses to pain Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure - ANSWER Vital signs if the intracranial pressure is rising weakness one side body may occur after stroke. Involves weakness face, tongue, arm, & leg on one side. Also aphasic: unable to discriminate words & letters. Generally cautious & anxious when attempting new task. Right-sided hemiparesis has weakness right arm, leg & needs assistance with feeding, bathing, & ambulating. - ANSWER Hemiparesis Loss of half visual field. Objects placed in intact field vision, & also should approach from intact side. Instructs to scan environment to overcome visual deficit & client teaching from within intact field vision. Encourage use personal eyeglasses, if available. - ANSWER Homonymous hemianopsia

May experience episodes respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. Ambu bag, intubation tray, & suction equipment available at bedsideSpace. Activities conserve energy & restore muscle strength. Take medication correctly maintain blood levels. Muscle-strength exercises not helpful & fatigue client. Overeating cause exacerbation symptoms, as is exposure heat, crowds, erratic sleep habit, & emotional stress. - ANSWER Myasthenia gravis Spasms pain start suddenly & last seconds to minutes. Characterized as stabbing; similar to electric shock. Accompanied spasms facial muscles, cause twitching parts of face, mouth, or closure eye.Triggered by Stimulation affected nerve by pressure & temperature. Pain minimized using cotton pads wash face; room temp water. Chew on unaffected side mouth, eat soft diet, & take in foods & beverages at room temperature. If toothbrushing triggers pain, oral rinse after meals may be helpful. Nnticonvulsant meds carbamazepine & gabapentin (Neurontin) help relieve pain. - ANSWER Trigeminal neuralgia Clinical syndrome; Progressive muscle weakness that develops rapidly. Has unknown origin. Report history respiratory or GI infection 1- 4 weeks before onset neurological deficits. On occasion, syndrome can be triggered by vaccination surgery. Have dysphagia; more likely aspirate clear liquids than thick or semisolid foods. Passive ROM exercises help prevent contractures, & assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Are at risk for hypotension or hypertension, bradycardia, & respiratory depression, frequent monitoring vital signs required. Retain carbon dioxide, leading to respiratory acidosis & ventilatory failure as paralysis develops. - ANSWER Guillain-Barré syndrome Providing information, giving positive feedback, & encouraging relaxation - ANSWER Guillain- Barré syndrome help cope with this illness Affect is flat, with periods of emotional lability - ANSWER Limbic system neurological deficit Nuchal rigidity, positive Brudzinski sign, & positive Kernig sign - ANSWER Indicate developing meningitis

Prescribed for Parkinson's disease. Adverse effect; Dyskinesia & Impaired voluntary movement. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, & akinesia frequent side effects. - ANSWER Carbidopa-levodopa (Sinemet) Potential decreased effectiveness of birth control pills while taking phenytoin - ANSWER phenytoin (Dilantin) for seziures Acetylcysteine (Mucomyst). Normal therapeutic serum level acetaminophen is 10-20 mcg /mL. Toxic level higher than 50 mcg/mL, & levels higher than 200 mcg/mL could indicate hepatotoxicity. - ANSWER Antidote for acetaminophen Opioid analgesic. Side/adverse effects; respiratory depression, drowsiness, hypotension, constipation, urinary retention, N&V, tremors. - ANSWER Meperidine hydrochloride (Demerol) Monitor vital signs & assess for hypotension. Increase fluid intake, palpate bladder for urinary retention, auscultate bowel sounds, monitor bowel because cause constipation. Monitor respiratory status & initiate deep-breathing & coughing exercises. Monitors effectiveness pain medication. - ANSWER Codeine sulfate Plaster cast 24-72 hours to dry (synthetic casts 20 min). Cast & extremity elevated reduce edema. Wet cast handled palms hand until dry, extremity turned (unless contraindicated) so that all sides of wet cast will dry. Cool setting hair dryer can be used dry plaster cast (heat cannot be used because cast heats up & burns skin). Kept clean & dry, Not stick anything under because risk break skin integrity. Monitor circulatory impairment; pain, swelling, discoloration, tingling, numbness, coolness, diminish pulse. HCP notified if circulatory impairment occurs - ANSWER Cast Earliest symptom is paresthesia (numbness & tingling in fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, pallor & coolness to distal limb. Cyanosis is a late sign. - ANSWER Compartment syndrome Skin traction often applied after hip fracture before fracture is reduced in surgery. Traction reduces muscle spasms & helps immobilize fracture. - ANSWER Buck's (extension) traction

