Pass the NCLEX NCLEX Certification NCLEX-PN Questions and answers with CertsForce

A dark red color is an abnormal finding when assessing the stoma. It indicates inadequate blood supply. The

other findings are normal one day postoperatively.Physiological Adaptation

His wife is exhibiting obsessive-compulsive behavior. Because this is an anxiety disorder, it is desirable to maintain an environment that is calm and as stress free as possible. Attempting to stop or focusing on the behavior can increase the wife’s anxiety and therefore the repetitive behavior.Psychosocial Integrity

A client newly diagnosed with Diabetes Mellitus needs teaching about diet and exercise.Physiological

Adaptation

Syphilis is an acute and chronic treponemal disease characterized clinically by a primary lesion, a secondary

eruption involving skin and mucous membranes, long periods of latency, and late lesions of skin, bone viscera, the

CNS, and the cardiovascular system. The primary lesion (chancre) appears about three weeks after exposure as an

indurated, painless ulcer with serous exudate at the site of initial invasion. Invasion of the bloodstream precedes

development of the initial lesion, and a firm, nonfluctuant, painless lymph node (bubo) commonly follows.

Infection might occur without a clinically evident chancre; that is, it might be in the rectum or on the cervix. After

four–six weeks, even without specific treatment, the chancre begins to involute, and, in approximately one-third of

untreated cases, a generalized secondary eruption appears, often accompanied by mild constitutional symptoms.

This symmetrical maculopapular rash involving the palms and soles, with associated lymphadenopathy is classic.

Secondary manifestations resolve spontaneously within weeks to 12 months. Again, about one-third of untreated

cases of secondary syphilis become clinically latent for weeks to years. In the early years of latency, infectious

lesions of the skin and mucous membranes might recur. Specific treatment includes long-acting penicillin G

(benzathine penicillin), 2.4 million units given in a single IM dose on the day that primary, secondary or early

latent syphilis is diagnosed. This ensures effective therapy, even if the client fails to return. Serologic testing is

important to ensure adequate therapy. Tests are repeated three and six months after treatment and later as needed.

In HIV-infected clients, testing should be repeated one, two, and three months after treatment, and at three-month

intervals thereafter. Any fourfold titer rise indicates the need for retreatment.Physiological Adaptation

There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.

Physiological Adaptation

Nasogastric feedings are most appropriate for a client who is unable to swallow. Nothing by mouth leads to

nutritional deficiencies. The client might aspirate a clear liquid diet. TPN is not necessary as long as the gut is

still functioning.Reduction of Risk Potential

If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers. The nurse

needs to provide emotional support to help the family deal with the infant’s condition, which might involve a

host of conditions that could lead to death or marked neurological damage. RhoGam is never given to a woman

already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given

after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman

within 72 hours of delivery. Rh-immune globulin is never given to the newborn. To determine if sensitization has

occurred, an Indirect Coombs’ is drawn on the mother to measure the number of Rh-positive antibodies.Health

Promotion and Maintenance

The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence

that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something

doesn’t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether

they are lying beside the paper, stacked on the paper or moved to the paper.Centrationis the ability to concentrate

on one feature of a situation while neglecting all other aspects.Causalityis based on the sequence of events, one

event ordinarily following another.Nonreversibilityrefers to the inability of preschoolers to reverse their

operations. They are only able to think forward, not retrace or reverse their thought processes.Health Promotion

and Maintenance

Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless

bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the

uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright

red, painless bleeding. The abdomen might be soft, nontender, and relax between contractions.Physiological

Adaptation

Folic acid should not be used if pernicious anemia is suspected because it does not protect the client from

CNS changes common to this type of anemia. Folic acid is usually given with Vitamin B12. Both are part of the

Vitamin B complex and are essential for cell growth and division. Folic acid is sometimes used as a rescue drug

for cells exposed to some toxic chemotherapeutic agents. The nature of the anemia must be confirmed to ensure

that the proper drug regimen is being used.Physiological Adaptation

Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age

indicates the need for further developmental or neurological evaluation. Laying the infant on her stomach

promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral

should be the first action. These findings are not normal for a 6-month-old infant. Significant head lag can be seen

in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those

disorders might have mental retardation as a component. However, this child needs to have the referral to

determine the cause of the head lag first.Health Promotion and Maintenance

Topical agents produce a localized, rather than systemic, effect. When treating atopic dermatitis with a steroidal preparation, the site is vulnerable to invasion by organisms. Viruses, such as herpes simplex or varicella zoster, present a risk of disseminated infection. Educate the client using topical corticosteroids to avoid crowds or people known to have infections and to report even minor signs of an infection. Topical corticosteroid use results in little danger of concurrent infection with the agents in choices 1, 3, and 4.Pharmacological Therapies

Valium is a sedative that might be given prior to receiving a CT scan. The other medications are not sedatives.

Reduction of Risk Potential

Iron should not be mixed with antacids.Physiological Adaptation

Pulling an object works with gravitational force not opposing it, lowering risk of muscle strain.Basic Care

and Comfort