Eating Garlic Boosts Hydrogen Sulfide Which Relaxes Arteries

Eating garlic is one of the best ways to lower high blood pressure and protect yourself from cardiovascular disease. A new study from the University of Alabama at Birmingham (UAB) shows this protective effect is closely linked to how much hydrogen sulfide (H2S) is produced from garlic compounds interacting with red blood cells.

The UAB researchers found this interaction triggered red blood cells to release H2S, which then led to the relaxation of blood vessels. Fresh garlic was used at a concentration equal to eating two cloves. The resulting H2S production caused up to 72 percent vessel relaxation in rat arteries.

This relaxation is a first step in lowering blood pressure and gaining the heart-protective effects of garlic, said David Kraus, Ph.D., a UAB associate professor in the Departments of Environmental Health Sciences and Biology and the study's lead author.

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Diabetes control causes favorable shift of cholesterol balance

Diabetes control causes favorable shift of cholesterol balance

By Philip Ford

15 October 2007

Atherosclerosis 2007; 194: 465-472

MedWire News: Effective control of Type 1 diabetes causes a change in lipid metabolism that makes for a less atherogenic lipid profile, results published in the journal Atherosclerosis show.

"The metabolism of different lipoproteins in Type 1 diabetes has been studied extensively, indicating abnormalities in every lipoprotein fraction, but that of cholesterol has been assayed only in five moderately small-scale studies," report Tatu Miettinen (University of Helsinki, Finland) and fellow researchers.

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Reprinted with kind permission from MedWire News

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Asymptomatic Carotid Artery Blockage A Significant Stroke Risk

Carotid artery blockages, such as the one Senator Kennedy had removed, are a significant risk factor for stroke but many do not know that they have the life-threatening condition. Doppler ultrasound screening is a successful tool for revealing blocked carotid arteries prior to the onset of a stroke and before death or disability occurs.

Life Line Screening, the nation's leading provider of mobile vascular screening, including carotid artery screening, has identified nearly 100,000 people with seriously blocked carotid arteries who had no symptoms at the time of the screening.

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Tumor-fighting immune cells reduced in breast cancer

By Andrew Czyzewski

12 October 2007

Br J Cancer 2007; Advance online publication

MedWire News: Women with advanced breast cancer have fewer and less immunoresponsive dendritic cells than healthy individuals, study findings indicate.

The researchers also show that the immune response of these compromised cells can be boosted with CD40 ligand in vitro, offering hope for effective immunotherapies for breast cancer.

Dendritic cells are antigen-presenting cells that play a central role in initiating and directing antitumor immunity and are therefore important in the defense against cancer, explain José Alejandro López (Queensland Institute of Medical Research, Brisbane, Australia) and colleagues in the British Journal of Cancer.

Tumors employ numerous mechanisms to evade immune detection and elimination, however, including suppression of dendritic cells.

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Philippine Nursing

http://Philippinenursing.blogspot.com

MEDICAL-SURGICAL NURSING 50 Items

1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?
a. checking stools for occult blood
b. performing range-of-motion exercises to the left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees

ANS: D
Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
a. destroys the odor-proof seal
b. wont affect the colostomy system
c. is appropriate for relieving the gas in a colostomy system
d. destroys the moisture barrier seal

ANS: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.

3. When assessing the client with celiac disease, the nurse can expect to find which of the following?
a. steatorrhea
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure

ANS: A
Because celiac disease destroys the absorbing surface of the intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn’t cause a widened pulse pressure.

4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:
a. reducing sodium promotes urea nitrogen excretion
b. reducing sodium improves her glomerular filtration rate
c. reducing sodium increases potassium absorption
d. reducing sodium decreases edema

ANS: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn’t affected by sodium intake.

5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the:
a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

ANS: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.

6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:
a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus

ANS: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. Notify the physician about cloudy or foul-smelling urine
d. Report bright pink urine within 24 hours after the procedure

ANS: C
The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal because of residual stone products. Hematuria is common after lithotripsy.

8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?
a. deficient fluid volume related to osmotic diuresis
b. decreased cardiac output related to elevated heart rate
c. imbalanced nutrition: Less than body requirements related to insulin deficiency
d. ineffective thermoregulation related to dehydration

ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition: Less then body requirements isn’t appropriate. A temperature of 100.6º F isn’t life threatening, eliminating ineffective thermoregulation as the top priority.

9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s:
a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m.
d. onset to be at 4 p.m. and its peak at 6 p.m.

ANS: C
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg

ANS: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from the MAP; in this case , 70 mmHg – 18 mmHg = 52 mmHg.

11. A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes

ANS: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retraction—not eversion—may be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benigned cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass.

12. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist

ANS: D
An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.

13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?
a. basilar
b. temporal
c. occipital
d. parietal

ANS: A
Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.

14. A male client should be taught about testicular examinations:
a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20

ANS: D
Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.

15. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results

ANS: B
Before weaning a client from mechanical ventilation, it’s most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

16. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women:
A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation every 2 years

ANS: B
According to the ACS guidelines, “Women older than age 40 should perform breast self-examination monthly (not annually).” The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers

ANS: C
Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.

18. A 49-yer-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair:
A. has very low complication rate
B. maintains reduction and overall hand function
C. is less bothersome than a cast
D. is best for older people

ANS: B
Complex intra-articular fractures are repaired with external fixators because they have a better long-term outcome than those treated with casting. This is especially true in a young client. The incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be taught how to do pin care and assess for development of neurovascular complications.

19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?
A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”

ANS: C
In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in Protein), bananas (high in potassium), and fluid because the kidneys can’t secrete adequate urine.

20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has tow children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
A. Tell the client’s spouse or partner to be supportive while she recovers.
B. Encourage the client to proceed with the next phase of treatment.
C. Recommend that the client remain cheerful for the sake of her children.
D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.

ANS: D
The client isn’t withdrawn or showing other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client’s spouse or partner to listen to concerns, but the nurse shouldn’t tell the client’s spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can’t be expected to be cheerful at all times.

21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should include the fact that:
A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a possible infection.
C. The test was ordered because clients who have testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the testosterone level.