Infection & pancytopenia are side/adverse effects. Assess white blood cell counts & platelet counts - ANSWER Etanercept for treatment of rheumatoid arthritis Encourage drink 3000 mL fluid day. Full effect may take 1 week or longer. Given with, or immediately after, meals or milk. Develops rash, irritation eyes, swelling of lips or mouth;contact HCP because may indicate hypersensitivity. Medication prevents, treats hyperuricemia caused by chemotherapy. May increase effect of Warfarin sodium if this medication was prescribed for client, should verify prescription with HCP - ANSWER Allopurinol (Zyloprim) Prescribed for gout. Used with caution older adults, debilitated clients, & clients with cardiac, kidney, or GI disease. - ANSWER Colchicine (Colcrys) Take medication with full glass of water after rising in morning. Not eat or drink anything for 30 minutes following administration - ANSWER Alendronate (Fosamax) prescribed for osteoporosis Liver damage most serious adverse effect. To reduce risk of liver damage, liver function tests should be performed before treatment & throughout treatment. Administered lowest effective dosage for shortest time necessary. - ANSWER Dantrolene sodium (Dantrium) Used with caution history of urinary retention, glaucoma, & increased intraocular pressure. - ANSWER Cyclobenzaprine hydrochloride (Flexeril) Skeletal muscle relaxant. May cause urine to turn brown, black, dark green color. Needs to be told; harmless effect. Medication can cause hypotension & bradycardia. Drowsiness & dizziness can also occur. - ANSWER Methocarbamol (Robaxin) Autoimmune disease causes blistering in epidermis. Large flaccid blisters (bullae). Blisters are in epidermis, have thin covering of skin & break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. - ANSWER Pemphigus

Health care worker, people who work in rubber industry, or have had multiple surgeries, have spina bifida, wear gloves frequently; food handlers, hairdressers, & auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts. - ANSWER Individuals at risk for developing a latex allergy Multisystem infection that results from bite by tick carried by several species of deer. Blood to detect performed 4 to 6 weeks following tick bite. Antibody formation takes place in the following manner. Ticks should be removed with tweezers & area washed with an antiseptic. - ANSWER Lyme disease Prevention; insect repellent on skin & clothes in an area where ticks likely found. Long-sleeved tops & long pants, closed shoes, & hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up & over pant legs to prevent ticks from entering under clothing. - ANSWER Lyme disease Avoid uncooked eggs & unpasteurized milk. Fruits & vegetables washed before eating. Contact materials possibly contaminated with cat feces; litter boxes, sand boxes, garden soil avoided. Avoid touching mucous membranes mouth or eyes while handling raw meat, wash all kitchen surfaces that come contact with uncooked meat, wash hands after handling raw meat. Symptoms; altered mental status, headache, & cognitive impairment. - ANSWER Toxoplasmosis Caused by inhalation of spores from bat or bird droppings. An opportunistic infection that affects lungs & can occur in client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, & bronchoscopy - ANSWER Histoplasmosis Chronic connective tissue disease. Corticosteroids prescribed treat inflammation. Topical agents may provide some relief from joint pain. Activity encouraged as tolerated & room temperature constant. Clients need sit up for 1-2 hours after meal if esophageal involvement present - ANSWER Scleroderma Nephrotoxicity, bone marrow depression, GI effects, hepatotoxicity, dermatological effects, & neurological symptoms; headache, dizziness, vertigo, ataxia, depression, & seizures. - ANSWER sulfonamide monitor for signs/symptoms of which side/adverse effects

Can cause pancreatitis. Serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis. Medication is also hepatotoxic & can result in liver failure - ANSWER Didanosine (Videx) Used manage HIV in clients who do not respond to or who cannot tolerate conventional therapy. Can cause peripheral neuropathy. Should monitor gait closely & ask about paresthesia.

