HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN EXAMINATION (2013, Elsevier) 4TH EDITION ISBN: 978-1-4557-2752-0 401 PAGES

HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN EXAMINATION (2013, Elsevier) 4TH EDITION ISBN: 978-1-4557-2752-0 401 PAGES CONTENTS xii CONTENTS Treatment Modalities 303 Anxiety 307 Anxiety Disorders 308 Somatoform Disorders 311 Dissociative Disorders 313 Personality Disorders 314 Eating Disorders 317 Mood Disorders 318 Thought Disorders 325 Substance Abuse 329 Abuse 333 Organic Disorders 336 Childhood and Adolescent Disorders 337 8 GERONTOLOGIC NURSING 340 Theories of Aging 340 Physiologic Changes 340 Dementia 348 Psychosocial Changes 349 Health Maintenance and Preventive Care 350 APPENDIXES 353 A Normal Values 353 B Recommended Daily Requirements and Food Sources 361 Index 363 1 INTRODUCTION 1 TO TESTING AND THE NCLEX-RN® EXAM Three cheers for you! You have made the wise decision to prepare, in a structured way, for the NCLEX-RN. A. You have already successfully completed a basic nursing program and are well acquainted with your ability to take and pass tests and to perform successfully in the clinical area. B. You have the basic knowledge required to pass the licensing exam. However, it is wise to: 1. Organize your knowledge. 2. Review content learned during the years of your basic nursing curriculum. 3. Identify weaknesses in content knowledge so that you can focus your study time appropriately. 4. Develop test-taking skills so you can demonstrate the knowledge you have. 5. Reduce your level of anxiety by increasing your predictability. 6. Know what to expect. Remember: Knowledge is power. You are powerful when you are well prepared and know what to expect. Test-Taking Tips There are no absolute ways to ensure that exam questions will always be answered correctly. These test-taking tips are guidelines to help the student study and understand the exam questions. On the NCLEX-RN exam, many different areas are tested with each question. For example, a question may on the surface be a medical/surgical or pediatric question but included in the question can be such topics as communication, nutrition, growth and development, medication, client and family education, and safety. A. Understanding the question 1. Determine if the question is written in a positive or negative style. a. A positive style may ask what the nurse should do or ask for the best or first action to implement. HESI Hint • Most questions are written in a positive style. b. A negative style may ask what the nurse should avoid, which prescription the nurse should question, or which behavior indicates the need for re-teaching the client. HESI Hint • Negative style questions will contain key words that denote the negative style. EXAMPLES 1. “Which response indicates to the nurse a need to re-teach the client about…?” (Which information/ understanding by the client is incorrect?) 2. “Which prescription (order) should the nurse question?” (Which prescription is unsafe, not beneficial, inappropriate to this client situation, etc…?) 2. Find the key words in the question. a. Ask yourself which words or phrases provide the critical information. b. This information may be the age of the client, the setting, the timing, a set of symptoms or behaviors, or any number of other factors. c. For example, the nursing actions for a 10-yearold 1 day postop are different than those for a 70-year-old 1 hour postop. 3. Rephrase the question in your own words. a. This will help you eliminate nonessential information in the question and help you determine the correct answer. b. Ask yourself, “What is this question really asking?” c. While keeping the options covered, rephrase the question in your own words. 4. Rule out options. a. Based on your knowledge, you can probably identify one or two options that are clearly incorrect. b. Physically mark through those options on the test booklet if allowed. Mentally mark through those options in your head if using a computer. 2 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION c. Now differentiate between the remaining options, considering your knowledge of the subject and related nursing principles, such as roles of the nurse, the nursing process, the ABCs (airway, breathing, and circulation), CAB (circulation, airway, and breathing for cardiopulmonary resuscitation [CPR]), and Maslow’s Hierarchy of Needs. B. General guidelines about test taking 1. Consider the content of the question and what the question is asking. 