ANS: C
HCG is one of the tumor markers for testicular cancer. The HCG level won’t identify the site of an infection or evaluate prostatic function or testosterone level.

22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.

ANS: B
Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but the don’t indicate that therapy isn’t effective.

23. Which assessment finding indicates dehydration?
A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention

ANS: A
Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration.

24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.

ANS: B
The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.

25. For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
A. Administer aspirin if the temperature exceeds 38.8º C.
B. Inspect the skin for petechiae once every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.

ANS: B
Because thrombocytopenia impairs blood clotting, the nurse should assess the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it can increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure

ANS: B
SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesn’t indicate the client’s overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn’t enough data to assume that the client’s problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.

27. For a client in addisonian crisis, it would be very risky for a nurse to administer:
A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone

ANS: A
Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature:
A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes

ANS: D
Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.

29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
A. Putting on sterile gloves then opening a container of sterile saline.
B. Cleaning the wound with a circular motion, moving from outer circles toward the center.
C. Changing the sterile field after sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

ANS: C
A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren’t sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area—for example, from the center outward. The outer inch of a sterile field shouldn’t be considered sterile.

30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein

ANS: C
Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High- fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps in increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high-calorie foods are.

31. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which organ?
A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid

ANS: A
Excessive of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the cathecolamines—epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for infective endocarditis?
A. appendectomy
B. pernicious anemia
C. diabetes mellitus
D. valve replacement

ANS: D
A heart valve prosthesis, such as a mitral valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, IV drug abuse, and immunosuppression. Although diabetes mellitus may predispose a person to cardiovascular disease, it isn’t a major risk factor for infective endocarditis, nor is an appendectomy or pernicious anemia.

33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. She’s fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client?
A. Deficient fluid volume related to inability to conserve water
B. Imbalanced nutrition: less than body requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency

ANS: A
The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client.

34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?
A. Let the client eat as desired during the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a typical day.
D. Place the client on I & O status and draw blood for electrolyte levels.

ANS: C
When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn’t be permitted to eat as desired. Weighing the client daily, placing her on I & O status, and drawing blood to determine electrolyte level aren’t part of a nutritional assessment.

35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular fitness.

Regular follow-up care for the client with Grave’s disease is critical because most cases eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client’s ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise to improve cardiovascular fitness is important, for this client the importance of regular follow-up is most critical.

36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
A. Deficient knowledge related to interventions used to treat acute illness
B. Impaired physical mobility related to complete bed rest
C. Social isolation related to restricted visiting hours in the intensive care unit
D. Anxiety related to the threat of death

ANS: D
Anxiety related to the threat of death is an appropriate nursing diagnosis because the client’s anxiety can adversely affect hear rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death is a real and immediate concern. Unless anxiety is dealt with first, the client’s emotional state will impede learning. Client teaching should be limited to clear concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the deficient knowledge would continue despite attempts t teaching. Impaired physical mobility and social isolation are necessitated by the client’s critical condition; therefore, they aren’t considered problems warranting nursing diagnoses.

37. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care?
A. Putting on a mask when entering the client’s room.
B. Instructing the client to wear a mask at all times
C. Wearing a gown and gloves when providing direct care
D. Keeping the door to the client’s room open to observe the client

ANS: A
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client’s room. Having the client wear a mask at all the times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client’s blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.

38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:
A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of nausea.
C. Irrigate the NG tube gently with normal saline solution.
D. Reposition the NG tube if pulled out.

ANS: C
The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously, not every hour. The NG tube shouldn’t be clamped postoperatively because secretions and gas will accumulate, stressing the suture line.

39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24 hours
C. administer a dextrose solution containing normal saline solution
D. administer IV fluid slowly to prevent circulatory overload and collapse

ANS: A
Regardless of the client’s medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in case of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

40. Which of the following is an adverse reaction to glipizide (Glucotrol)?
A. headache
B. constipation
C. hypotension
D. photosensitivity

ANS: D
Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesn’t cause headache, constipation, or hypotension.

41. The nurse is caring for four clients on a step-down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy tube

ANS: B
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artificial airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. Whit standard procedures the other choices wouldn’t be at high risk.

42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.

ANS: C
In chronic bronchitis, the diaphragmatic is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing—not chest breathing—increases lung expansion.

43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to her would be:
A. “You seem angry. Would you like to talk about it?”
B. “Calm down. You know that stress will make your symptoms worse.”
C. “Would you like to talk about the problem with the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when you’ve calmed down.”

ANS: A
Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn’t acknowledge her feelings. Offering to get the nursing supervisor also doesn’t acknowledge the client’s feelings. Ignoring the client’s feelings suggest that the nurse has no interest in what the client has said.

44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of total calories
D. Avoiding foods that increase levels of high-density lipoproteins (HDLs)

ANS: A
Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels.

45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be:
A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent

ANS: A
Gastric decompression is typically low pressure and intermittent. High pressure and continuous gastric suctioning predisposes the gastric mucosa to injury and ulceration.


46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body requirements

ANS: A
In osteoarthritis, stiffness is common in large, weight bearing joints such as the hips. This joint stiffness alters functional ability and range of motion, placing the client at risk for falling and injury. Therefore, client safety is in jeopardy. Osteoporosis doesn’t affect urinary elimination, breathing, or nutrition.

47. Parathyroid hormone (PTH) has which effects on the kidney?
A. Stimulation of calcium reabsorption and phosphate excretion
B. Stimulation of phosphate reabsorption and calcium excretion
C. Increased absorption of vit D and excretion of vit E
D. Increased absorption of vit E and excretion of Vit D

ANS: A
PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vit D to its active form: 1 , 25 dihydroxyvitamin D. PTH doesn’t have a role in the metabolism of Vit E.

48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse?
A. A bathroom with grab bars for the tub and toilet
B. Items stored in the kitchen so that reaching up and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches t the top and bottom of the stairs

ANS: C
The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a resident at high risk for falls.

