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NCLEX/CGFNS REVIEW BULLETS 2

• In the immediate postoperative period following a radical neck dissection, the
nurse assesses for stridor (a coarse, high-pitched sound on inspiration when
auscultating over the trachea). This finding is reported immediately, because
it indicates airway obstruction.

• Variances are actual deviations or detours from the critical paths. Variances
can be positive or negative, avoidable or unavoidable, and can be caused by
a variety of things. Positive variance occurs when the client achieves
maximum benefit and is discharged earlier than anticipated. Negative
variance occurs when untoward events prevent a timely discharge. Variance
analysis occurs continually in order to anticipate and recognize negative
variance early, so that appropriate action can be taken

• In functional nursing, a task approach method is used to provide care to

clients.

• The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are

deep and nonlabored. They occur as the body tries to eliminate carbon
dioxide to compensate for lactic acidosis. As ketoacidosis improves, this
pattern of respiration resolves. The nurse monitors the client’s respiratory
status as part of the client’s overall status.

• The client is likely to have tachycardia due to efforts by the body to

compensate for the effects of anemia. The client with anemia is likely to
complain of fatigue, because of decreased ability of the body to carry oxygen
to tissues to meet metabolic demands. Increased respiratory rate is not an
associated finding, although some clients may have shortness of breath.

• Spinal cord compression should be suspected in a client with metastatic

disease, particularly when a new and sudden onset of back pain occurs.
Spinal cord compression causes back pain before neurological changes occur.
Spinal cord compression is an oncological emergency, and the physician
should be notified.

• The client with iron deficiency anemia should increase intake of foods that
are naturally high in iron. The best sources of dietary iron are red meat, liver
and other organ meats, blackstrap molasses, and oysters.

• Iron preparations can be very irritating to the stomach and are best taken
after a meal. The tablet is swallowed whole, not chewed. Because the client

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 might experience constipation, the client should increase fluids and fiber in
the diet to counteract this side effect of therapy.

• For most hematological laboratory studies, including CBC, no special care is

needed either before or after the test. There is no reason to fast after
midnight, drink extra liquids, or avoid red meat prior to the laboratory test
being drawn.

• Before bone marrow aspiration, the site is cleansed with an antiseptic

solution such as povidone-iodine. This helps reduce the number of bacteria
on the skin, and decreases the risk of infection from the procedure.

• When delegating nursing assignments, the nurse needs to consider the skills
and educational levels of the nursing staff. The nursing assistant can most
appropriately give a shower, a bed bath, ambulate a client with a walker,
take an oral temperature. The LPN can administer the rectal suppository to
the client requiring the enema. The LPN is skilled in wound irrigations and
dressing changes, and this client would most appropriately be assigned to
this staff member.

• After ear surgery, clients need to avoid straining when having a bowel
movement. Clients need to be instructed to avoid drinking with a straw for 2
to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid
getting their head wet, washing their hair, and showering for 1 week.
Swimming is also avoided. Clients need to avoid moving the head rapidly,
bouncing, and bending over for 3 weeks.

• Exacerbation of Ménière’s disease is characterized by severe vertigo. The

nurse instructs the client to make slow head movements to prevent
worsening of the vertigo. Dietary changes such as salt and fluid restrictions
that reduce the amount of endolymphatic fluid are sometimes prescribed.
Activities such as reading and watching TV will worsen the vertigo. Clients are
advised to stop smoking because of its vasoconstrictive effects.

• The client who is thrombocytopenic is at risk for bleeding. The family should
observe the puncture site for bleeding for several days after the procedure,
since the client is at high risk. Acetaminophen may be given for discomfort,
and aspirin should be avoided because it could aggravate bleeding

• The client who has had surgical resection of the stomach or small intestine
may develop pernicious anemia as a complication. This results from
decreased production of intrinsic factor (gastrectomy) or decreased surface
area for vitamin B12 absorption (intestinal resection). The client then requires
vitamin B12 injections for life. Decreased iron intake leads to iron deficiency
anemia, which is often easily treated with iron supplements.