• ANSWER stavudine (d4T, Zerit) Emphasizes self-expression, self-exploration, & self-awareness in present. Client & therapist focus on everyday problems & try to solve them. - ANSWER Gestalt therapy Promotes individual's comfort in group, which then transfers to other relationships. Based on one-to-one or group therapy approach in which therapist-client relationship often used as way for client to examine other relationships in his/her life. - ANSWER Interpersonal group therapy Focuses on how irrational beliefs and thoughts contribute to psychological distress. Correction distorted thinking. - ANSWER Rational emotive therapy Help others express their feelings toward one another during group sessions. - ANSWER Rogerian therapy "Therapeutic community," has as its focus living, learning, or working environment. Provide safe, therapeutic environment. All treatment team members are viewed significant & valuable to client's successful treatment outcomes. - ANSWER Milieu therapy Based on rewards & punishment - ANSWER Behavior modification Consistent daily routine & low stimulating environment important when disoriented. Use an indirect light source & turn off TV. - ANSWER Delirium becomes disoriented & confused at night

Often withdrawn, experience difficulty concentrating, loss of interest or pleasure, low energy, fatigue, feelings worthlessness & poor self-esteem. Plan of care provide successful experiences in stimulating yet structured environment. - ANSWER Depression Fear situations which one might be embarrassed, criticized; fear of speaking, performing, eating in public. Fears making fool of oneself. - ANSWER Social phobia Fear open spaces & fear of being trapped in situation from which there may not be escape. - ANSWER Agoraphobia Alteration loss of physical function cannot be explained by any known pathophysiological mechanism. Thought to be an expression of psychological need or conflict. - ANSWER Conversion disorder Disturbance or alteration in normally integrative function identity, memory, consciousness - ANSWER Dissociative disorder Facilitates communication by sitting silence, ask open-ended questions rather than direct questions, pausing provide opportunities to respond. - ANSWER Catatonic stupor Prevent from harming self or others. Low-stimulation environment maintain client in calm state. Monitor vital signs closely & report abnormal findings. Reorient to reality frequently & would address hallucinations therapeutically. Adequate nutritional & fluid intake maintained. - ANSWER Withdrawal from alcohol Delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes LOC, agitation, fever, & delusions. - ANSWER Alcohol withdrawl Include loss of or change of job, death of loved one, abortion, change financial status, divorce, addition new family members, pregnancy, & severe illness - ANSWER Situational crisis

Crisis of disaster; it is unplanned or accidental; Witnessing a murder, fire destroyed home, recent rape episode experienced - ANSWER adventitious crisis Administered once every 24 hours. Administered morning or evening, but evening administration may be preferable because drowsiness is side effect. - ANSWER Sertraline (Zoloft); antidepressant Anticonvulsant & hypnotic agent. Avoid taking any other central nervous system depressants such as alcohol while taking medication. - ANSWER Phenobarbital sodium (Luminal) Causes constipation, instructed increase fluid intake & bulk (high fiber) in diet. If heart beats fast, HCP notified could indicate overdose. Diarrhea could indicate incomplete intestinal obstruction HCP notified. - ANSWER Oxazepam (Serax) Cause orthostatic hypotension. Sunlight avoided. Psychotropic med, caution with (driving, other activities requiring alertness) determine if alertness affected. Atypical antipsychotic renal & liver function studies done. - ANSWER Risperidone (Risperdal) maximum therapeutic effect may not occur for 2-3 weeks after antidepressant therapy initiated.

