NCLEX STUDY GUIDE

The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory reporting. Signs of abuse may include:  Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)  Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid  Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)  Injuries to genitalia  Lapsed time between the injury and the time when care is sought  Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) (Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures within the home to prevent future injury. Educational objective: The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws. Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may refuse treatment or aid out of fear of being harmed. Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged food (Option 4). Educational objective: Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened, individually packaged food to promote adequate intake without reinforcing delusions. Steps for indwelling urinary catheter insertion for the male client include:  Perform hand hygiene and open sterile catheterization kit (Option 3).  Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).  Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks.  Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now considered contaminated and remains in this position for duration of procedure (Option 6).  Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).  Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).  Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced. Educational objective: To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon. Allowing family to be present during resuscitative efforts and invasive procedures can help the family process and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's way) and another nurse should explain the treatment measures that are occurring (Option 1). Educational objective: During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire. 1 Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in the case of a poor outcome. Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line–related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis. In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4). Educational objective: When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery (Option 3). Educational objective: When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is immunocompromised in a room with a client who has an active or suspected infection. Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a person to make decisions on their behalf. Educational objective: Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for medical care are honored over the wishes of family members. Suicide risk & protective factors Risk factors  Psychiatric disorders, prior suicide attempts  Hopelessness  Never married, divorced, separated  Living alone  Elderly white man  Unemployed or unskilled  Physical illness  Family history of suicide, family discord  Access to firearms  Substance abuse, impulsivity Protective factors  Social support/family connectedness  Pregnancy  Parenthood  Religion & participation in religious activities