MARK KLIMEK NCLEX EVALUATION SET
QUESTIONS AND ANSWERS SET A+
✔✔PPE take off - ✔✔in ABC order... gloves, goggles, gown, mask!
✔✔PPE put on - ✔✔reverse ABC for the G's, but mask comes 2nd.. gown, mask,
goggles, gloves!
✔✔CRUTCHES: how do you measure? - ✔✔Length of crutch: 2-3 finger widths below
the anterior axillary fold to a point lateral to and slightly in front of the foot.. Hand grip:
when properly set, the elbox flexion will be about 30 degrees
✔✔2 point gait - ✔✔1 crutch/opposite foot.. other crutch/other foot..
✔✔3 point gait - ✔✔moving 2 crutches & the bad leg...
✔✔4 point gait - ✔✔move everything separately
✔✔Swing through gait - ✔✔NON-weight bearing.. *amputations* plant the crutches &
swing through...
✔✔how to pick a gait - ✔✔Even for even; odd for odd = use the even # of gates when
the weakness is evenly distributed... Use 2 point (mild), 4 point (severe).. use odd #
gate (3), when 1 leg is odd.. can't bear weight/amputation = swing through!
✔✔which gait for early stages of RA? - ✔✔2 point gait
✔✔which gait for 1st day post-op R knee replacement with partial weight bearing
allowed? - ✔✔3 point gait
✔✔which gait for bilateral knee replacement? - ✔✔4 point gait
, ✔✔which gait for left hip replacement; 2nd day post op non weight bearing - ✔✔swing
through gait
✔✔Going up and down stairs with crutches: - ✔✔UP with the GOOD, DOWN with the
BAD!
✔✔CANES: - ✔✔Hold the cane on the strong side...
✔✔WALKERS: - ✔✔Pick them up, set them down... If they must tie belongings to the
walker; have them tie it to the side & not the front (can tip over); no wheels/tennis balls
(per boards!)
✔✔what is the first thing you should decide when you have a psych patient question - -
✔✔is my patient NON-psychotic or psychotic
✔✔NON psychotic (neurotic): - ✔✔has insight and reality based; they know they have a
problem... they need "good general therapuetic communication
✔✔psychotic - ✔✔has NO insight & is not reality-based; they don't have a problem/they
aren't sick; they blame everyone else... "unique specific strategies"
SYMPTOMS: delusions, hallucinations & illusions...
✔✔delusion - ✔✔a false fixed idea or belief; there is no sensory component.
✔✔hallucination - ✔✔false fixed sensory (hear, feel, taste, smell, see)
✔✔most common hallucination = - ✔✔auditory.. then visual... then tactile (feeling),
gustatory (taste).. olfactory (smell)
most common auditory = voices telling you to harm yourself.
✔✔A FUNCTIONAL psychosis - ✔✔they can function in every day life (schizophrenia,
schizoaffective disorder, major depression, manic)
✔✔DEMENTIA: - ✔✔the brain is damaged (senile, alzheimers, organic brain syndrome)
✔✔FUNCTIONAL: this person has the potential to learn reality/improve.. Teach ....... -
✔✔reality... Use 4 step process.. acknowledge feeling, present reality, set a limit,
enforce the limit.. Example (answer): FEELING: I see you're angry, you seem upset, tell
me more of how you're feeling... REALITY: I know that the voices are real to you, but
they are not real... I'm a nurse, this is a hospital... SET LIMIT: That topic is off limits in
our converstion.. We aren't going to talk about that.. ENFORCE LIMIT: I see you are too
ill to stay reality based, so our conversation is over
QUESTIONS AND ANSWERS SET A+
✔✔PPE take off - ✔✔in ABC order... gloves, goggles, gown, mask!
✔✔PPE put on - ✔✔reverse ABC for the G's, but mask comes 2nd.. gown, mask,
goggles, gloves!
✔✔CRUTCHES: how do you measure? - ✔✔Length of crutch: 2-3 finger widths below
the anterior axillary fold to a point lateral to and slightly in front of the foot.. Hand grip:
when properly set, the elbox flexion will be about 30 degrees
✔✔2 point gait - ✔✔1 crutch/opposite foot.. other crutch/other foot..
✔✔3 point gait - ✔✔moving 2 crutches & the bad leg...
✔✔4 point gait - ✔✔move everything separately
✔✔Swing through gait - ✔✔NON-weight bearing.. *amputations* plant the crutches &
swing through...
✔✔how to pick a gait - ✔✔Even for even; odd for odd = use the even # of gates when
the weakness is evenly distributed... Use 2 point (mild), 4 point (severe).. use odd #
gate (3), when 1 leg is odd.. can't bear weight/amputation = swing through!
✔✔which gait for early stages of RA? - ✔✔2 point gait
✔✔which gait for 1st day post-op R knee replacement with partial weight bearing
allowed? - ✔✔3 point gait
✔✔which gait for bilateral knee replacement? - ✔✔4 point gait
, ✔✔which gait for left hip replacement; 2nd day post op non weight bearing - ✔✔swing
through gait
✔✔Going up and down stairs with crutches: - ✔✔UP with the GOOD, DOWN with the
BAD!
✔✔CANES: - ✔✔Hold the cane on the strong side...
✔✔WALKERS: - ✔✔Pick them up, set them down... If they must tie belongings to the
walker; have them tie it to the side & not the front (can tip over); no wheels/tennis balls
(per boards!)
✔✔what is the first thing you should decide when you have a psych patient question - -
✔✔is my patient NON-psychotic or psychotic
✔✔NON psychotic (neurotic): - ✔✔has insight and reality based; they know they have a
problem... they need "good general therapuetic communication
✔✔psychotic - ✔✔has NO insight & is not reality-based; they don't have a problem/they
aren't sick; they blame everyone else... "unique specific strategies"
SYMPTOMS: delusions, hallucinations & illusions...
✔✔delusion - ✔✔a false fixed idea or belief; there is no sensory component.
✔✔hallucination - ✔✔false fixed sensory (hear, feel, taste, smell, see)
✔✔most common hallucination = - ✔✔auditory.. then visual... then tactile (feeling),
gustatory (taste).. olfactory (smell)
most common auditory = voices telling you to harm yourself.
✔✔A FUNCTIONAL psychosis - ✔✔they can function in every day life (schizophrenia,
schizoaffective disorder, major depression, manic)
✔✔DEMENTIA: - ✔✔the brain is damaged (senile, alzheimers, organic brain syndrome)
✔✔FUNCTIONAL: this person has the potential to learn reality/improve.. Teach ....... -
✔✔reality... Use 4 step process.. acknowledge feeling, present reality, set a limit,
enforce the limit.. Example (answer): FEELING: I see you're angry, you seem upset, tell
me more of how you're feeling... REALITY: I know that the voices are real to you, but
they are not real... I'm a nurse, this is a hospital... SET LIMIT: That topic is off limits in
our converstion.. We aren't going to talk about that.. ENFORCE LIMIT: I see you are too
ill to stay reality based, so our conversation is over