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• Otoscopic examination in a client with mastoiditis reveals a red, dull, thick,
and immobile tympanic membrane with or without perforation. Postauricular
lymph nodes are tender and enlarged. Clients also have a low-grade fever,
malaise, anorexia, swelling behind the ear, and pain with minimal movement
of the head.

• The RN would plan to care for the client who is scheduled for surgery at 1:00
p.m. first. There are several items that need to be addressed preoperatively,
including client preparation (physically and emotionally) and physician orders
that need to be carried out. This preparation takes time. Additionally, many
times the operating room makes late changes in the schedule, depending on
room and physician availability, and requests an earlier surgical time.
Therefore, it is best to ensure that this client is prepared.

• Clozapine is an antipsychotic medication with no demonstrated

extrapyramidal side effects. The risk of extrapyramidal effects with the other
medications listed is moderate (chlorpromazine) to high (haloperidol,
loxapine).

• Denial is a response by the rape victim. It is described as an adaptive and

protective reaction. Projection is blaming or “scapegoating.” Rationalization is
justifying the unacceptable attributes about himself or herself.
Intellectualization is the excessive use of abstract thinking or generalizations
to decrease painful thinking.

• Agoraphobia is a fear of open spaces and the fear of being trapped in a

situation in which there may not be an escape. Agoraphobia includes the
possibility of experiencing a sense of helplessness or embarrassment if a
phobic attack occurs. Avoidance of such situations usually results in reduction
of social and professional interactions. Social phobia focuses more on a
specific situation, such as the fear of speaking, performing, or eating in
public. Claustrophobia is a fear of closed in spaces. Clients with
hypochondriacal symptoms focus their anxiety on physical complaints and
are preoccupied with their health.

• Appropriate nursing diagnosis for a client scheduled to have

electroconvulsive theraphy (ECT) is Risk for aspiration. Aspiration is
safeguarded against by keeping the client NPO for 6 to 8 hours before the
procedure, removing dentures, and administering glycopyrrolate (Robinul) or
atropine sulfate as prescribed.

• When analyzing data obtained from a client suspected of family violence, the
physiological well-being of the client is always considered first.

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• During the acute phase of the rape crisis, the client can display a wide range
of emotional and somatic responses. All of the symptoms noted in the
question indicate a normal reaction to a very intensely difficult crisis event.
Although the client’s initial reactions may be predictive of later problems,
they do not indicate an abnormal initial response.

• Finding the right drug at the right dose that provides the least side effects for
the client, providing clients with the injectable, long-acting form of the
medication, and including the family in the medication planning process are
measures that will promote compliance. Not all medications can be given on
a once-per-day dosing regimen due to a short half-life of some medications.
Lithium carbonate is an example of one such medication that must be taken
throughout the day to maintain steady serum drug levels.

• Obsessions are defined as persistent thoughts that are intrusive and that the
person tries to ignore or suppress. This client wants to “snap out of” this daily
review, but the thoughts continue for hours. Compulsions are defined as
repetitive behaviors that the client feels driven to perform, such as changing
clothes frequently until he gets it “just right.”

• Al-Anon support groups provide a supportive opportunity for spouses and

significant others to learn what to expect about successful behavioral
changes.

• Any clear threats by psychiatric clients to harm specific people must be

reported to the authorities (law enforcement) and the intended victims by
mental health care providers and psychotherapists.

• Major depression occurs twice as frequently in females as in males. Reacting

to loss by experiencing altered sleep for 1 week is a normal grief response.
While depression is often associated with substance abuse, it would not, in
and of itself, constitute a major depression.

• A conversion disorder is an alteration or loss of a physical function that

cannot be explained by any known pathophysiological mechanism. It is
thought to be an expression of a psychological need or conflict. In this
scenario, the client witnessed an accident that was so psychologically painful
that the client became blind. Psychosis is a state in which a person’s mental
capacity to recognize reality, communicate, and relate to others is impaired,
thus interfering with the person’s capacity to deal with life demands. A
dissociative disorder is a disturbance or alteration in the normally integrative
functions of identity, memory, or consciousness. Repression is a coping
mechanism in which unacceptable feelings are kept out of awareness.

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• Ego defense mechanisms are operations outside of a person’s awareness that
the ego calls into play to protect against anxiety. Displacement is the
discharging of pent-up feelings on persons less dangerous than those who
initially aroused the emotion. In this scenario, the nurse manager reprimands
the unit secretary for overusing clerical supplies. The secretary lashes out at
the temporary secretary and student nurses for wasting supplies. These are
much “safer targets” to become angry with than the nurse manager. Denial
is the blocking out of painful or anxiety-inducing events or feelings.
Suppression is consciously keeping unacceptable feelings and thoughts out of
awareness. Repression is unconsciously keeping unacceptable feelings out of
awareness.

• Taking time to discuss the client’s concerns is as important a nursing action

in many instances as any intervention for physical care. Therapeutic
communication should focus on the client’s nonverbal cues and encourage
the client to express feelings or concerns about surgery.

• When a client harms himself, immediate 1:1 nursing supervision is instituted.

This meets the safety needs of the client. After doing this, the psychiatrist is
notified of the incident. The client should not be restrained or placed in
seclusion.

• Tardive dyskinesia, the involuntary movements of the tongue, jaw,

lips, and facial muscles, is a manifestation of EPS. Flaccid muscles
are not a characteristic of EPS. Agraphia, the inability to read or
write, is not a characteristic of EPS. Dystonia is characterized by
acute spasms of the tongue, neck, face, and back, laryngospasms,
torticollis, and eyes locked upwards.

• The dosage of lithium carbonate needs to remain constant to maintain blood

levels between 0.6 mEq/L and 1.2 mEq/L. There is a narrow margin between
therapeutic and toxic levels. Blood levels are necessary to assess this narrow
range. Adequate salt and fluids are necessary to prevent toxicity. Vomiting
and diarrhea could be signs of toxicity and need to be reported. Dosages
should never be adjusted.

• Amitriptyline (Elavil) has a sedative effect, and a single maintenance dose

should be taken at bedtime. This also precludes the need for insomnia
medication.

• Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI). Clients

taking MAOIs should report any headache to the physician, because it may
signal an impending hypertensive crisis. A low tyramine diet needs to be
consumed. Dry crackers can be eaten if the client gets nauseated. Chewing
sugarless gum is appropriate.

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• The client needs to be able to put the trauma into a new context. The client
needs to realize that the trauma did not occur because he or she did
something wrong, used poor judgment, or somehow deserved it. The client
will often express feelings of guilt, but the goal will be to assist to put it in
perspective and eventually to be able to work through the feelings of guilt.

• A situational crisis arises from external rather than internal sources. External
situations that could precipitate crisis include loss of or change of a job, the
death of a loved one, abortion, a change in financial status, divorce, the
addition of new family members, pregnancy, and severe illness.

• An adventitious crisis is not a part of every day life, is unplanned, and

accidental.

• As with all loss experienced by individuals and families, opening up the

communication channels is a key factor in successful grieving and surviving.
Often, estrangement occurs in families because well-meaning relatives and
friends do not know how to respond. This uncertainty and fear causes
relatives and friends to isolate when communication and an opportunity to
grieve with support are crucial. Joining a survivor-victim group is a positive
outcome, but if the client is not talking with his or her family members, it is
likely that maximum benefit from the group will not be achieved.

• Recognizing situations that produce anxiety allows the client to prepare to

cope with anxiety or avoid specific stimulus. Counselors will not be available
for all anxiety-producing situations.

• Sertraline hydrochloride (zoloft), a selective serotonin reuptake inhibitor, can

cause a dry mouth that is alleviated by sucking on sugarless hard candy and
chewing gum. Foods such as cheese, wine, and chocolate contain an amino
acid, tyramine that reacts with monoamine oxidase inhibitors. Monthly blood
levels are usually required for clients who are receiving lithium carbonate
(Eskalith) therapy. Sertraline is usually taken with meals.

• Central nervous system depressants such as alcohol will produce an addictive

effect if taken with diazepam, which can be lethal. Diazepam can cause initial
drowsiness. It should not be discontinued abruptly, because the client may
develop withdrawal symptoms. Many of the over-the-counter medications
used to treat the flu contain medication that should not be taken when a
client is taking diazepam.

