NCLEX Notes

Notes I got from allnurses.com, thank you very for sharing this and so I will share to others, too. 




RN 
- Invasive procedure = I AM RN EDUCATED
- Initial/Comprehensive/Baseline (assessments)

- Assess (FREQUENT/ONGOING =UNSTABLE Patients)
- MANAGING and LEADING client care environment
Ex. Clients who are in severe and Refusing Meds (needs more assessment)

- Review
- NSG Process/ NSG Judgement Use (APIE= Assessment,Planning, Implementation,Evaluation)

- Encourage
- Develop
- Use Of IV meds (ex. plasma, blood products-- these and IV are done by RN only)
- Consult/Counsel/Suggest & Update
- ADMISSION .. NEW & POST OP
- Teach 
- Educate 
- DISCHARGE & ADMISSION Preparation

LPN/LVN- 
-Certain Invasive Task =I-SOUND STAR CROSS ++
- IM adm

- SQ adm.
- ORAL meds adm 
- URINARY CATHETERIZATION
- Nitroglycerin
- DREASSING of WOUND (CHANGING & IRRIGATING) very commonly seen Q.
- SUCTIONING
- TUBE FEEDING
- Auscultate/Listen
- Routine/Standard

- Check(s) 
- Reinforce/remind
- Observe 
- Set up (basic equipment)
- Specimen Collection & Data Colletion 
+
-Blood glucose readings
-Monitor
-Review/Teach-- Usually standard practices (hand washing/hygiene) or med administration (ie. eye drops) -- RN mostly teaches/educated and LPNs Reinforce
+
CAST & TOE Amputation are stable clients and need on going assessment and pain mgt./La Charity Book(Don’t know too..just dont deprive with it.. just follow the book
Data Collection such as LISTENING to LUNG SOUNDS & CHECKING for PERIPHERAL EDEMA_Part of LPN scope of practice: /LaCharity Book
** Don't assign LVN/LPN to do a task an nurse assistant can complete**

NURSING ASSISTANT/UAP- Unlicense assistive personnel
- Non Invasive procedure/Basic Care =SPARRTACUS GROAM +++
-SKIN CARE (ex. bed rest with a skin tear and hematoma from a fall 2 days ago, Apply and care for a client’s rectal pouch )
-POSITIONING-- Special positioning-- requires initial education by RN -- assistant will assist not teach
-AMBULATION/ Assisting with ADL (AMBULATION of FRACTURED HIP only RN& PT) ( Patienst with CHESTUBE ambulating the hall-LPN/LVN)
-RECORDING & MONITORING of V/S (BP,Pulse, Oxygen sat,)
-RANGE OF MOTION &EXERCISE
-TRANSPORT OF CLIENT
-ASSIST (Assisting for Prep for SITZ Bath)
-COLLECTION OF 
-URINE &
-STOOL
-GROAM (Groaming & Hygiene Measure, Bathing & checking water temp)
+
WEIGHTING
INTAKE & OUTPUT
FEEDING 
+ 
- Remind/Reinforce: usually reminds pt. TO do something rather than HOW to do it (skills previously taught by other health care professional or precaution measures)***
- They can detach suction and remove a foley but not connect or insert
- Gather (equipment)
+
- Measurement of ankle and bracial blood pressure for ankle brachial index calculation.(Calculated already)
( Calculation on the ankle-brachian index is responsibility of RN)
-Experienced Nsg Assistant should have been taught how to..
Monitor Apical Pulse, However, the RN should observe to be sure that s/he mastered this skills.
---La Charity Book---

NEW RN
-Education and hospital orientation includes.. SAFE administration of IV meds.
-STABLE PATIENTS

SOME KEY POINTS:
Patients that require teaching about drugs or need procedures done are NOT RN priority. 

PHYSICIAN
-Informed Consent
-Medical diagnosis
-Prescriptions
-Order procedures

Avoid These Assignments for New/Float/LVN/LPN/Traveling
-New onset/sudden/acute
-New admission
-Transfer
-Newly diagnosed
-Discharge
-Require education/teaching (beyond basic skills -- tend to be complex and specific to patients on that particular unit)
- Unstable (ie. High risk of sudden respiratory failure, or requires frequent assessments and changes in therapy(like electrolyte imbalances)
Give:
- Chronic
- Routine meds/procedures
- Stable

Top 10 Things Your Doctor Won’t Tell You

As I was browsing my facebook, I saw this post and I just would like to share it to others because its very informative. It is good to know this facts and be responsible to our own health.

