Nclex review Uworld

 Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is therefore used only in clients with treatment-resistant schizophrenia. must have their WBC and ANC monitored regularly throughout the course of therapy (initially once every week). the health care provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying infection from neutropenia. also cause metabolic syndrome (weight gain, hyperlipidemia, insulin resistance/diabetes) and seizures.  Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be calculated  Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased blood glucose) should be monitored  Dyslipidemia—a lipid profile should be obtained A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should:  Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors  Administer stool softeners to reduce strain during bowel movements (Option 1)  Reduce exertion, maintain strict bed rest, assist with activities of daily living  Maintain head in midline position to improve jugular venous return to the heart Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to infection. Treatment typically includes:  Corticosteroids and other immunosuppressants (eg, cyclosporine)  Loss of appetite management by making foods fun and attractive  Infection prevention (eg, limiting social interaction until the child is better) Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome:  Massive proteinuria – caused by increased glomerular permeability  Hypoalbuminemia – resulting from excess protein loss in the urine  Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities  Hyperlipidemia – related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit. Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications. The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours. Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock. Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia. Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Central chemoreceptors located in the respiratory center of the brain (medulla) respond to changes in blood carbon dioxide and hydrogen ions by either increasing or decreasing ventilation to normalize the pH. When the receptors sense a low pH (acidosis), ventilation increases to rid the body of excess carbon dioxide; when the receptors sense a high pH (alkalosis), ventilation decreases to retain carbon dioxide. Peripheral chemoreceptors located in the carotid and aortic bodies respond to low levels of oxygen and stimulate the respiratory center to increase ventilation. Many clients with COPD breathe because their oxygen levels are low rather than because carbon dioxide levels are high. This is commonly referred to as the hypoxemic drive. If they receive too high a level of inspired oxygen, this drive can be blunted. It is therefore important for these clients to receive a "guaranteed" amount of oxygen as an increase in inspired oxygen can decrease the drive to breathe. To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified, guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is the most appropriate intervention to promote adequate gas exchange. Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). (Option 3) As with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water," is painless. (Option 4) Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix. Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people. The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage participation in activities that require some interaction with others. Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following:  Inappropriate, flat, or bland affect, and apathy  Emotional ambivalence, disheveled appearance  Inability to establish and move toward goal accomplishment  Lack of energy, pacing and rocking, odd posturing  Regressive behavior, inability to experience pleasure  Seeming lack of interest in the world and people It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage day-to-day social interactions. The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with psychotropic medications; negative symptoms tend to persist even with medication. Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia. Ankylosing spondylitis (AS) is an inflammatory disease affecting the spine that has no known cause or cure. AS is characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. The client with AS should do the following:  Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports (Option 2)  Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications (Option 3)  Manage pain with moist heat and nonsteroidal anti-inflammatory drugs (NSAIDs)  Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility (Option 1) It is best to rest during flare-ups. The client should wait to exercise until the pain and inflammation are under control. (Option 4) Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity. (Option 5) Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset. Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients. Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109 /L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes:  Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1).  Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes lowimpact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2).  Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4). (Option 3) Clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5) Clients with ITP should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management. Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in theAirway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention. surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes. Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal (Option 3). Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following:  Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3)  Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms  Reduce stress and avoid alcohol use  Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep.  In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary  Buerger's disease (thromboangiitis obliterans) is a nonatherosclerotic vasculitis involving the arteries and veins of the lower and upper extremities. It occurs most often in young men (age <45) with a long history of tobacco or marijuana use and chronic periodontal infection, but no other cardiovascular risk factors.  Clients experience thrombus formation, resulting in distal extremity ischemia, ischemic digit ulcers, or digit gangrene. They often have intermittent claudication of the feet and hands. Over time, rest pain and ischemic ulcerations may occur. Many clients also develop secondary Raynaud phenomenon (cold sensitivity).  The mainstay treatment of Buerger's disease is the cessation of all tobacco and marijuana use in any form. Nicotine replacement products (eg, nicotine patch) are contraindicated. However, bupropion and varenicline can be used for smoking cessation. Clients may have to choose between continued use of tobacco and marijuana and their affected limbs. Conservative management includes avoidance of cold exposure to affected limbs, a walking program, antibiotics for any infected ulcers, analgesics for ischemic pain, and avoidance of trauma to the extremities.  (Option 1) Clients should avoid exposure to cold (not warm) weather to prevent vasoconstriction and worsening of symptoms.  (Option 2) Statins do not provide much benefit as this is a vasculitis and not an atherosclerotic condition.  (Option 3) Warfarin is an anticoagulant and is not indicated in the treatment of Buerger's disease. Calcium channel blockers, cilostazol, and sildenafil have been used, but there is insufficient evidence to support their effectiveness. Intravenous iloprost has been shown to improve rest pain, promote healing of ulcers, and decrease the need for amputation.  Educational objective: Buerger's disease is a nonatherosclerotic vasculitis involving small to medium arteries and veins of the upper and lower extremities. Young male smokers are typically affected. Clients should avoid exposure to cold weather and cease using tobacco and marijuana in all forms. Smoking cessation can be achieved with bupropion or varenicline but not with nicotine replacement products. Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach – for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) 2. Avoid antacids or dairy products – tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) 3. Take with a full glass of water – tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity – severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: 1. Allergic contact dermatitis (rash, itching, vesicles) developing 3–4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). 2. Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include: o Glove use o Procedures involving balloon-tipped catheters (eg, arterial catheterization) o Blowing up toy balloons o Use of bottle nipples, pacifiers o Use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation. Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby. Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium)