Patient-Specific Care - NCLEX-PN
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At what age should an infant show stranger anxiety?
At what age should an infant show stranger anxiety?
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An infant begins to show signs of anxiety toward strangers between 8 and 12 months of age and may recur until two years of age. This anxiety can show as silence, staring, writhing or crying in the presence of people they don't know.
An infant begins to show signs of anxiety toward strangers between 8 and 12 months of age and may recur until two years of age. This anxiety can show as silence, staring, writhing or crying in the presence of people they don't know.
At what age does an infant learn object permanence?
At what age does an infant learn object permanence?
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Object permanence is the understanding that an object still exists even when it can not be seen, heard, or touched. It is often tested by placing an object on a surface, then covering that object and allowing the infant to attempt to uncover it, thus demonstrating a knowledge that the object remains present though it is hidden.
Object permanence is the understanding that an object still exists even when it can not be seen, heard, or touched. It is often tested by placing an object on a surface, then covering that object and allowing the infant to attempt to uncover it, thus demonstrating a knowledge that the object remains present though it is hidden.
At what age does an infant develop the grasping response?
At what age does an infant develop the grasping response?
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The grasping reflex is the earliest reflex developed by the infant. It is often present at birth: the infant will grasp at objects such as a finger placed into their open palm.
The grasping reflex is the earliest reflex developed by the infant. It is often present at birth: the infant will grasp at objects such as a finger placed into their open palm.
At what age will an infant develop an inferior pincer grasp?
At what age will an infant develop an inferior pincer grasp?
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The inferior pincer grasp is the ability to pick up small objects such as by resting the forearm on a surface and pinching using the sides of the thumb and the index finger. It is an important milestone in the development of fine motor skills.
The inferior pincer grasp is the ability to pick up small objects such as by resting the forearm on a surface and pinching using the sides of the thumb and the index finger. It is an important milestone in the development of fine motor skills.
Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of what?
Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of what?
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Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of postpartum depression, a condition that affects as many as four out of five people after giving birth. Postpartum psychosis is a much more serious condition, involving delusions, extreme mood swings, and risk of self harm.
Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of postpartum depression, a condition that affects as many as four out of five people after giving birth. Postpartum psychosis is a much more serious condition, involving delusions, extreme mood swings, and risk of self harm.
What is the cause of postpartum depression?
What is the cause of postpartum depression?
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While vitamin deficiencies, lack of sleep, and social stresses can all contribute to depressed mood after giving birth, the primary cause of postpartum depression is an extreme drop in hormones (primarily estrogen and progesterone) that occurs after delivery of the placenta.
While vitamin deficiencies, lack of sleep, and social stresses can all contribute to depressed mood after giving birth, the primary cause of postpartum depression is an extreme drop in hormones (primarily estrogen and progesterone) that occurs after delivery of the placenta.
You have just calculated a newborn's five minute APGAR score as 5. What is the proper response?
You have just calculated a newborn's five minute APGAR score as 5. What is the proper response?
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The APGAR scale goes from 0-10. A score of 0-3 would indicate severe depression of function, 4-6 would indicate moderate depression, and 7-10 would be a normal, healthy score. In the case of moderate depression, the newborn should be monitored closely. Immediate emergency intervention may not be required, as healthy neonates can have moderately low APGAR score indicators that improve in the first few hours of life.
The APGAR scale goes from 0-10. A score of 0-3 would indicate severe depression of function, 4-6 would indicate moderate depression, and 7-10 would be a normal, healthy score. In the case of moderate depression, the newborn should be monitored closely. Immediate emergency intervention may not be required, as healthy neonates can have moderately low APGAR score indicators that improve in the first few hours of life.
What is a normal heart rate for a newborn two hours postpartum?
What is a normal heart rate for a newborn two hours postpartum?
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A newborn's heart rate is significantly higher than that of an adult. Normal heart rate for a newborn two hours postpartum is 110-160 beats per minute. Heart rate decreases in the first year of life to 80-140 beats per minute.
A newborn's heart rate is significantly higher than that of an adult. Normal heart rate for a newborn two hours postpartum is 110-160 beats per minute. Heart rate decreases in the first year of life to 80-140 beats per minute.
A nurse is monitoring an 18 year old who is experiencing heroin withdrawal. What symptoms might the nurse observe?
A nurse is monitoring an 18 year old who is experiencing heroin withdrawal. What symptoms might the nurse observe?
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Yawning, cramps, and diarrhea are common signs of heroin withdrawal.
Yawning, cramps, and diarrhea are common signs of heroin withdrawal.
An emergency room nurse is assessing a 26 year old female patient who frequently uses opium. What symptoms would indicate that she is experiencing withdrawal?
An emergency room nurse is assessing a 26 year old female patient who frequently uses opium. What symptoms would indicate that she is experiencing withdrawal?