49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In considering her response to the client, the nurse must depend on the ethical principle of:
A. beneficence
B. autonomy
C. advocacy
D. justice

ANS: B
Autonomy ascribes the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence and justice aren’t the principles that directly relate to the situation. Advocacy is the nurse’s role in supporting the principle of autonomy.

50. Which of the following is t he most critical intervention needed for a client with myxedema coma?
A. Administering and oral dose of levothyroxine (Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and output
D. Maintaining a patent airway

ANS: D
Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Thyroid replacement will be administered IV. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming blankets would be appropriate. Intake and output are very important but aren’t critical interventions at this time.


Sven
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New Evidence Supports Non-invasive Routine Screening And Earlier Diagnosis Of Colon Cancer

New results of a pivotal study recently presented at a meeting of the American College of Radiology Imaging Network (ACRIN), showed that Computed Tomography (CT) colonography is at least as sensitive as conventional colonoscopy in detecting adenomas of 1 cm diameter or larger. Adenomas are precursors to colorectal cancer, the second most common cause of death from cancer in the EU with more than 138,000 deaths in 20001. The results of the study are expected to lead to wider adoption of CT colonography (also known as virtual colonoscopy) as routine screening for colorectal cancer. The study, funded by the US National Institutes of Health (NIH), was initiated in 2005 and has involved more than 2,500 asymptomatic patients aged 50 or over at 15 centres across the USA.

The trial compared the detection of polyps and early-stage cancer of the colon using either conventional optical colonoscopy or CT colonography, in which X-ray slice images are reconstructed by computer to provide a virtual image of the colon. Patients were investigated using both procedures and the resulting CT images were read by a panel of radiologists.

Dr Stuart Taylor of University College Hospital, London, a consultant radiologist, commented: "This very well designed study is the largest to date which has specifically investigated the use of CT colonography to screen for colorectal neoplasia in asymptomatic individuals, and has produced very positive results. The 90% sensitivity for identifying patients harbouring a 1 cm adenoma essentially validates the previously reported excellent performance of screening CT colonography by Dr Perry Pickhardt in 2003. I think we can now conclude that, when performed by appropriately trained readers, CT colonography is a viable and robust screening tool for colorectal cancer."

Click here to see the rest of this article in Medical News Today

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Philippine Nursing

http://Philippinenursing.blogspot.com

Half of asthma cases due to atopy

By Liam Davenport

01 October 2007

J Allergy Clin Immunol 2007; Advance online publication

MedWire News: Around half of asthma cases in the general population are due to atopy, and almost a third of these are due to cat allergy, report US scientists who say that the prevention or reversal of atopy could substantially reduce the burden of asthma.

Atopy, which is defined as a propensity to develop immunoglobulin E antibodies in response to allergen exposure, is a known risk factor for asthma. However, it is not clear how many asthma cases are attributable to atopy.

Click here to see the rest of this article in MedWire News
Reprinted with kind permission from MedWire News

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NLE | NCLEX | Psychiatric nursing reviewer

Psychiatric Nursing | Preparation to NLE | NCLEX

Note: This post is supposed to be hidden and should not be posted in a navigation bar

I. Basic Concepts in Psychiatric Nursing

Mental Health

Mental Ill Health

Psychiatric Nursing

-Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences.

Both a Science and Art

Core of Psychiatric Nursing:

-Interpersonal process

Clientele:

-Individual, family and the community

- Both mentally healthy and mentally ill

Main Tool of the Nurse

-Therapeutic use of Self

CONCEPTS

Use of Self

Therapeutic use of self - positive use of one’s self in the process of therapy

- it requires self-awareness

Basic Principles

Basis: Joharis Window

	Known to self	Not Known to self
Known to others	Public Self I	Semi-public Self II
Not known to others	Private self III	Areas of the Unknown IV

Goal: To increase quadrant I, decrease quadrant II and III

Methods Used to Increase Self- Awareness

1. Introspection:

-Viewing one’s self as honestly as possible

2. Discussion:

- Learning about oneself through association with others

3. Enlarging One’s Experience:

- Engage in a particular activity and noting one’s reaction to it.

4. Role playing:

- A situation in which participants enact a role

Core Concepts on the Care of the Psychotic Patient

On Admission of the Client

1. Priority
2. Determine the reason why the client sought help
3. Client’s rights
4. Initial assessment

J

O

I

M

A

T

Common Behavioral Signs and Symptoms

1. Disturbance in perception:

Illusion -misperception of an actual external stimuli

Hallucination -false sensory perception in the absence of external stimuli

Visual -seeing

Tactile -feeling that there are some insects crawling on the skin

2. Disturbances in thinking

Neologism - pathologic coining of words

Circumstantiality - over inclusion of details

Word Salad - incoherent mixture of words and phrases

Verbigeration - incoherent mixture of word or phrases

Perseveration - persistence of a response to a previous question

Echolalia - pathological repetition of words

Flight of ideas - shifting from of one topic from one subject to another in a somewhat related way

Looseness of association - shifting of a topic from one subject to another in a completely unrelated way

Clang association - the sound of the word gives direction to the flow of thought

Delusion - false belief which is inconsistent with one’s knowledge and culture

3. Disturbances of affect

Inappropriate affect - disharmony between the stimuli and the emotional reaction

Blunted effect - severe reduction in emotional reaction

Flat affect - absence or near absence of emotional reaction

Apathy - dulled emotional tone

Ambivalence - presence of two opposing feelings

Depersonalization - feeling of strangeness towards one’s self

Derealization - feeling of strangeness towards the environment

4. Disturbances in Motor Activity

Echopraxia - the pathological imitation of posture/action of others

Waxy flexibility – maintaining the desired position for long periods of time without discomfort

5. Disturbances in memory

Confabulation - filling in of memory gaps

Amnesia - inability to recall past events

Anterograde amnesia - loss of memory of the immediate past

Retrograde amnesia - loss of memory of the distant past

Déjà vu - feeling of having been to a place which one has not yet visited

Jamais vu - feeling of having been to a place which one has visited before

Use of Appropriate Communication Techniques

Communication:

Reciprocal exchange of ideas between or among persons.

Modes of communication:

1. Verbal - written/spoken

2. Non-verbal - posture, tone of voice, facial expression

3. Meta communication - based on role expectations/hidden meaning of words

Elements of Communication

Sender - originator of information

Message - information being transmitted

Receiver - recipient of information

Channel - Mode of communication

Feedback - return response

Context - the setting of communication

Criteria of successful communication

Feedback

Appropriateness

Flexibility

Efficiency

Common Problems in Communication

1. Dysfunctional communication
2. Double bind communication
3. Denotative vs. connotative meaning
4. Incongruent communication

Techniques of Communication

If your goal is:

To initiate conversation:

Giving broad opening

Giving recognition

To establish rapport and build trust:

Giving information

Use of silence

To gather information:

Focusing

Validating

Reflecting

Interpreting

Restating

To close a conversation:

Summarizing

How to Choose a Therapeutic Response in The Board Exam

Establish Nurse Patient Relationship

Nurse-Patient Relationship

Series of interaction between the nurse and the patient in which the nurse assists the patient to attain positive behavioural change.

1. Characteristics

NPR Social Relationship

2. Phases

1. Pre-Interaction Phase

- begins when the nurse IS assigned/chooses a patient

- phase of NPR in which patient is excluded as an active participant

- nurse feels certain degree of anxiety

- includes all of what the nurse thinks and does before interacting with the patient

Major task of the nurse:

to develop self-awareness

Other tasks:

data gathering, planning for first interaction

2. Orientation Phase

- when the nurse-patient interacts for the first time

- parameters of the relationship are laid

- nurse begins to know about the patient

Major task:

to develop a mutually acceptable contract

Other tasks:

determine why the patient sought help

establish rapport, develop trust, assessment

3. Working Phase

- it is highly individualized

- more structured than the orientation phase

- the longest and most productive phase of the nurse-patient relationship

- limit setting is employed

Major task:

identification and resolution of the patient’s problems

Other tasks:

Planning and implementation

4. Termination Phase

- it is a gradual weaning process

- it is a mutual agreement

- it involves feeling of anxiety, fear and loss

- it should be recognized in the orientation phase

- it should be recognized in the orientation phase

Major task:

to assist the patient to review what he has learned and transfer his learning to his relationship with others.

Other task:

Evaluation

When to terminate?

How to terminate?

Common Problems Affecting NPR

1. Transference - the development of an emotional attitude of the patient either positive or negative towards the nurse.

2. Resistance - development of ambivalent feelings towards self-exploration.

3. Counter Transference - as experienced by the nurse

Initial Interventions

Principles of Care in Psychiatric Settings

1. The nurse views the patient as a Holistic human being with interdependent and interrelated needs.

2. The nurse accepts the patient as a unique being with inherent value and worth exactly as he is.

3. The nurse should focus on the patient’s strengths and assets and not on his weakness and liabilities.

4. The nurse views the patient’s behaviour non-judgmentally, while assisting the patient to learn more adaptive ways of coping.

5. The nurse should explore the patient’s behaviour for the need it is designed to meet and message it is communicating.

6. The nurse has the potential for establishing a nurse-patient relationship with most if not all patients.

7. The quality of the nurse-patient relationship determine the degree of positive change that can occur in the patient’s behaviour.

Level of Interventions in Psychiatric Nursing

Primary – Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors.

Secondary – interventions that limits the severity of a disorder.

2 Components

1. Case Finding

2. Prompt treatment

Tertiary – interventions aimed at reducing the disability after a disorder.

2 Components

1. Prevention of complication

2. Active program of rehabilitation

Characteristics of a Psychiatric Nurse

1. Empathy – the ability to see beyond outward behaviour and sense accurately another person’s inner experience.

2. Genuineness/Congruence – ability to use therapeutic tools appropriately.

3. Unconditional Positive Regard – respect

Roles of the Nurse in Psychiatric Settings

1. Ward Manager

Responsibility:

2. Socializing Agent

Responsibility:

3. Counselor

Responsibility:

4. Parent Surrogate

Responsibility:

5. Patient Advocate

Responsibility:

6. Teacher

Responsibility:

7. Technician

Responsibility:

8. Therapist

Responsibility:

9. Reality Base

Responsibility:

10. Healthy Role Model

Responsibility:

Types of Interventions

7.1 Biologic

7. 1. 1 Pharmacologic

II. Basic Concepts on Psychoparmacology

Neurons:

Neurotransmitters:

Classification of Psychopharmacologic Agents

A. Major Tranquilizers/Antipsychotics:

Indication:

MOA:

Examples:

Haloperidol (Haldol)

Fluphenazine ( Prolixin

Prochlorperazine (Compazine)

Chlorpromazine (Thorazine)

Side effects:

Blurred vision, dry mouth, tachycardia, palpitation, constipation, urinary retention

Skin: Photosensitivity

BP: Orthostatic hypotension

EPS: Extra Pyramidal Symptoms

- Pseudoparkinsonism

-pill-rolling tremor, mask-like face, cog-wheel rigidity, propulsive gait

- Akathisia

-restless leg syndrome

- Dystonia

- defect in muscle tone

Adverse effect:

1. Tardive dyskinesia-lip smacking

2. Agranulocytosis

3. Hepatoxicity

Principles of Nursing Care

C

H

E

C

K

B. Anti-Parkinsonian Agents:

Indication:

2 Types:

1. Dopaminergic Drugs

MOA:

Examples: Amantadine (Symmetrel)

2. Anticholinergic Drugs

MOA:

Trihexyphenidyl (Artane)

Biperiden Hydrochloride (Akineton)

Benztropine Mesylate (Cogentin)

Diphenhydramine Hydrochloride (Benadryl)

Side effects:

Anticholinergic: blurred vision, constipation, orthostatic hypotension

Adverse effects:

Dry mouth, urinary retention, sore throat

Principles of Nursing Care

C

H

E

C

K

C. Minor Tranquilizers/Anxiolytics

Indications:

MOA:

Examples:

Diazepam (Valium)

Chlordiazepoxide (Librium)

Aprazolam (Xanax)

Oxazepam (Serax)