Top 10 Things Your Doctor Won’t Tell You: Click anywhere below to display a larger poster on your screen.

Source: http://wellbody.net/2012/02/27/top-10-things-your-doctor-wont-tell-you/

Practice..

http://nclexreviewers.com/nclex-sample-questions/psychosocial-adaptation/nclex-questions-for-psychosocial-integrity.html

Score: 14/15

1. When a depressed client becomes more active and there is evidence that her mood has lifted, an appropriate goal to add to the nursing care plan is to

a. Encourage her to go home for the weekend.
b. Move her to a room with three other clients.
c. Begin to explore the reasons she became depressed.
d. Monitor her whereabouts at all times.

2. One day the nurse overhears a client with the diagnosis of schizophreniatalking to herself. She is saying, “The mazukas are coming. The mazukas are coming.” Her use of the word mazuka is most likely

a. An example of associative looseness.
b. A manifestation of dyslexia.
c. A neologism.
d. Flight of ideas.

3. Persons with personality disorders tend to be manip ulators. Which principle is it important for the nurse to know in planning the care of a person with this diagnosis?

a. The nurse should appeal to the client’s sense of loyalty in adhering to the rules of the community.
b. When the client’s manipulations are not successful, anxiety will increase.
c. The establishment of a nurse-client relationship will decrease the client’s manipulations.
d. The nurse should allow manipulation so as to not raise the client’s anxiety.

4. The best explanation for the term depersonalization, as seen in schizophrenics, is

a. A flight from reality related to oneself or the environment.
b. A mechanism seen in chronic schizophrenia.
c. The client cannot tolerate personal relationships.
d. The client personalizes all threats and uses projection.

5. A 16 year old is hospitalized for adolescent adjustment problems. After assessing her, the nurse’s first objective is to establish a nurse-client relationship. The next day, the nurse is late for the appointment. Knowing that the client has difficulty assuming responsibility for her own behavior, the nurse would like to use this situation as an opportunity for role modeling. The most appropriate statement the nurse could make is

a. “Oh, you are here. I thought we’d be arriving at the same time.”
b. “What do you mean you are angry with me? I bet you keep people waiting.”
c. “Thank goodness you are still here; I just had a flat tire.”
d. “I’m late. I apologize.”

6. A client has the diagnosis of cognitive disorder-Alzheimer’s disease. The client is constantly making up stories that are untrue. This characteristic of the disease is called

a. Lability.
b. Memory loss.
c. Confabulation.
d. Senility.

7. A 60-year-old male client has been admitted to the psychiatric unit, with symptoms ranging from fatigue, an inability to concentrate, an inability to complete everyday tasks, to refusal to care for himself and preferring to sleep all day. One of the first interventions should be aimed at

a. Talking to his wife for cues to help him.
b. Encouraging him to join activities on the unit.
c. Developing a structured routine for him to follow.
d. Developing a good nursing care plan.

8. The treatment in crisis intervention centers is specifically intended to help clients

a. Make long-range plans for the future.
b. Return to prior levels of functioning.
c. Accept their illness.
d. Understand the dynamics underlying symptoms.

9. A female client has just received the diagnosis of hypochondriasis. This client continually focuses on gastrointestinal problems and constantly rings for a nurse to meet her every demand. The best nursing approach is to

a. Assign various staff members to work with the client so no staff member will become negative.
b. Anticipate the client’s demands and spend time with her even though she does not demand it.
c. Ignore the demands because the nurse knows it is not necessary to respond.
d. Provide for the client’s basic needs, but do not respond to her every demand, which reinforces secondary gains.

10. A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, “I’m feeling sad. I don’t want to talk now.” The nurse’s best response would be

a. “It will help you feel better if you talk about it.”
b. “Sometimes it helps to talk.”
c. “I’ll stay with you a few minutes.”
d. “I’ll come back when you feel like talking.”

11. When the nurse is talking with a schizophrenic client, she suddenly says, “I’m frightened, do you hear that? Terrible things.” Which initial response by the nurse would be most appropriate?

a. “Who is saying terrible things to you.”
b. “I don’t hear anything, but you do seem frightened.”
c. “I don’t hear anything.”
d. “What is someone saying to you?”

12. When assessing a client for possible suicide, an important clue would be if the client

a. Is hostile and sarcastic to the staff.
b. Begins to talk about leaving the hospital.
c. Identifies with problems expressed by other clients.
d. Seems satisfied and detached.