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Anxiety, nausea, and vomiting are common symptoms of opium withdrawal.
Anxiety, nausea, and vomiting are common symptoms of opium withdrawal.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) criteria for substance abuse includes all of the following except .
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) criteria for substance abuse includes all of the following except .
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All of the items listed are part of the DSM V criteria for substance abuse. In addition, the individual's symptoms must not qualify for substance dependence and recurrent substance-related legal problems are other DSM V criteria for substance abuse.
All of the items listed are part of the DSM V criteria for substance abuse. In addition, the individual's symptoms must not qualify for substance dependence and recurrent substance-related legal problems are other DSM V criteria for substance abuse.
A 42 year old man presents to the ER for alcohol toxicity. While taking the history, the nurse discovers that he drinks on average one fifth of vodka per night, and often must drink an additional 6-12oz to get "a good buzz." When he doesn't drink, he experiences tremors and feels unwell until he is able to drink again. When asked if he would like to quit drinking he states that he has tried unsuccessfully several times over his life. He knows that he needs to get control over his drinking because it is seriously impairing his relationship with his husband and their 13 year old daughter.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V), this patient can be considered to have which of the following conditions?
A 42 year old man presents to the ER for alcohol toxicity. While taking the history, the nurse discovers that he drinks on average one fifth of vodka per night, and often must drink an additional 6-12oz to get "a good buzz." When he doesn't drink, he experiences tremors and feels unwell until he is able to drink again. When asked if he would like to quit drinking he states that he has tried unsuccessfully several times over his life. He knows that he needs to get control over his drinking because it is seriously impairing his relationship with his husband and their 13 year old daughter.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V), this patient can be considered to have which of the following conditions?
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The symptoms described by this patient put his alcohol use in the category of substance dependency, according to the DSM V, a more severe form of abuse than substance addiction. The criteria for this condition are:
- Tolerance
- Withdrawal
- Unintentional excesses in consumption
- Persistent desire or unsuccessful efforts to reduce or control substance use
- A great deal of time is spent to get, use, or recover from the substance
- Interference with social life
- The substance use is continued despite knowledge problems caused by use
The symptoms described by this patient put his alcohol use in the category of substance dependency, according to the DSM V, a more severe form of abuse than substance addiction. The criteria for this condition are:
- Tolerance
- Withdrawal
- Unintentional excesses in consumption
- Persistent desire or unsuccessful efforts to reduce or control substance use
- A great deal of time is spent to get, use, or recover from the substance
- Interference with social life
- The substance use is continued despite knowledge problems caused by use
Which of the following drugs is considered a central nervous system (CNS) depressant?
Which of the following drugs is considered a central nervous system (CNS) depressant?
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All of the drugs listed are considered to be CNS depressants. While generally classified as a psychedelic, marijuana has multiple central depressant effects such as sedation and muscle relaxation. Also, alcohol is another commonly used depressant.
All of the drugs listed are considered to be CNS depressants. While generally classified as a psychedelic, marijuana has multiple central depressant effects such as sedation and muscle relaxation. Also, alcohol is another commonly used depressant.
Prolonged alcohol abuse can result in a severe deficiency in what vitamin?
Prolonged alcohol abuse can result in a severe deficiency in what vitamin?
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Prolonged alcohol abuse can result in a severe deficiency in thiamine, or vitamin B1 by reducing dietary thiamine intake, impairing gastrointestinal absorption of thiamine, and causing impaired thiamine utilization in cells. Note that individuals who partake in prolonged alcohol abuse may have various other dietary deficiencies.
Prolonged alcohol abuse can result in a severe deficiency in thiamine, or vitamin B1 by reducing dietary thiamine intake, impairing gastrointestinal absorption of thiamine, and causing impaired thiamine utilization in cells. Note that individuals who partake in prolonged alcohol abuse may have various other dietary deficiencies.
Alcohol abuse-induced thiamine deficiency can cause which of the following?
Alcohol abuse-induced thiamine deficiency can cause which of the following?
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Wernicke-Korsakoff syndrome is caused by a severe deficiency in thiamine, often seen in severe alcohol dependency. It is characterized by visual disturbances, ataxia, and altered consciousness. Wolf-Hirschhorn syndrome is a genetic disorder causing developmental disability and may involve seizures. Lewy body dementia is associated with Parkinson's disease. Agnosia is a neurological disorder causing impaired ability to process sensory information.
Wernicke-Korsakoff syndrome is caused by a severe deficiency in thiamine, often seen in severe alcohol dependency. It is characterized by visual disturbances, ataxia, and altered consciousness. Wolf-Hirschhorn syndrome is a genetic disorder causing developmental disability and may involve seizures. Lewy body dementia is associated with Parkinson's disease. Agnosia is a neurological disorder causing impaired ability to process sensory information.
Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal?
Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal?
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Delirium tremens (DT) is a rapid onset of confusion seen during alcohol withdrawal. The symptoms of DT include altered mental status, autonomic instability, and even seizures. DT is also characterized by hallucinations such as the sensation of something "crawling" on the patient. DT is the most severe consequence of withdrawal and can be fatal if untreated.
Delirium tremens (DT) is a rapid onset of confusion seen during alcohol withdrawal. The symptoms of DT include altered mental status, autonomic instability, and even seizures. DT is also characterized by hallucinations such as the sensation of something "crawling" on the patient. DT is the most severe consequence of withdrawal and can be fatal if untreated.
The nurse is discussing end-of-life care procedures with an elderly patient who is Buddhist. The nurse knows that the patient will most likely want to incorporate:
The nurse is discussing end-of-life care procedures with an elderly patient who is Buddhist. The nurse knows that the patient will most likely want to incorporate:
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Buddhists will want time for meditation, and may refuse medications that alter awareness. A shrine to Buddha may be placed in the client's room.
Buddhists will want time for meditation, and may refuse medications that alter awareness. A shrine to Buddha may be placed in the client's room.
The nurse cares for an 82-year-old woman with frequent constipation. Which of the following statements by the nurse would be inappropriate?
The nurse cares for an 82-year-old woman with frequent constipation. Which of the following statements by the nurse would be inappropriate?
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Elderly patients may suffer from bowel problems like constipation due to lower motility in the gastrointestinal tract. The nurse should advise this client to exercise daily (to increase blood flow to the GI tract), stay hydrated (to prevent hard, dry stools), eat more fiber (such as fruits, vegetables, nuts, grains, and beans), and stay away from milk and cheese (as lactose sensitivity is common and may be a cause of constipation or bloating). This patient should not take laxatives each time a bowel movement is expected; reliance on laxatives is not recommended because it can desensitize the bowel and make constipation worse.
Elderly patients may suffer from bowel problems like constipation due to lower motility in the gastrointestinal tract. The nurse should advise this client to exercise daily (to increase blood flow to the GI tract), stay hydrated (to prevent hard, dry stools), eat more fiber (such as fruits, vegetables, nuts, grains, and beans), and stay away from milk and cheese (as lactose sensitivity is common and may be a cause of constipation or bloating). This patient should not take laxatives each time a bowel movement is expected; reliance on laxatives is not recommended because it can desensitize the bowel and make constipation worse.
A first time mother comes in ten days after giving birth to a healthy daughter. She is concerned because she has been bleeding continuously from her vagina since labor. The blood is red to brown, and she has been using sanitary napkins, which she must change about every 3 hours. How do you counsel her?
A first time mother comes in ten days after giving birth to a healthy daughter. She is concerned because she has been bleeding continuously from her vagina since labor. The blood is red to brown, and she has been using sanitary napkins, which she must change about every 3 hours. How do you counsel her?
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Postpartum bleeding, referred to as lochia, is a normal process wherein the individual sheds blood, mucus, and uterine tissue after delivery. This bleeding can continue for up to six weeks, and coloration can change from bright red blood (lochia rubra) to pinkish-brown discharge (lochia serosa).
Postpartum bleeding, referred to as lochia, is a normal process wherein the individual sheds blood, mucus, and uterine tissue after delivery. This bleeding can continue for up to six weeks, and coloration can change from bright red blood (lochia rubra) to pinkish-brown discharge (lochia serosa).
A new mother comes in two weeks postpartum. She is complaining of left breast tenderness and heat. On PE you note a slightly enlarged left breast that is mildly erythematous and very tender on palpation. This is most likely what condition?
A new mother comes in two weeks postpartum. She is complaining of left breast tenderness and heat. On PE you note a slightly enlarged left breast that is mildly erythematous and very tender on palpation. This is most likely what condition?
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Mastitis is an inflammation of the breast tissue, often due to milk stasis in a breastfeeding individual and occurring most commonly in the first few weeks after delivery. Causes can include poor latching, tight bras or clothing, or infection. Incidence is higher in individuals who are immunocompromised, and in people with cracked nipples or a past history of mastitis with a previous birth. Mastitis is not an emergency, nor is it any type of cancer, cyst, or serious breast disease.
Mastitis is an inflammation of the breast tissue, often due to milk stasis in a breastfeeding individual and occurring most commonly in the first few weeks after delivery. Causes can include poor latching, tight bras or clothing, or infection. Incidence is higher in individuals who are immunocompromised, and in people with cracked nipples or a past history of mastitis with a previous birth. Mastitis is not an emergency, nor is it any type of cancer, cyst, or serious breast disease.