NCLEX UWORLD NOTES
PRE-ASSESSMENT EXAM
1. Signs of child abuse
1. Shaken Baby Syndrome (irritability or lethargy, poor feedig, emesis, seizures)
2. Burns in the shape of household items, from cigarettes, or from immersion in scalding
liquid
3. Repeated injuries in varied stages of healing (bruises, burns, fractures)
4. Injuries to the genitalia
5. Lapsed time between the injury and the time care is sought.
6. Inconsistency between the injury and the caregiver’s explanation of the injury (clients
developmental stage, mechanism of injury)
*toddlers and young children are prone to many accidental injuries (aspiration or poisoning from
foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table)
*RN should instruct the caregivers on child safety measures within the home to prevent future injury.
2. Room assignments
Remember that a client with an ACTIVE OR SUSPECTED INFECTION SHOULD NOT BE PAIRED
WITH A CLIENT WHO HAS A FRESH SURGICAL WOUND OR IMMUNOCOMPROMISED.
*a client with uncontained or excessive excretions, drainage, or secretions (profuse diarrhea,
intractable diarrhea, draining wounds) is more likely to spread infection, if present, should be
assigned to a private room.
3. Advanced Directives
- Outlines the client’s choices for medical care (CPR, mechanical ventilation) ahead of time.
- This allows the family and healthcare team to FOLLOW THE CLEINT’S WISHES at the end of
life, when the client may be unable to make choices known. *WITH AN (AD) IN PLACE, THE
, CLIENT’S WISHES ARE FOLLOWED, EVEN IF THEY CONFLICT WITH THE WISHES OF LOVED
ONES.
- RN’S must ADVOCATE for client’s wishes, even if family members are in disagreement.
4. Suicide risks and assessment
Clients receiving treatment for depression and suicidal ideation must be carefully monitored for
indications of increasing suicidal intent. The RN should assess
- Access to psychiatric medications
- Availability of help during crisis (counselor, family)
- Future goals and plans
- Home and work environment risks
- Overall affect and level of energy
- Possible access to weapons
*clients who articulate lone-term personal goals and family milestones are less likely
to commit suicide.
*clients feel more energetic after beginning treatment, yet thoughts of suicide may
not have fully resolved and the client may now have the energy to follow through
suicide plans.
*”No harm/ no suicide” contracts are widely used in clinical practice to support a
client’s ability to avoid acting on suicidal thoughts. These agreements DO NOT
GUARANTEE SAFETY AND ARE NOT BEST INDICATOR OF DECREASED SUICIDE RISK.
,5. Steps for male indwelling catheter insertion
,
PRE-ASSESSMENT EXAM
1. Signs of child abuse
1. Shaken Baby Syndrome (irritability or lethargy, poor feedig, emesis, seizures)
2. Burns in the shape of household items, from cigarettes, or from immersion in scalding
liquid
3. Repeated injuries in varied stages of healing (bruises, burns, fractures)
4. Injuries to the genitalia
5. Lapsed time between the injury and the time care is sought.
6. Inconsistency between the injury and the caregiver’s explanation of the injury (clients
developmental stage, mechanism of injury)
*toddlers and young children are prone to many accidental injuries (aspiration or poisoning from
foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table)
*RN should instruct the caregivers on child safety measures within the home to prevent future injury.
2. Room assignments
Remember that a client with an ACTIVE OR SUSPECTED INFECTION SHOULD NOT BE PAIRED
WITH A CLIENT WHO HAS A FRESH SURGICAL WOUND OR IMMUNOCOMPROMISED.
*a client with uncontained or excessive excretions, drainage, or secretions (profuse diarrhea,
intractable diarrhea, draining wounds) is more likely to spread infection, if present, should be
assigned to a private room.
3. Advanced Directives
- Outlines the client’s choices for medical care (CPR, mechanical ventilation) ahead of time.
- This allows the family and healthcare team to FOLLOW THE CLEINT’S WISHES at the end of
life, when the client may be unable to make choices known. *WITH AN (AD) IN PLACE, THE
, CLIENT’S WISHES ARE FOLLOWED, EVEN IF THEY CONFLICT WITH THE WISHES OF LOVED
ONES.
- RN’S must ADVOCATE for client’s wishes, even if family members are in disagreement.
4. Suicide risks and assessment
Clients receiving treatment for depression and suicidal ideation must be carefully monitored for
indications of increasing suicidal intent. The RN should assess
- Access to psychiatric medications
- Availability of help during crisis (counselor, family)
- Future goals and plans
- Home and work environment risks
- Overall affect and level of energy
- Possible access to weapons
*clients who articulate lone-term personal goals and family milestones are less likely
to commit suicide.
*clients feel more energetic after beginning treatment, yet thoughts of suicide may
not have fully resolved and the client may now have the energy to follow through
suicide plans.
*”No harm/ no suicide” contracts are widely used in clinical practice to support a
client’s ability to avoid acting on suicidal thoughts. These agreements DO NOT
GUARANTEE SAFETY AND ARE NOT BEST INDICATOR OF DECREASED SUICIDE RISK.
,5. Steps for male indwelling catheter insertion
,
