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NCLEX/RN/NCLEX RN EXAM TEST BANK
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Is a process of learning a different culture to adapt to a new or changing environment. Acculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group Ethnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). Low-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. High risk of obesity & diabetes mellitus
Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. Jehovah's Witnesses Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. Orthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. Five categories of complementary and alternative medicine (CAM): Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her Autocratic leader
Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypophosphatemia Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. Hyperphosphatemia Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. Causes of a fluid volume deficit Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium. Causes of overhydration or fluid overload: Trauma, burns, sepsis, or metabolic or respiratory acidosis. Hyperkalemia causes:
Cushing's syndrome or colitis & over use of laxatives. Hypokalemia causes: Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. Metabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. Metabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD Respiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs.
Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, High Sodium foods: Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. Clear liquid diet: Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices. Full liquid diet: Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes. High Thiamine foods On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart. Suspects air embolism. Should immediately place client in which position?
We have an expert-written solution to this problem! Assess for known allergies to eggs to prevent anaphylaxis. Fat emulsion (lipids) Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately. Hyperglycemia: Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia. Parenteral nutrition; PN monitor Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer) Parenteral nutrition; Patients needing
Dyspnea, a swollen tongue, & cyanosis. Hypersensitivity reaction: Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. PICC line Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray. Central venous catheter insertion: Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia. Systemic infection Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration.
Air embolism Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock Septicemia Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. Platelets Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished. Fire event Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask. Meningococcal pneumonia Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while
Child begins to understand the environment. Paiget's sensorimotor stage Child is able to classify, order, and sort facts. Paiget's concrete operational stage Child learns to think in terms of past, present, & future. Paiget's preoperational stage 20 to 40 breaths/minute Normal respiratory rate in a 12-month-old 90 to 130 beats/minute Normal apical heart rate in a 12-month-old 90/56 mm Hg Average blood pressure in a 12-month-old
Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age Anterior fontane Decreased lean body mass & age-associated decreased glomerular filtration rate. older client is at risk for medication toxicity because Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes. Romberg's test Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing Cheyne-Stokes respirations Physical obstruction to transmission of sound waves Conductive hearing loss
Testing sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. Positive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus. Fetal circulation Connects umbilical vein to inferior vena cava Ductus venosus Is temporary opening between right & left atria. Foramen ovale
Joins the aorta & pulmonary artery Ductus arteriosus Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. Probable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. Positive signs of pregnancy Pregnancy avoided for 1-3 months. Vaccine administered subcutaneous route.Exposure immunosuppressed individuals avoided. Hypersensitivity reaction can occur if client has allergy to eggs. Rubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. Classic signs of preeclampsia
Result from pressure on fetal head during a contraction. Early decelerations Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection. Assessment finding following an amniotomy should be conducted first Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae. Abruptio placentae Symptoms increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. Concealed bleeding Prenatal
Improperly implanted placenta lower uterine segment. Manual pelvic exam contraindicated vaginal bleeding apparent until diagnosis made & placenta previa ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound. Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft abdomen & painless, bright red vaginal bleeding in second/third trimester pregnancy symptom. (Sudden onset painless vaginal bleeding) Placenta previa Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen. Pulmonary embolism is suspected Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated. Cystitis May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Newborn infant with respiratory distress syndrome