Chlorazepate Dipotassium (Tranxene)

Side effects:

Adverse effects:

Principles of Nursing Care:

C

H

E

C

K

D. Antidepressants

Common Types:

1. Tricyclics
2. MAO inhibitor
3. Stimulants

MOA:

Examples:

Imipramine (Tofranil)

Amitriptyline (Elavil)

Tranylcypromine (Parnate)

Isocarboxazid (Marplan)

Phenelzne (Nardil)

Ritalin (Methylphenidate)

Amphetamine (Benzedrine)

Adverse effect:

Cardiac arrhythmia, hypertensive crisis, growth suppression

Side effect:

Principles of Nursing Care:

C

H

E

C

K

Drug update: SSRI – Selective Serotonin Reuptake Inhibitor

- inhibits serotonin uptake

Example : Fluoxetine (Prozac)

Side effects : GI Discomforts

Adverse effects: Tremors, decrease in libido

E. Anti-manic agents

1. Lithium Carbonate

MOA:

C

H

E

C

K

2. Carbamazepine

7. 1. 2. Somatic Therapy

Electro-convulsive Therapy

MOA:

Voltage:

Duration:

Number of treatment

Frequency:

Indicators of effectiveness:

Indications:

1. Depression
2. Mania
3. Catatonic schizo

Contraindications: (relative) – there is no absolute contraindication to ECT

1. Fever
2. ICP brain tumor
3. Cardiac
4. TB with history of hemorrhage
5. Recent fracture
6. Retinal detachment
7. Pregnancy

Patient Preparation:

Before the procedure:

Consent:

Physical exam:

X-ray

ECG

EEG

NPO

Restrainments:

Administration of Atropine SO4

Anectine (Succinylcholine)

Methohexital Na (Brevital)

During the procedure:

Observe the patient tonic-clonic contraction

After the procedure:

Position

Vital signs

Reorient the patient

Common complications: Memory loss, headache, fracture, apnea

7.2 Psychosocial Interventions

III. Common Psychotherapeutic Interventions

1. Remotivation therapy

5 Different Steps

1. Climate of acceptance
2. Creating of bridge to reality
3. Sharing the world we live in
4. Appreciation of the works of the world
5. Climate of appreciation

2. Music Therapy

3. Play Therapy

4. Group Therapy

5. Psychodrama

6. Milieu Therapy

7. Family Therapy

8. Psychoanalysis

9. Hypnotherapy

10. Humor Therapy

11. Transactional Analysis

12. Behavior Modification

13. Aversion Therapy

14. Token Economy

15. Gestalt Therapy

IV. Dynamics of Human Behavior

Need – is an organismic condition which requires a certain activity

Stress – pressure of varying degrees: Distress – unhealthy stress

Eustress – healthy stress

Behavior – way in which an organism responds to a stimulus

Conflict – situation that arise from the presence of two opposing drives

Types:

Approach-Approach -both of each chosen have positive attributes

Avoidance-Avoidance -negative attribute

Approach-Attribute - choice have positive and negative attributes Double approach - avoidance

V. Basic Concepts on the Client

Personality

- The integration of those systems and habits that represents an individuals characteristic adjustment to his environment

- Expressed through behaviour.

2 Characteristics of Personality

1. Distinctiveness - each individual is unique

2. Stability and consistency personality is predictable

Determinants:

1. Psychological - type of climate at home

2. Cultural - customs and traditions

3. Biological - personality is not inherited

4. Familial - parenting style

3 divisions of the mind:

1. Conscious - part of the mind that is focused on awareness

2. Subconscious - part of the mind that contains information that can be recalled at will.

3. Unconscious - largest part of the mind; contains materials and information that can never be recalled.

Structures of Personality

ID EGO SUPEREGO

Theories of Personality Development

A. Freud’s Psychosexual theory

First to identify/classify the stages of development

0-18 mos: Oral Stage

Area of Gratification:

Indicators of Fixation:

18 mos – 3 years: Anal Stage

Area of Gratification:

Indicators of Fixation:

3-6 years: Phallic Stage

Area of Gratification:

Indicators of Fixation:

6-12 years Latency: (Quiet Stage)

Area of Gratification:

Indicators of Fixation:

12 -21 years Genital Stage

Area of Gratification:

Indicators of Fixation:

B. Erikson’s Psychosocial Theory

First to include adulthood as a stage of development

0-12 mos: Trust vs. Mistrust

If the needs of the child is consistently met, trust develops.

1-3 years: Autonomy vs. Shame and Doubt

If toilet training is not hurried, autonomy develops.

3-6 years: Initiative vs. Guilt

If the child’s sexual curiosity is handled without anxiety, initiative develops.

6-12 years: Industry vs. Inferiority

If the child’s efforts at learning is supported, industry develops.

12-18 years: Identity vs. Role Diffusion

If the adolescent’s vocational decision is supported, identity develops.

18-25 years: Intimacy vs. Isolation

If the adolescent’s decisions regarding love relationship is supported, intimacy develops.

25-65 years: Generativity vs. Stagnation

If an individual enjoys support from the family, generativity develops.

65 onward: Integrity vs. Despair

If the person has a satisfying past recollection, integrity develops.

C. Piaget’s Cognitive Theory of Development.

First to Focus on Cognitive Development

0-2 years: Sensory Motor Stage

Development proceeds from reflex activity to sensory motor learning

Child learns that he is separate from the environment

Child learns the concept of object permanence

2-7 years: Pre-operational Stage

2-4 yrs: pre-conceptual development proceeds from sensory motor learning to pre-logical thought.

The child learns language and symbols.

4-7 yrs: intuitive thought: The child is able to think in terms of class.

The child is able to determine that individuals have roles.

7-12 years: Concrete Operational Stage

Development proceeds from pre-logical concrete thought.

12 years to adulthood: Formal Operational Stage

The child is able to think abstractly, able to apply the scientific method.

VI Crisis and Crisis Intervention

Crisis – situation that occurs when an individual’s habitual coping ability becomes ineffective to meet the demands of a situation.