• Clients who are taking monoamine oxidase inhibitors (MAOIs) must maintain
a low tyramine diet and receive health teaching regarding the foods,
beverages, and medications that must be avoided. Foods with aged cheese
can cause a hypertensive crisis if taken with MAOIs.

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• Fluoxetine hydrochloride (Prozac) tends to improve the energy level,
and if it is taken late in the day, insomnia may occur. Many clients
suffer from sexual dysfunction throughout treatment, such as
decreased libido. Side effects can be expected to some degree with
any medication. The lag time from the time the medication is started
until therapeutic effects are achieved is anywhere from 2 to 4 weeks
or longer. This is true with any antidepressant.

• Sodium depletion will decrease renal excretion of lithium, thereby causing

the medication to accumulate and potentiating toxicity. Clients need to be
instructed to maintain a normal sodium intake. Diuretics promote sodium
loss, and these medications need to be used with caution in the client taking
lithium. Sodium loss secondary to diarrhea can cause lithium accumulation,
and the client should be forewarned of this possibility.

• Chlorpromazine blocks dopamine neurotransmission at postsynaptic

dopamine receptor sites, reversing psychotic symptoms.

• Lithium is an antimanic medication and is used to treat the manic phase of a

manic-depressive disorder.

• Neuroleptic malignant syndrome is a serious and potentially fatal reaction to

antipsychotics. The classic symptoms include hyperthermia; severe
extrapyramidal symptoms, such as muscular rigidity; and autonomic
dysfunction, such as hypertension and tachycardia.

• The first priority in planning care for a client with dysfunctional grieving is to
assess the risk for violence toward self and others. The plan will include
efforts to work toward resolving the grief through emotional, cognitive, and
behavioral means.

• Ensuring safety is a major aspect in the plan of care for the abused elder. The
nurse may need to contact the social worker to plan care for the client, but
this is not the priority action.

• In all child abuse cases, the primary concern is the health and safety of the
child.

• Adventitious crises are the unpredictable tragedies that occur

without warning. A maturational crisis involves the normal life
transition that creates changes with individuals and how they
perceive themselves, their role, and their status. A situational crisis
occurs when a specific, external event disturbs an individual’s
psychological equilibrium. An individual may experience a crisis;
however, there is no formal type of crisis known as individual crisis.

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• In the ECT suite, blood pressure, cardiac, and electroencephalographic
monitors are placed on the client to assess vital functions. Whenever ECT is
administered, emergency equipment, including oxygen, suction, and a
cardiac arrest cart, must also be available.

• In the norming stage, members express intimate personal opinions

and feelings around personal tasks. In the forming or initial stage,
the members are identifying tasks and boundaries. Storming
involves responding emotionally to tasks. In the performing stage,
members direct group energy toward the completion of tasks.

• Feelings of low self-esteem and worthlessness are common symptoms of the

depressed client. Reminders of the client’s recent accomplishments or
personal successes are ways to interrupt the client’s negative self-talk and
distorted cognitive view of self.

• In a client with a diagnosis of delirium. It is important to provide a

consistent daily routine and a low stimulating environment when the
client is disorientated. Noise, including radio and television, can add
to the confusion and disorientation. A well-lit room will increase
stimulation.

• In the immediate post-disaster period, it is important that a nurse go to

places where victims are likely to gather, such as morgues, hospitals, and
shelters. Rather than waiting for people to publicly identify themselves as
being unable to cope with stress, it is suggested that nurses work with the
American Red Cross. The nurse should talk to people waiting to receive
assistance, go door to door, or go to a relocation site. The nurse should ask
people how they are managing their affairs and explore their reactions to
stress.

• If a client is in the act of preparing to commit suicide, the most appropriate

nursing activity is to communicate with the client and attempt to develop a
therapeutic relationship. The nurse should communicate hope, and hope is
most often the most therapeutic element in any nursing intervention with a
suicidal patient.

• Identification is the process by which a person tries to become like someone

he or she admires by taking on thoughts, mannerisms, or tastes of that
person. Intellectualization is excessive reasoning or logic used to avoid
experiencing disturbed feelings. Projection is attributing one’s thoughts or
impulses to another person. Regression is retreating to a behavior
characteristic of an earlier level of development.