13. A depressed client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. The most appropriate nursing action is to

a. Tell her the rules of the unit are that no client can remain in bed.
b. Suggest she better get out of bed or she will go hungry later.
c. Allow her to remain in bed until she feels ready to join the other clients.
d. Tell her that the nurse will assist her out of bed and help her to dress.

14. A client is suffering from post-traumatic stress disorder following a rape by an unknown assailant. One of the primary goals of nursing care for this client would be to

a. Establish a safe, supportive environment.
b. Discuss the client’s nightmares and reactions.
c. Control aggressive behavior.
d. Deal with the client’s anxiety.

15. A client has the diagnosis of manic episode. Her disruptive behavior on the unit has been increasingly annoying to the other clients. One intervention by the nurse might be to

a. Set limits on the client’s behavior and be consistent in approach.
b. Ignore the client’s behavior, realizing it is consistent with her illness.
c. Tell the client she is annoying others and confine her to her room.
d. Make a rigid, structured plan that the client will have to follow.

1. D. The goal is to implement suicide precautions because the danger of suicide is when the depression lifts and the client has the energy to formulate a plan. The nurse would not encourage her to go home (1) where she could not be observed constantly. She could be moved into a room with other clients (2), but this is not the priority concern.

2. C. Mazuka is a made-up word or neologism. This characteristic is frequently present with the disorder and is a part of associative looseness. Answer (1) is not incorrect, but answer (3) is more specific. Flight of ideas is observed with a manic episode.

3. B. Because a person with this disorder tends to manage his or her life through manipulation of others, when it doesn’t work, the anxiety level goes up. The nurse should never allow the client to manipulate. Answers (2) and (4) are not true.

4. A. Depersonalization is the feeling or subjective experience of separating oneself or alienation; it is also the state in which the client cannot distinguish the self from others and involves disintegration of the ego-often observed in schizophrenics as a flight from reality.

5. D. Assuming responsibility for one’s behavior includes acknowledging the behavior and may include a statement of one’s current status. It does not include making excuses, focusing outside of oneself, or blaming another.

6. C. When clients make up stories or lies, it is called confabulation. This is an attempt to fill in memory gaps caused by the destruction of the neurons. This process protects their self-esteem and should not be discouraged or confronted.

7. C. While a good nursing care plan is important, the priority would be to get the client mobilized. Even without a specific diagnosis, the nurse will realize that part of what is happening with the client is a depressed mood. Providing a structured plan of activities for the client to follow will help his mood to lift and provide a focus so that he will not be centered on internal suffering.

8. B. The major goal in crisis treatment centers is to have the client return to a prior level of functioning. At this time in a crisis, it is not therapeutic to work on the dynamics underlying the symptom (2) or make long-range plans (3). Accepting their illness (4) may be a part of returning to a prior level of functioning.

9. B. Anticipating demands (rather than ignoring them) from a hypochondriacal client will break the pattern of demanding behavior. These clients are usually fearful and anxious. Spending time with the client will be reassuring and therapeutic. Assigning various staff members (2) may be useful so no one will become overwhelmed, but it is not the primary approach.

10. C. Simply offering comfort by staying with the client and being open for communication is the most therapeutic. The other responses place an additional burden on the client if she does not wish to talk.

11. B. The best response when a client has the diagnosis of schizophrenia is to validate reality by saying the nurse doesn’t hear anything and then to explore real feelings, like fear. Answer (1) is not enough to be therapeutic; answers (2) and (4) give validity to the voices if, in fact, the client is hallucinating.

12. D. Most suggestible of suicide is the sudden sense of satisfaction or relief (perhaps from finally making the decision to commit suicide) and detachment. Hostility (1), identifying with others (2), or thinking of the future (4) do not as clearly suggest suicidal thinking.

13. D. Be positive, definite, and specific about expectations. Do not give depressed clients a choice or try to convince them to get out of bed. Physically assist the client to get up and dressed to mobilize her. Do not allow her to remain in bed (4) or try to convince her by quoting the rules of the unit (1).

14. A. A goal for this disorder should be broad-based and general, like establishing a safe, supportive environment. Other answers would more directly refer to implementation of the goal strategies.

15. A. Setting limits is important to avoid rejection of the other clients with subsequent lowering of self-esteem. Confronting the client (1) will not be productive and may just increase the annoying activity. Ignoring the behavior (2) will also be nontherapeutic, and the other clients on the unit will become even more hostile. This client will not be able to follow a rigid plan.