Characteristics:

Types of Crisis:

1. Maturational/developmental crisis - expected, predictable and internally motivated.

Example: growth

2. Situational/accidental - unexpected, unpredictable and externally motivated.

Example: car accident

3. Social crisis - due to acts of nature

Example: earthquake

Crisis intervention

A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress.

Phases of Crisis

Denial – initial reaction

Increased tension – the person recognizes the presences of a crisis and continues to do activities of daily living.

Disorganization – the person is preoccupied with the crisis and is unable to ADL.

Attempts to reorganize – individual mobilizes previous coping mechanism.

Some Conditions Requiring Crisis Intervention

1. Rape

Some Facts of Rape:

Ruthless

Abusive

Personal

Experience

Essential Elements Necessary to Define an Act of Rape

1. Use of threat/force
2. Lack of consent of the victim
3. Actual penetration of the penis into the vagina

Different Kinds of Rape

Power

Anger

Sadistic

Principles of Nursing Care:

Rape Trauma Syndrome (RTS)

1. acute phase

2. denial

3. heightened anxiety

4. stage of reorganization

Battered Wife Syndrome (BWS)

Characteristics of Abusive Husband:

1. They usually come from violent families

2. They are immature, dependent and non-assertive

3. They have strong feelings of inadequacy

Phases

1. Tension building phase

2. Acute battering incident

3. Aftermath/honeymoon stage

Principles of Nursing Care:

Child Abuse

Abuse - is what happens when an adult takes advantage of his authority over a child.

Violence - refers to the use of force.

Neglect - lack of provision of those things which are necessary for the child’s growth and development.

Physical abuse - abuse in the form of inflicting pain

Emotional abuse - insult and undermining one’s confidence

Sexual abuse - abuse in the form of unwanted sexual contact

Characteristic of Abusive Parents

- they come from violent families

- they were also abused by their parents

- they have inadequate parenting skills

- they are socially isolated because they don’t trust anyone

- they are emotionally immature

- they have negative attitude towards the management of the abused

Indicators of Child Abuse

Principles of Nursing Care:

Where to report:

Whom to report:

Priority:

Anxiety:

Causes of Anxiety

2 classification factors

1. Predisposing factor

Factors that make you at risk

2. Precipitating factor

Factors that cause direct effect

Psychoanalytic theory

Anxiety is caused by a conflict between the Id and the Superego

Interpersonal Theory

Cause of anxiety is fear of interpersonal rejection

Behavioral Theory

Anxiety is a product of frustration

Learning Theory

Exposure to early life fearful experiences causes anxiety

Conflict theory

Presence of opposing drives

Biologic Theory

Anxiety may accompany physical ailments/diseases

Family Studies

Anxiety can run in families

Precipitating factors

Threat to one’s biological integrity

e. g. surgery

Threat to one’s self system

e. g. insult

Signs and Symptoms of Anxiety

Signs and Symptoms	Mild	Moderate	Severe	Panic
Physical	PR, RR, Pupillary dilatation, sweating	nausea, anorexia, vomiting, diarrhea, constipation, restlessness	S/Sx becomes the focus of attention	S/Sx of exhaustion are ignored
Cognitive	Attentive and alert	narrowed perceptual field and selective inattention	perceptual field is greatly narrowed; focus of attention is trivial events	personality disorganized
Emotional	Minimal use of defenses	use of any defense mechanism available	defense mechanisms operate to prevent panic, amnesia, and dissociation	defense mechanisms fail

Nursing Diagnosis

Principles of Nursing Care:

BE C-ALM

A-DMINISTER MEDICATIONS

L-ISTEN

M-INIMIZE ENVIRONMENTAL STIMULI

Defense Mechanisms:

Unconscious, specific intrapsychic adaptive efforts which are employed by the individual to resolve emotional conflict and to cope with anxiety

Characteristics:

It is automatic

It is not the defense mechanism that is pathological but it is the frequent use of it

Used by both mentally healthy and mentally ill individuals

Types:

Compensation - an attempt to overcome a real or imagined shortcoming

Conversion - emotional problems are converted to physical symptoms

Denial - failure to acknowledge an intolerable thought, feeling, experience or reality

Displacement - the redirection of feelings to a less threatening object

Dissociation - detachment of certain activities from normal consciousness which then function alone

Fantasy - conscious distortion of unconscious feelings or wishes

Fixation - arrest of maturation at certain stages of development

Isolation - cutting of or blunting of an unacceptable aspect of a total experience

Introjection - symbolic assimilation or taking into one’s self a love/hatred object

Identification - conscious patterning of one’s self from another person

Intellectualization - over use of intellectual concepts by an individual to avoid expression of feelings

Projection - attributing to other’s one’s unconscious wishes/fears

Reaction formation - expression of feelings that is the direct opposite of one’s real feelings

Rationalization - justifying one’s actions which are based on other motives

Regression - returning to an earlier level of development in the face of stress

Repression - unconscious forgetting

Suppression - conscious forgetting

Substituting - replacing the desired unattainable goal with one that is attainable

Sublimation - the channelling of unacceptable instinctual drive with one that is acceptable

Symbolization - less threatening object is used to represent another

Undoing - an attempt to erase an act, thought, feeling or desire

Anxiety Disorders

Panic Attacks

Intervention:

Agoraphobia

Intervention:

Social Phobia

Intervention:

Simple Phobia

Intervention:

Obsessive-compulsive behaviour

Intervention:

General Anxiety Disorder

Intervention:

Post-traumatic Stress Disorder

Intervention:

Nursing Diagnosis

Drug of Choice:

VII. Personality Disorders

Etiological Factors

1. Genetic Factors
2. Temperamental Factors
3. Biological Factors
4. Psychoanalytic Factors

Types:

Hypochondriacal

Anti-social - habitually breaks the law; with low self-esteem; lacks sense of guilt.