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• Direct expressions of self-hate or low self-esteem can include the client’s
expression of self-criticism. The client will exhibit negative thinking and
believe that he is doomed to failure. The underlying goal of the client is to
demoralize himself or herself. The client may describe himself as stupid, no
good, or a born loser. The client will view the normal stressors of life as
impossible barriers and become preoccupied with self-pity.

• It is the nurse’s responsibility to tell a client that secrets cannot be kept and
also that any disclosures that reveal behavior that may be harmful to the
client will need to be communicated to the appropriate professionals in the
health care team.

• To de-escalate aggressive behavior, the nurse should manage the

environment by persuading the client to move to another area. This will help
prevent anxiety contagion and protect others. The nurse should also give the
client clear instructions that are brief and assertive and should also negotiate
options with the client. This shows the nurse’s confidence and leadership and
also avoids misunderstandings in regard to not knowing what to do.
Negotiating options allows the client to feel that he or she has some room in
exercising the options. The nurse must allow the client body space and
should not stand closer than about 8 feet to the client. Standing close to the
client will convey a threat.

• Recreational therapy helps clients with personality disorders explore

ways to enjoy themselves without the use of self-destructive
behaviors, such as abusing alcohol or drugs. This modality is helpful
to clients who have difficulty socializing, because recreation
strengthens social skills. Movement therapy may be helpful for
clients who become “numb” when experiencing intense feelings. Art
therapy may be helpful for the client who is angry. The client who is
exhibiting violent behavior may require medication therapy.

• Concentration and memory are poor in severe depression. When a client has
a diagnosis of severe depression, the nurse needs to provide activities that
require little concentration. Activities that have no right or wrong choices or
activities that require minimal decision making minimize opportunities for
clients to put themselves down.

• When the client demonstrates calm behavior and communicates that he or

she is no longer a threat to self or others, the nurse would gather additional
assessment data to determine if the client is safe to come out of seclusion.

• Social phobia focuses on a specific situation, such as the fear of speaking,

performing, or eating in public. Agoraphobia is a fear of open spaces and the
fear of being trapped in a situation from which there may not be an escape.

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 Claustrophobia is a fear of closed places. Clients with hypochondriacal
symptoms focus their anxiety on physical complaints and are preoccupied
with their health.

• It is most therapeutic for the nurse to empathize with the client’s experience.
Disagreeing with delusions may make the client more defensive and the
client may cling to the delusions even more. Encouraging discussion
regarding the delusion is inappropriate.

• If a client with severe anxiety is left alone, he or she may feel abandoned and
become overwhelmed. Placing the client in a quiet room is also important,
but the nurse must stay with the client. It is not possible to teach the client
deep breathing exercises until the anxiety decreases. Encouraging the client
to discuss the accident would not take place until the anxiety has decreased.

• Systematic desensitization is a form of therapy used when the client is

introduced to short periods of exposure to the phobic object while in a
relaxed state. Gradually, exposure is increased, until the anxiety about or
fear of the object or situation has ceased.

• If a client is monopolizing the group, it is important that the nurse be direct

and decisive. The best action is to suggest that the client stop talking and try
listening to others.

• Using therapeutic communication techniques, the nurse acknowledges the

husband’s concerns and conveys that the client’s symptoms are common
with myxedema. With thyroid hormone therapy, these symptoms should
decrease, and cognitive function often returns to normal within 2 weeks.

• When a nurse delegates aspects of a client’s care to another staff member,

the nurse assigning the tasks is responsible for ensuring that each task is
appropriately assigned on the basis of the educational level and competency
of the staff member. Noninvasive interventions can be assigned to a nursing
assistant.

• A drop in blood pressure and rise in pulse rate could indicate postoperative
bleeding, which is a complication of a parathyroidectomy. Because bleeding
might not be observed on the front of the dressing due to the effects of
gravity, the nurse must check underneath it as well.