• ANSWER Imipramine (Tofranil) (MAOI) Avoid foods high in tyramine. Ingestion of these foods could trigger potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; fruits such as avocados, raisins, or figs. - ANSWER Phenelzine (Nardil); for depression Can occur from use monoamine oxidase inhibitor; hypertension, occipital headache radiating frontally, neck stiffness & soreness, N&V. - ANSWER Hypertensive crisis Reaction antipsychotic medication. Ucontrollable involuntary movements of body, extremities, mouth, face, & particularly tongue. - ANSWER Tardive dyskinesia

Tremors, masklike facies, rigidity, & shuffling gait. - ANSWER Parkinsonism Potentially fatal syndrome, may occur any time during therapy neuroleptic (antipsychotic) medications. Characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, & skeletal muscle rigidity. - ANSWER Neuroleptic malignant syndrome Affects GI system by causing nausea & vomiting, cramping, & diarrhea. - ANSWER Fluoxetine (Prozac) Effective if absence of these manifestations occurs; Rapid heartbeat or anxiety - ANSWER Buspirone (Buspar); treatment of anxiety Serum level 0.6 to 1.2 mEq/L. Symptoms toxicity appear levels 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage & possible peritoneal dialysis or hemodialysis. Symptoms toxicity; vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, & tremors. - ANSWER Lithium carbonate Tricyclic antidepressant treat obsessive-compulsive disorder. Sedation sometimes occurs. Weight gain & tachycardia side /adverse effects of medication. - ANSWER Clomipramine (Anafranil); treats OCD Seizure activity can occur taking dosage greater 450 mg daily. Weight gain occasional side effect, constipation common side effect. - ANSWER Bupropion (Wellbutrin); antidepressive agent Excitement, euphoria, hyperactivity, excessive energy, decreased need sleep, impaired ability concentrate or complete single train of thought. Mood predominantly elevated, expansive, or irritable. Nonstop physical activity & poor nutritional intake problem. - ANSWER Mania Treat hypoglycemia because it increases blood glucose levels. Family instructed how to administer. Unconscious client, arousal usually occurs within 20 min glucagon injection. When consciousness regained, oral carbohydrates should be given. - ANSWER Glucagon

Mild cognitive deficits to severe, life-threatening alteration neurological function. Confabulation or fabrication events/experiences fill in memory gaps not unusual. Lack inhibitions first indication something "wrong" to significant others. As progresses; difficulty sleeping & episodes wandering/sun downing - ANSWER Dementia Desire please others. Need to be correct or perfect interferes with rational decision-making processes. Moralistic. Rules & rituals help manage anxiety. Observe rigid rules/regulations - ANSWER Anorexia nervosa Best absorbed taken empty stomach with water or vitamin C containing juice. Iron supplements usually cause constipation. Meats excellent source iron. Pregnant client take iron supplements regardless of food intake - ANSWER Iron supplementation If taken with Warfarin sodium; decreased dosage of warfarin. - ANSWER Levothyroxine (Synthroid); prescribed for Hypothyroidism Head neutral, midline position. Head of bed raised to 30 to 45 degrees. Avoid flexing or extending neck or turning head from side to side. - ANSWER Basilar skull fracture risk Increase ICP. Place in which positions? Operative positioned elevated on pillow & not exceeding shoulder elevation. Promotes optimal drainage from limb, without impairing circulation to arm. - ANSWER After undergoing right mastectomy. Place right arm in which position? Acts more rapidly than regular insulin, shorter duration action. Effect begin 25 minutes after subcutaneous injection, peak 0.5 to 1.5 hours, & duration action 5 hours. Because rapid onset, administered 15 minutes to immediately before eating. - ANSWER Lispro insulin (Humalog) Onset action is 1.5 hours, peaks 4 to 12 hours, & duration action 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time. - ANSWER Humulin N is an intermediate-acting insulin