Dependent - incessant demands for attention from others

Schizoid – withdrawn, last to catch up in fashion, introvert, aloof

Shizotypal – bizarre behaviour, silly laughter

Borderline - fears separation; impulsive; unstable but intense relationships

Histrionic – overly concerned with physical appearance, attention seeking behaviour

Extrovert

Avoidant – fears rejection

Paranoid – extreme mistrust and suspiciousness

Passive-Aggressive – loves to procrastinate, expresses anger through passivity

Emphatic Narcissistic – (self-love), believe that they are special and they demand special attention

Obsessive-Compulsive – repetitive thoughts and action, perfectionist, inflexible, rigid

Nursing diagnoses;

1. Ineffective individual coping
2. Self- esteem disturbance

Principles of Nursing Care

1. consistency
2. limit setting

VIII Autism

Treatable but not curable

More common among boys

Usually diagnosed at age 2

Main Problem: Interpersonal functioning

Most Acceptable Cause:

Biological factors – brain anoxia, intake of drugs

Signs and symptoms

1. resist normal teaching method
2. silly laughing or giggling
3. echolalia
4. acts as if deaf
5. no fear of danger
6. insensitive to pain
7. crying tantrums
8. loves to spin objects
9. resists change in the routine
10. not cuddly
11. sustained odd play
12. difficulty interacting with others
13. no eye contact
14. wants blocks not ball
15. points to anything
16. attachment to inanimate objects

Management of priority problems

Tantrum - involves headbanging = place a helmet on the head

Communication – all vowels = use build up and break down

Routines – consistency

Nursing diagnosis:

Potential for injury

IX. Mental Retardation

IQ less than 70

Not a mental illness

Main problem: Inadequate mental functioning

Age of Onset: 18 years old

Causes:

Maternal infection

Exact gestational age is not reached (premature)

Birth injuries

Nutritional deficiency

Toxoplasmosis

Anoxia

Lead poisoning

Recent infection – measles

Environmental factors

Thyroid deficiency

Alcoholic Mother

RH Incompatibility

Damage to brain from various causes

AIDS

Toxemia

Inherited factor

Opiate intoxication

Neurological/neurodevelopment impairment

Levels of Mental Retardation

1. Mild/Moron IQ: 50/55-70 Educable

2. Moderate/Imbecile IQ: 35/40 -50/55 Trainable

3. Severe/Idiot IQ: 20/25 -35/40 Needs close supervision

4. Profound Below 20-25 Needs custodial care

Nursing diagnosis:

Principles of Nursing Care:

1. Repetition
2. Role Modeling
3. Restructuring

Focus of Education:

Reading, writing, basic arithmetic

X. Attention Deficit Hyperactivity Disorder

Common in boys

Usually diagnosed before age 7

Main problem: Inattention, hyperactivity, and impulsivity

Causes:

Neurologic impairment

Pre-natal trauma

Early malnutrition

Frontal lobe-hypoperfusion

Use of drug by mother

Signs and symptoms:

Difficulty remaining seated

Easily distracted by extraneous stimuli

Fidgeting

Interrupts/intrudes on others

Child exhibits hyperactivity

Indulges in destructive behaviour

Talks excessively

Nursing diagnosis: Potential for injury

Principles of Nursing Care:

Nutrition:

Safety:

Drug of Choice: Methylphenidate (Ritalin)

XI. Eating Disorders

Common among females (adolescents)

Most common cause:

Psychological factors

Individual factors (conflict about growing up)

Parental factors (domineering parents)

Socio-cultural factors

Anorexia

Main sign: fear of gaining weight

Amenorrhea

No organic factor accounts for weight loss

Obviously thin but feels fat

Refusal to maintain normal body weight

Epigastric discomfort

X symptoms (peculiar symptoms)

Intense fear of gaining weight

Always thinking of food

Bulimia

Binge eating

Under strict dieting or vigorous exercise

Lacks control over eating binges

Induced vomiting

Minimum of 2 binge eating episode a week for 2 months

Increased/persistent concern of body size/shape

Abuse of diuretics and laxatives

Nursing diagnosis: Body image disturbance/self-esteem disturbance

Ineffective individual coping

Principles of Nursing Care:

1. Monitor patient’s weight
2. Oral hygiene
3. Stay with the patient during mealtime and within 2 hours after meals
4. encourage the patient to remain in a public place after meals
5. behaviour modification

XII. Sexual Disorders

Cause: Psychological factors, unresolved oedipal complex

Paraphilia – a term which generally refers to abnormal sexual behaviour

Types: Sexual Stimulus

Exhibitionism - publicly showing the genitals

Fetishism - from inanimate objects

Anilingus - tongue brushing the anus

Cunnilingus - tongue brushing the vulva

Fellatio - inserting the penis into the mouth

Partialism - inserting the penis into the other parts of the body

Pedophilia - sexual intercourse with a child

Urophilia - urinating on the partner

Coprophilia - smearing feces on the partner

Masochism - sexual gratification from experiencing pain

Sadism - inflicting pain

Telephone scatologia - sex on phone

Voyeurism - sexual gratification by seeing others in the nude

Frotteurism - rubbing the genitalia to the body parts

Transvestism - using the apparel of the opposite sex

Nursing diagnosis: Altered sexual functioning

Principles of Nursing Care:

1. Limit setting
2. Behavior Modification

XIII. Schizophrenia

“Split Mind”

Not a single disease but a combination of disorders

Main Problem:

Signs and Symptoms:

1. Associative looseness

2. Autism

3. Apathy

4. Ambivalence

5. Auditory Hallucination

Most acceptable theory on the cause of Schizophrenia, Biologic Theory

Signs and Symptoms

Social isolation

Catatonic behaviour

Hallucination

Incoherent/marked looseness of association

Zero/lack of interest, energy, and initiative

Obvious failure to attain expected levels of development

Peculiar behaviour

Hygiene and grooming are impaired

Recurrent illusions and unusual perceptual experiences

Exacerbation and remissions are common

No organic factor accounts for signs or symptoms

Inability to return to baseline functioning after each relapse

Affect is inappropriate

Different Types

	Catatonic	Disorganized	Paranoid
Onset	Acute	Insidious	Abrupt
Distinguishing feature	Abnormal motor behavior	Bizarre behavior	Suspiciousness and ideas of reference
Defense mechanism	Repression	Regression	Projection
Nursing diagnosis	Impaired motor activity	Impaired social functioning	Potential for injury directed at others
Priority nursing care	Circulation Nutrition	Assistance with ADL	Nutrition and Safety
Prognosis	Good	Poor	Good

Other types: Undifferentiated

Residual – with minimal symptoms

Criteria for Prognosis

Favorable Prognosis	Unfavorable Prognosis
1. Good socialization 2. Late/acute onset 3. Adequate support system 4. Family history of mood disorder	Poor/no socialization Early and insidious prognosis Few//no support system History of chronicity/many relapses

XIV. Mood Disorders

Predisposing Factors:

Genetic: If one parent ahs bipolar disorder, 25 percent chance of transmission to the child.

