The Lean Machine: NCLEX RATIONALEs #1. Autonomy is the right of individuals to take action for themselves. Beneficence is duty to help others by doing what is best for them, whereas negligence is a legal term. Veracity is truthfulness. Privacy is the nondisclosure of information by the health care team. A Nurse Practice Act serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills the responsibility to protect the public is by defining the scope of nursing practice in that state. The state’s board of nursing approves schools to operate but does not accredit them. It does not enforce ethical standards. Braxton- Hicks contractions are probably caused by stretching of the myometrium. They are usually relieved by position changes, frequent emptying of the bladder, resting in a lateral recumbent position, and walking or light exercise. The dye used in angiography is nephrotoxic, and a client should have adequate fluids after the procedure to eliminate the dye. The client should lie with the affected leg extended for 6 to 8 hours. Leg exercises are not recommended because exercise could disrupt the clot that formed at the insertion site. Option 1 is incorrect because it gives false reassurance to a client who could be at risk if fluids are not taken in. Compression stockings exert pressure on the veins of the lower extremities, promoting venous return back to the heart. Stockings are removed for at least an hour per day to allow for inspection and ensure blood flow through small, superficial vessels. Flexing the extremities does not aid tissue perfusion, although it maintains joint range of motion. However, after this surgery clients are taught to either stand or lie down and avoid flexing at the hip and knee. Numbness is a temporary or rarely permanent complication of surgery. Briskly scrubbing the extremities will not aid tissue perfusion. The final stage of the atherosclerotic process is the development of atheromas, which are complex lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular waste, and capillaries. The calcified lesions may rupture or ulcerate, stimulating thrombosis. The other options are not consistent with the ultimate or final changes in the atherosclerotic process. Leg pain (also called intermittent claudication) is a primary manifestation of peripheral arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, resulting in tissue hypoxia. Peripheral edema and brownish discoloration to the skin on the leg would be consistent with venous disease, not arterial disease. The 38 organisations participating in the Sheep CRC highly value the CRC framework as it provides them with direct input into the research, avoids duplication, and. GUIDELINES FOR CONSISTENCY MODIFICATIONS OF FOODS AND LIQUIDS. Alterations to the consistency of foods and/ or liquids presented to the individual are. Widened pulse pressure would be an unrelated finding. Nicotine in cigarettes promotes vasoconstriction. The three most significant risk factors for development of peripheral arterial disease are smoking, hyperlipidemia, and hypertension. The presence of dysrhythmias, low- protein intake, and exposure to cool weather are not risk factors for the disease, although cool weather could worsen the symptoms when disease is already present. Aneurysms vary by size and location. Signs of rupture depend on the location of the aneurysm. Dissection can occur anywhere but most often occurs in the ascending aorta where pressure is the highest. The medication the client is receiving is vague and is not directly related. The blood pressure relates to whether the aneurysm may rupture, not to the associated signs and symptoms. The age and gender of the client are unrelated to the size and symptoms of aneurysm rupture. An important outcome in care of the hypertensive client is the ability to identify and counteract personal risk factors that the client has the ability to change. A mechanical soft diet is made up of foods that are easy to chew and swallow. It's useful for people who have trouble chewing food, perhaps while learning to use. And whether the individual has a colostomy. Chronic hoarseness and dysphagia should raise suspicion of a hiatus hernia with impaired esophageal sphincter tone. Atherosclerosis Definition Atherosclerosis is the build up of a waxy plaque on the inside of blood vessels. In Greek, athere means gruel, and skleros means hard. Free NCLEX practice review exam questions and answers with reasoning/explanation. Actual NCLEX questions and problems. Free NCLEX tutorial. Free NCLEX practice review. Modifiable risk factors for hypertension include smoking, hypercholesterolemia, diabetes mellitus, sedentary lifestyle, obesity, stress, and alcohol use. Option 1 is not likely to be an issue. Option 3 may or may not be sufficient. Option 4 is contraindicated. The client should avoid long periods of standing or sitting to promote adequate blood flow. The legs and feet should be below heart level to increase peripheral circulation. Regular exercise enhances development of collateral circulation, increases vascular return, and is recommended for clients with either arterial or venous insufficiency. Moist heat is helpful for venous problems. The client is exhibiting symptoms of acute arterial occlusion. Without immediate intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg to maintain warmth and protect it from further injury, and should then quickly notify the