Discontinue wearing contacts until infection cleared completely. New contact lenses eliminate chance reinfection from contaminated contact lenses & would lessen risk corneal ulceration. - ANSWER Conjunctivitis & use of contact lenses Endoscopic procedure surgically remove pituitary tumor through incision in the sphenoid sinus. Brushing teeth not be permitted for at least 2 weeks after surgery to prevent disruption of surgical site. - ANSWER Transsphenoidal hypophysectomy Sometimes age has to do with decision for radiation therapy. Usually delayed until child 8 years old, whenever possible, prevent retardation of bone growth & soft tissue development. - ANSWER Radiation therapy Achieved by Ace wraps, boots, & slings that apply direct force on skin. Traction maintained with 5 to 8 lb of weight, & this type of traction can cause skin breakdown. - ANSWER Skin traction Person puts another person in fear of harmful or offensive contact & victim fears & believes that harm will result as a result of threat. - ANSWER Assault Most common side effect GI disturbances, including decreased appetite, nausea, & diarrhea. These generally subside over time. May lose average of 7-8 lb because medication causes nausea & decreased appetite. - ANSWER Metformin (Glucophage); Type II Diabetes Nocturia, incontinence, & enlarged prostate characteristics & need to be assessed all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males. - ANSWER Benign prostatic hyperplasia For hypothyroidism; Achieve normal thyroid hormone levels - ANSWER Levothyroxine (Synthroid) Early menarche, Family history breast cancer, High-dose radiation exposure to chest, Previous cancer of breast, uterus, or ovaries - ANSWER Risk factors for breast cancer

Most common form nonmechanical obstruction, Inability to pass flatus, pain usually manifests as more constant generalized discomfort. - ANSWER Paralytic ileus Respiratory rate & depth increase to compensate. Headache; restlessness; mental status changes, drowsiness & confusion. Visual disturbances; diaphoresis; cyanosis as hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; & dysrhythmias - ANSWER Respiratory acidosis Elevates head of bed maintain airway patency & prevent aspiration. Apply pressure over bleeding site & call HCP immediately. Monitors airway & vital signs. - ANSWER Hemorrhage from surgical site after radical neck dissection Decreased metabolism low levels of thyroid hormone. Interventions replace hormone. Cold intolerance, requires warm environment. Well-balanced diet low in fat for weight reduction & high in fluids & high-fiber foods to prevent constipation. Notify HCP chest pain because could indication overreplacement thyroid hormone. - ANSWER Hypothyroidism Provide warm environment, consume low-fat diet, well balanced diet, thyroid replacement therapy will be needed. - ANSWER Hypothyroidism Hypertension, cardiovascular disease, diabetes mellitus, & obesity associated with development

• ANSWER Glaucoma Labs do not establish diagnosis but often an elevation white blood cell count (leukocytosis) with shift to left (increased number of immature white blood cells). Sudden relief pain; suspected appendicitis is commonly indicative of ruptured appendix. Risk for peritonitis & shock. HCP notified immediately because need begin IV antibiotics to prevent further complication. NPO in anticipation of surgery. - ANSWER Appendicitis Decrease amount of food taken at each sitting, eat in semirecumbent position, eliminate ingesting fluids with meals, & avoid consumption of high-carbohydrate meals. - ANSWER Chronic dumping syndrome

Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, (NSAIDs), caffeine, alcohol, & stress. Certain medical conditions; Crohn's disease, Zollinger- Ellison syndrome, & hepatic & biliary disease can increase risk. - ANSWER Peptic ulcer disease risk factors Inflammatory disease large colon. Symptom: diarrhea, 10-20 liquid bloody stools per day, weight loss, anorexia, fatigue, increase WBC count, increase erythrocyte sedimentation rate, dehydration, hyponatremia, & hypokalemia. Because loss of blood, decreased hemoglobin & hematocrit levels. Rebound tenderness may indicate peritonitis; report to HCP. - ANSWER Ulcerative colitis Hypertonic solution 5% dextrose in 0.9% normal saline pull fluid into intravascular space; kidneys excrete excess fluid. - ANSWER IV solution client experiencing excess fluid volume secondary to heart failure Isotonic solutions given for fluid replacement - ANSWER Lactated Ringer's & 0.9% normal saline solutions, 5% dextrose in water (D5W) Hypotonic, which pulls fluid into intracellular space. Inappropriate for cerebral edema because hypotonic solutions have potential to cause cellular swelling & cerebral edema. - ANSWER 0.45% normal saline Mechanical ventilator requiring frequent assessment & suctioning - ANSWER registered nurse (RN Skilled wound irrigation & dressing changes - ANSWER Licensed practical (vocational) nurse Collecting 24-hour urine & helping with bed bath & frequent ambulation. - ANSWER Unlicensed assistive personnel (UAPs)