2. Generally, an assessment of the client occurs before an action is taken. 3. Identify the least invasive intervention before taking action. 4. Have all the necessary information and take all possible relevant actions before calling the physician or health care provider. 5. Determine which client to assess first (e.g., most at risk, most physiologically unstable). 6. Identify opposites in the answers. a. Example: Prone/supine; elevated/decreased b. Read VERY carefully; one is likely to be the answer, BUT not always c. If you do not know the answer, choose the most likely of the “opposites” and move on. 7. Take into account a client’s lifestyle, culture, and spiritual beliefs when answering a question. C. Use CRITICAL THINKING, reasoning, and common sense to answer questions. 1. DO respond based on… a. ABCs b. CAB for CPR c. Scientific, behavioral, sociologic principles d. Principles of teaching/learning e. Maslow’s Hierarchy of Needs f. Nursing process g. What’s in the stem: No more, no less (Do not read more into the question than is already there.) h. NCLEX-RN ideal hospital i. Basic anatomy and physiology 2. DON’T respond based on… a. YOUR past client care experiences or agency b. A familiar phrase or term c. “Of course, I would have already…” d. What YOU think is REALISTIC e. YOUR children, pregnancies, parents, elders, personal response to a drug, etc. f. The “what ifs” D. Keep memorizing to a minimum. 1. Growth and developmental milestones 2. Death and dying stages 3. Crisis intervention 4. Immunizations schedule 5. Principles of teaching/learning 6. Stages of pregnancy and fetal growth 7. Nurse Practice Act: Standards of Practice and Delegation E. Know commonly used lab ranges (Appendix A), what variations mean, and the BEST nursing actions. 1. H&H 2. WBCs, RBCs, platelets 3. Electrolytes: K+, Na+, Ca++, Mg++, Cl−, PO − 4 4. BUN and creatinine 5. Relationship of Ca++ and PO − 4 6. ABGs 7. PT, INR, PTT (Don’t get them confused.) F. Nutrition 1. Know commonly used nutrition information. a. High or low Na+ b. High or low K+ c. High PO − 4 d. Iron e. Vitamin K f. Proteins g. Carbohydrates h. Fats 2. Foods and diets related to a. Gastrointestinal/genitourinary disturbances b. Chemotherapy diets and restrictions c. Pregnancy and fetal growth needs d. Dialysis e. Burns 3. Remember concepts a. Introducing one food at a time (infants, allergies) b. Progression “AS TOLERATED” (What nursing assessment guides decisions regarding progression?) G. Medications—SAFE medication administration is more than just knowing the name, classification, and action of the medication. 1. “Six Rights, ” including techniques of skill execution 2. Drug interactions 3. Vulnerable organs a. What to assess b. Which lab values relate to specific organs 4. Allergies 5. Presence of suprainfections 6. Concepts of peak and trough 7. How you would know a. The drug is working b. There’s a problem 8. Nursing actions 9. Client education should include a. Safety b. Empowerment c. Compliance CHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 3 The NCLEX-RN® Licensing Exam A. The main purpose of a licensing exam like the NCLEXRN is to protect the public. B. The NCLEX-RN: 1. Was developed by the National Council of State Boards of Nursing (the Council; this abbreviation is used to refer to the NCSBN throughout this book) 2. Is administered by the State Board of Nurse Examiners 3. Is designed to test candidates’ a. Capabilities for safe and effective nursing practice b. Essential entry-level nursing knowledge Job Analysis Studies A. Essential knowledge is determined by job analysis studies. HESI Hint • The Council wants to ensure that the licensing exam measures current entry-level nursing behaviors. For this reason, job analysis studies are conducted every 3 years. These studies determine how frequently various types of nursing activities are performed, how often they are delegated, and how critical they are to client safety, with criticality given more value than frequency. B. Job analysis studies indicate that newly licensed registered nurses are using all five categories of the nursing process and that such use is evenly distributed throughout the five nursing process areas. Therefore, equal attention is given