physician. The leg should not be elevated above heart level because doing so would worsen the tissue ischemia, and passive range of motion will also increase ischemia by increasing tissue demand for oxygen. The client with venous ulcers must keep the legs elevated above the level of the heart as much as possible. Elevation of the extremities enhances venous return and improves circulation, providing oxygen and nutrients to the lower extremities. The client with a leg ulcer should avoid exercise to prevent further damage to tissues at risk. Option 1 may or may not be indicated. Asepsis is important, but no ulcer will heal unless the edema and stagnant tissue metabolites can be reduced through leg elevation. Heat may relieve pain caused by increased joint mobility resulting from hormonal changes. Aspirin (option 3) should be avoided in the last trimester because it increases bleeding time. Option 1 is not a therapeutic communication. Option 2 may not be helpful for maternal–fetal circulation because the gravid uterus may cause pressure on the great vessels in the abdomen. The client should lie on one side; often the left is advised. A major risk factor for formation of thrombophlebitis is oral contraceptive use in women who smoke. Being 1- week postpartum does not place a client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent development of thrombi. Laparoscopic surgical procedures are associated with more rapid recovery times with reduced immobility, keeping this client at lower risk than the client in option 3. The open ductus arteriosus will allow a small amount of mixing of oxygenated and unoxygenated blood. Stress will increase the cardiac workload and therefore is a priority for the nurse to avoid. Maintaining caloric intake and comfort are the next priorities using Maslow’s hierarchy. Documenting vital signs is a routine activity and not a priority when compared to actual care activities. The main complication of rheumatic fever is carditis. The nurse must assess for early signs of bacterial endocarditis. The client should be encouraged to rest during the acute phase, and hydration needs may not be sufficiently met with sips of water. Narcotic analgesics may not be necessary, although NSAIDs are likely to be ordered. Decreased circulation to lower extremities would contribute to muscle fatigue and pain in the legs. Many of the children returning from recess will have increased respiratory rate secondary to play activities. Blurred vision and bruises are not related to coarctation. Salicylates prevent platelet agglutination. Gastrointestinal bleeding is often a side effect of aspirin therapy. It is not necessary to avoid other children. Tingling of extremities is not a concern, although ringing in the ears could be a sign of salicylate toxicity. A low- calorie diet is not indicated. Allowing mobility is helpful to promote growth and development in the toddler. Strategies should be discussed to promote mobility while maintaining the supplemental oxygen. Options 1 and 4 are unnecessary. Signs of oxygen toxicity are not the priority based on the information in the question. The client would exhibit pain, pallor of the affected skin, diminished or absent radial pulse, parasthesias (altered local sensation), paralysis (weakness or inability to move extremity), and poikilothermia (cooler temperature). The client would not have a bounding radial pulse (opposite finding is true) or pitting edema, indicating a fluid volume excess or heart failure. A positive Kernig’s sign is common in intracranial hematomas, which is described in option 1. Option 2 is a negative Babinski; with a hematoma, the nurse should expect a positive Babinski (dorsiflexion of the toes in an adult). Option 3 is common in many illnesses; option 4 is specific to Parkinson’s disease. Corneal abrasion in the client with myasthenia gravis is caused by dryness of the cornea from inability to close the eyelids and blink. It can be prevented by application of artificial tears every 1 to 2 hours. The other options do not address this need. The nurse should first encourage the client experiencing a loss to express his or her feelings. This answer acknowledges the client’s feelings, is open- ended, and promotes further discussion. Option 2 provides false reassurance. Options 3 and 4 do not address the client’s feelings as shared with the nurse. The doula is a trained professional who provides physical and emotional support during labor. A doula does not replace either the father or the labor and delivery nurse in the delivery room. The doula is not responsible for clinical tasks and will not deliver the baby. When the muscles involved in chewing and swallowing as well as the diaphragm and intercostal muscles are weak, the client may aspirate or experience poor gas exchange; both increase the risk for pneumonia. Options that protect the airway always have highest priority. The client is not at risk for hemorrhage (option 1) or pneumonia (option 2). Option 4 may be an element of routine care. A stiff sore neck is a sign of meningeal irritation and possible meningitis. The nurse may further inquire if flexion of the neck causes pain and the hip and knee to flex (Brudzinski’s sign) and how high the fever is. The other symptoms are typical of influenza. The first signs of increased intracranial pressure are often subtle changes in level of consciousness.
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