• Democratic leadership is a people-centered approach that is

primarily concerned with human relations and teamwork. This
leadership style facilitates goal accomplishment and contributes to
the growth and development of the staff. In autocratic leadership,
the leader retains all authority and is primarily concerned with task
accomplishment. Situational leadership is a comprehensive approach

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 that incorporates the leader’s style, the maturity of the work group,
and the situation at hand. Laissez faire is a permissive style of
leadership in which the leader gives up control and delegates all
decision making to the work group.

• To promote adequate healing and to meet continued high metabolic needs,

the client with a major burn should eat a diet that is high in calories, protein,
and carbohydrate. This type of diet also keeps the client in positive nitrogen
balance.

• Autocratic leadership is an approach in which the leader retains all authority

and is primarily concerned with task accomplishment. It is an effective
leadership style to implement in an emergency or crisis situation. The leader
assigns clearly defined tasks and establishes one-way communication with
the work group, making all of the decisions alone. Situational leadership is a
comprehensive approach that incorporates the leader’s style, the maturity of
the work group, and the situation at hand. Laissez faire is a permissive style
of leadership in which the leader gives up control and delegates all decision
making to the work group. Democratic leadership is a people-centered
approach that is primarily concerned with human relations and teamwork.
This leadership style facilitates goal accomplishment and contributes to the
growth and development of the staff.

• The clinical manifestations of a disulfiram-alcohol reaction include flushing,

throbbing in the head and neck, difficulty breathing, nausea, vomiting,
sweating, dizziness, and weakness. This type of reaction can occur in a client
taking disulfiram (Antabuse). The reaction can occur even if only one-half
ounce of alcohol is absorbed into the body (whether ingested by mouth or
applied to the skin).

• Clients who are depressed often suffer insomnia, and relaxation measures
are recommended to induce sleeping. The nurse might also give the client a
back rub and use soft, dim lighting.

• Responsible assertiveness provides clients with the skill to stand up for their
personal and professional rights and to express their thoughts and beliefs
directly, honestly, and appropriately in a manner that will not violate the
rights of other.

• Benztropine mesylate is an anticholinergic agent that is used in the

treatment of Parkinson’s disease and the extrapyramidal symptoms
(except tardive dyskinesia) that result from the use of neuroleptic or
antipsychotic medication. The medication increases and prolongs
the dopamine activity in the CNS, thereby correcting

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 neurotransmitter imbalances and minimizing involuntary
movements.

• Buspirone hydrochloride (Buspar) is used in the management of

anxiety disorders. It is contraindicated in clients with severe renal or
hepatic impairment and in clients taking monoamine oxidase
inhibitors. The nurse would notify the physician if the client had a
history of renal impairment.

• A therapeutic serum level for the use of carbamazepine is a level between 3

mcg/mL to 12 mcg/mL.

• Neuroleptic malignant syndrome is a rare, life-threatening syndrome

that is an adverse reaction of the use of chlorpromazine. Its signs
include severe rigidity, fever, increased white blood cell count,
unstable blood pressure, tachycardia, tachypnea, and renal failure.
Signs of acute dystonias include painful neck spasms, torticollis,
oculogyric crisis, and convulsions. Tardive dyskinesia includes
choreiform movements of the tongue, face, mouth, jaw, and possibly
the extremities.

• Common side effects experienced during the first 2 weeks of therapy with
disulfiram include mild drowsiness, fatigue, headaches, metallic or garlic
aftertaste, allergic dermatitis, and acne eruptions. Symptoms disappear
spontaneously with continued therapy or reduced dosage.

• Donepezil hydrochloride is a cholinergic medication and is to be taken in the

evening before bedtime. The medication should be taken with food;
therefore, a snack should be provided to the client when the medication is
administered.

• Fluoxetine hydrochloride (Prozac) takes 2 to 5 weeks to produce an elevation

of mood. Advantages of the medication are few anticholinergic side effects
and a low incidence of cardiovascular effects. It may, however, impair
judgment, thinking, and motor skills. The client should be instructed that it
will take more time for the medication to produce the desired effect.

• Lithium should be administered with meals. The client should be instructed to

maintain a regular diet and an average salt intake to keep the serum lithium
level in the therapeutic range. The client is instructed to avoid alcohol and to
drink 2 to 3 liters of liquids per day during initial therapy, and 1 to 1.5 liters
per day during the remainder of therapy.

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