to each part of the nursing process in selecting test items (Table 1-1). Nursing Diagnoses A. Nursing diagnoses are formulated during the analysis portion of the nursing process. They give form and direction to the nursing process, promote priority setting, and guide nursing actions (Table 1-2). B. To qualify as a nursing diagnosis, the primary responsibility and accountability for recognition and treatment rest with the nurse. C. The National Conference of the North American Nursing Diagnosis Association (NANDA) provided the following definition of a nursing diagnosis: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (Box 1-1). TABLE 1-1 The Nursing Process Category Activities Associated with Nursing Process Assessment • Gather objective and subjective data. • Verify data. Analysis • Interpret data. • Collect additional data when necessary. • Identify and communicate nursing diagnoses. • Determine health team’s ability to meet client’s needs. Planning • Determine and prioritize outcomes of care. Include client, significant others, and health team in setting outcomes. • Develop and modify plan for delivery of client’s care. Implementation • Organize and manage the client’s care, including assignment and delegation of tasks. • Perform or assist in performance of client’s care. • Counsel and teach client, significant others, and health team. • Provide care specifically directed toward achieving outcomes. Evaluation • Compare actual outcomes with expected outcomes. • Evaluate compliance with the established regimen or plan. • Record and describe client’s response to plan. • Modify plan as indicated and set priorities. TABLE 1-2 Components of a Nursing Diagnosis Component Explanation Response • Includes potential or actual health response • Describes measurable outcomes that can be derived • Cites potential for changes based on nursing actions • Example: Alteration in comfort, pain Etiology • Includes potential or actual health response • Addresses independent, interdependent, and dependent nursing functions • Example: Related to fractured left ankle 4 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION BOX 1-1 NANDA-Approved Nursing Diagnoses A Activity Intolerance Risk for Activity Intolerance Ineffective Activity Planning Risk for Ineffective Activity Planning Risk for Adverse Reaction to Iodinated Contrast Media Ineffective Airway Clearance Risk for Allergy Response Anxiety Risk for Aspiration Risk for Impaired Attachment Autonomic Dysreflexia Risk for Autonomic Dysreflexia B Disorganized Infant Behavior Risk for Disorganized Infant Behavior Readiness for Enhanced Organized Infant Behavior Risk for Bleeding Risk for Unstable Blood Glucose Level Disturbed Body Image Risk for Imbalanced Body Temperature Insufficient Breast Milk Ineffective Breastfeeding Interrupted Breastfeeding Readiness for Enhanced Breastfeeding Ineffective Breathing Pattern C Decreased Cardiac Output Caregiver Role Strain Risk for Caregiver Role Strain Readiness for Enhanced Childbearing Process Ineffective Childbearing Process Risk for Ineffective Childbearing Process Impaired Comfort Readiness for Enhanced Comfort Readiness for Enhanced Communication Impaired Verbal Communication Acute Confusion Risk for Acute Confusion Chronic Confusion Constipation Perceived Constipation Risk for Constipation Contamination Risk for Contamination Defensive Coping Ineffective Coping Readiness for Enhanced Coping Ineffective Community Coping Readiness for Enhanced Community Coping Compromised Family Coping Disabled Family Coping Readiness for Enhanced Family Coping D Death Anxiety Risk for Sudden Infant Death Syndrome Decisional Conflict Readiness for Enhanced Decision-Making Ineffective Denial Impaired Dentition Risk for Delayed Development Diarrhea Risk for Disuse Syndrome Deficient Diversional Activity Risk for Dry Eye E Risk for Electrolyte Imbalance Disturbed Energy Field Impaired Environmental Interpretation Syndrome F Adult Failure to Thrive Risk for Falls Dysfunctional Family Processes Interrupted Family Processes Readiness for Enhanced Family Processes Fatigue Fear Ineffective Infant Feeding Pattern Readiness for Enhanced Fluid Balance Risk for Imbalanced Fluid Volume Deficient Fluid Volume Risk for Deficient Fluid Volume Excess Fluid Volume G Impaired Gas Exchange Dysfunctional Gastrointestinal Motility Risk for Dysfunctional Gastrointestinal