Performed during first few weeks of life. Early repair improve bonding & makes feeding much easier. Revisions may be required at later age. - ANSWER Cleft-lip repair Lie down & place towel/pillow under shoulder on side of breast to be examined. - ANSWER Breast self-examination (BSE) Sebaceous glands located in areola. - ANSWER Montgomery's tubercles of breast. Proximal segment of bowel prolapses into distal segment of bowel. Common cause of bowel obstruction in infants & young children - ANSWER Intussusception Fecal incontinence & major concern if child is constipated. Signs; soiled clothing, scratching or rubbing anal area because of irritation, fecal odor without apparent awareness by child, & social withdrawal. - ANSWER Encopresis Antidiuretic hormone treat; diabetes insipidus,& nocturnal enuresis. Promote renal conservation water acting on collecting ducts of kidney increase permeability to water, results increased water reabsorption. Urine output exceeds 9 L per day generally requires treatment with desmopressin. - ANSWER Desmopressin (DDAVP) Empower staff toward excellence because this style leadership allows nurses opportunity grow professionally - ANSWER Democratic style Allows staff to work without assistance, direction, or supervision. - ANSWER Laissez-faire Task oriented & directive. - ANSWER Autocratic style Reduction of amount & degree of disability, injury, & damage after a crisis. Focused on rehabilitation skills. - ANSWER Tertiary prevention

Keeping crisis from occurring. Activities are actions designed to prevent disease from occurring or to reduce probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, & genetics. Focus on prevention. - ANSWER Primary prevention Reducing intensity & duration of crisis. Screening level that entails such procedures as vision screening, mammography, or similar screening tests. - ANSWER Secondary prevention Circulating levels of estrogen & progesterone are high. - ANSWER Ovulation ceases during pregnancy because? Promote insulin secretion by pancreas & may also increase tissue response to insulin - ANSWER Sulfonylureas Transmitted droplet nuclei. Private room with at least six air exchanges per hour & negative pressure in relation to surrounding areas. Vented to outside & should have ultraviolet lights installed. Cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills & sweats (which may occur at night), & low-grade fever. - ANSWER Tuberculosis (TB) Anti-TB medication given with other anti-tuberculosis medications. Pyrazinamide might not be discontinued if sputum cultures continue to be positive. - ANSWER Pyrazinamide Early signs; localized itching & edema, followed by more severe symptoms such as respiratory distress, stridor, & decreased blood pressure. - ANSWER Signs allergic reaction to contrast dye Flulike symptoms only - ANSWER Three stages associated with viral hepatitis. First (preicteric) stage Appearance jaundice & associated symptoms such as elevated bilirubin levels, dark or tea- colored urine, & clay-colored stools - ANSWER Three stages associated with viral hepatitis. Second (icteric) stage

Jaundice decreases & colors of urine & stool return to normal. - ANSWER Three stages associated with viral hepatitis. Third (posticteric) stage Contraindicated patient with renal impairment (Renal disease) - ANSWER Nitrofurantoin (Macrobid With food can cause N&V. Avoid problem, oral dose administered 1 hour before meals or 2 hours after meals. - ANSWER Bethanechol chloride (Urecholine) Painless vision changes & "tunnel vision. - ANSWER Primary open-angle glaucoma (POAG) Vitamin C (ascorbic acid) increases absorption iron by body. (Orange Juice) - ANSWER Oral iron supplements Enhances reabsorption sodium & chloride ions distal tubules of kidney & excretion potassium & hydrogen ions. Promote water retention. - ANSWER Fludrocortisone acetate (Florinef); prescribed for Addison's disease Communicable period 4 days before to 5 days after rash appears. Small blue-white spots with red base may appear in mouth; Koplik's spots. Respiratory symptoms; profuse runny nose, cough, & fever occur before rash. Rash usually begins on face & spreads downward toward feet

• ANSWER Rubeola (measles)