Motility Risk for Ineffective Gastrointestinal Perfusion Grieving Complicated Grieving Risk for Complicated Grieving Risk for Disproportionate Growth Delayed Growth and Development H Deficient Community Health Risk-Prone Health Behavior Ineffective Health Maintenance Impaired Home Maintenance Readiness for Enhanced Hope Hopelessness Risk for Compromised Human Dignity Hyperthermia Hypothermia I Readiness for Enhanced Immunization Status Ineffective Impulse Control Bowel Incontinence Functional Urinary Incontinence Overflow Urinary Incontinence Reflex Urinary Incontinence CHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 5 Stress Urinary Incontinence Urge Urinary Incontinence Risk for Urge Urinary Incontinence Risk for Infection Risk for Injury Insomnia Decreased Intracranial Adaptive Capacity J Neonatal Jaundice Risk for Neonatal Jaundice K Deficient Knowledge Readiness for Enhanced Knowledge L Latex Allergy Response Risk for Latex Allergy Response Sedentary Lifestyle Risk for Impaired Liver Function Risk for Loneliness M Risk for Disturbed Maternal-Fetal Dyad Impaired Memory Impaired Bed Mobility Impaired Physical Mobility Impaired Wheelchair Mobility Moral Distress N Nausea Unilateral Neglect Noncompliance Readiness for Enhanced Nutrition Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More Than Body Requirements O Impaired Oral Mucous Membrane P Acute Pain Chronic Pain Readiness for Enhanced Parenting Impaired Parenting Risk for Impaired Parenting Risk for Peripheral Neurovascular Dysfunction Disturbed Personal Identity Risk for Disturbed Personal Identity Risk for Poisoning Risk for Perioperative Positioning Injury Post-Trauma Syndrome Risk for Post-Trauma Syndrome Readiness for Enhanced Power Powerlessness Risk for Powerlessness Ineffective Protection R Rape-Trauma Syndrome Readiness for Enhanced Relationship Ineffective Relationship Risk for Ineffective Relationship Readiness for Enhanced Religiosity Impaired Religiosity Risk for Impaired Religiosity Relocation Stress Syndrome Risk for Relocation Stress Syndrome Risk for Ineffective Renal Perfusion Impaired Individual Resilience Readiness for Enhanced Resilience Risk for Compromised Resilience Parental Role Conflict Ineffective Role Performance S Bathing Self-Care Deficit Dressing Self-Care Deficit Feeding Self-Care Deficit Toileting Self-Care Deficit Readiness for Enhanced Self-Care Readiness for Enhanced Self-Concept Chronic Low Self-Esteem Risk for Chronic Low Self-Esteem Situational Low Self-Esteem Risk for Situational Low Self-Esteem Ineffective Self-Health Management Readiness for Enhanced Self-Health Management Self-Mutilation Risk for Self-Mutilation Self-Neglect Sexual Dysfunction Ineffective Sexuality Pattern Risk for Shock Impaired Skin Integrity Risk for Impaired Skin Integrity Sleep Deprivation Readiness for Enhanced Sleep Disturbed Sleep Pattern Impaired Social Interaction Social Isolation Chronic Sorrow Spiritual Distress Risk for Spiritual Distress Readiness for Enhanced Spiritual Well-Being Stress Overload Risk for Suffocation Risk for Suicide Delayed Surgical Recovery Impaired Swallowing T Ineffective Family Therapeutic Regimen Management Risk for Thermal Injury Ineffective Thermoregulation Impaired Tissue Integrity Ineffective Peripheral Tissue Perfusion BOX 1-1 NANDA-Approved Nursing Diagnoses—cont’d Continued 6 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION D. NCLEX-RN questions regarding nursing diagnosis can take several forms: 1. You may be given the nursing diagnosis in the stem and asked to select an appropriate nursing intervention based on the stated nursing diagnosis. 2. You may be asked to select, from the four choices, an appropriate nursing diagnosis for the described case. 3. You may be asked to choose, from four nursing diagnoses, the one that should have priority based on the data in the stem. HESI Hint • A nursing diagnosis is not a medical diagnosis. It must be subject to oversight by nursing management. The cause may or may not arise from a medical diagnosis. Client Needs A. Job analysis studies have identified categories of care provided by nurses called Client Needs. The test plan is structured according to these categories (Table 1-3). Prioritizing Nursing Care A. Many NCLEX-RN test items are designed to test your ability to set priorities—for example: 1. Identify the most important client needs.