Aggression turned inward theory: overdeveloped superego

Object loss theory: loss of parent before age 11

Personality Organization Theory: Obsessive-Compulsive theory, Oral dependent, hysterical personalities have higher predisposition to mood disorders.

Cognitive Theory: Mood disorder results from (-) view of self, (-) view of future, (-) interpretation of experience

Learned Helplessness Theory: Mood disorder is caused by a belief that one has no control over his environment

Psychoanalytic Theory: Mania is a defense against an underlying depression

Depression due to rigid SE

Biologic Factor: Mania is cause by increased norepinephrine while depression is cause by low norepinephrine

Precipitating Factors

1. Loss of a loved one

2. Major life events

3. Roles strain

4. Decreased coping resources

5. physiological changes

Types of Mood Disorders

1. Depression
1. Major Depression-severe, lasts for at least 2 weeks
2. Dysthymic Depression-less severe (2 years)
3. DNOS – lasts for 2 days – 2 weeks

2. Bipolar Disorders
1. Manic-severe, lasts for at least 1 week
2. Hypomanic-lasts for at least 4 days
3. Bipolar I – with history of mania

Bipolar II – with no history of mania

4. Cyclothymic – numerous episodes of hypomania and depressed mood that lasts for at least 2 years

Signs and symptoms:

Mania Depression

Appearance Colorful Sad

Behavior Highly driven, hyperactive Passivity/Psychomotor

retardation

Communication Talkative (Flight of ideas) Monotonous

Nursing Diagnosis Risk for injury Risk for injury to self

directed at others

Nursing Care Lithium ECT

Milieu Therapy Non-stimulating Stimulating

Activity Quiet Type Monotonous activity

Avoid competitive e. g. counting

Attitude therapy Matter of Fact Kind firmness

(attitude of casualness)

Suicide

Ultimate form of self-destruction

“cry for help”

Major intervention: Prevention

Listen

Risk Factors

Sex (more female attempts at suicide but more males commit suicide)

Unsuccessful previous attempt

Identification with a family member who committed suicide

Chronic

Illness (e.g. Cancer)

Depression/Dependent personality

Age (18-25 and 40)/Alcoholism

Lethality of previous attempt/Losses

Nursing Diagnosis: Risk for self-directed injury

Nursing Care:

1. One-on-one monitoring
2. Frequent unscheduled rounds
3. Avoid use of metals and glass utensils
4. Monitor for the signs of impending suicide (e.g. giving away of prized possession)

XV. Conditions Common in the Elderly

Delirium Dementia

Disorientation Loss/impairment of memory

Acute Chronic

Involves young and old Exclusive in the elderly

Clouded sensorium Clear sensorium

Reversible Irreversible

Good prognosis Poor prognosis

Alzheimer’s disease: Irreversible

Main pathology: presence of senile plaques-destroys neurons (decreased acethylcholline)

Signs and symptoms:

Aphasia-inability to talk

Agnosia- inability to recognize object

Apraxia-inability to perform ADL

Amnesia/Memory Loss/Mnemonic disturbance

3 phases

1. Forgetfulness Phase-difficulty of remembering appointments
2. Advance Phase-difficulty of remembering past events but not recent events
3. Terminal Phase-death occurs in 1 year

Nursing Diagnosis: Altered thought processes

Nursing Care:

- Calendar

- Clock (frequent orientation)

- Color

- Consistency (one nurse to lessen confusion)

XVI. Substance Abuse and Substance Dependence

Substance Abuse: use of a substance for other than its legitimate medical purpose

Substance Dependence: physiological and psychological dependence of the body on a substance as evidenced by tolerance and withdrawal

Tolerance: need for an increasing amount of the substance to produce its desired effect or it refers to the declining effect of the drug.

Withdrawal: syndrome or a group of symptoms experienced by the patient when the amount of the substance is reduced or when the intake is stopped.

Alcoholism

Definition:

WHO- alcoholism is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning.

Alcoholism – considered to be present when there is 1% or 10 ml for every 1000 ml of blood.

What happens at level:

.1-.2% (low coordination)

.2-.3% (presence of ataxia, tremors, irritability, stupor)

.3 and above (unconsciousness)

Theories of Causation

1. Psychoanalytic Theories
2. Learning Theories
3. Biological Theories
4. Socio-Cultural Theories

Progression of Alcoholism

1. Pre-alcoholic Phase – starts with social drinking tolerance begins to develop
2. Prodromal Phase – Alcohol becomes a need, blackout’s occur; denial begins to develop
3. Crucial Phase – cardinal symptoms of alcoholism develops (loss of control over drinking)
4. Chronic Phase – the person becomes intoxicated all day

Outcome:

Brain Damage

Alcoholic Hallucinosis

Death

Common Behavioral problems of the Alcoholic Patient

Denial Dependency Demanding Destructive Domineering

Common Withdrawal Signs and Symptoms

Hallucinations

Increased vital signs

Tremors

Sweating and Seizure

Criteria D. Tremens Korsakoff Psychosis Wernickes P.

Cause Faculty metabolism Thiamine & Niacin Thiamine

of alcohol deficiency deficiency

Onset Acute Chronic Chronic

Essential Delirium Memory disturbances

feature

Other S/Sx Vital Signs Retrograde A Confusion

Visual and tactile Anterograde A Opthalmoplegia

Coarse tremors Confabulation Ataxia

Korsakoff’s P. Thiamine def.

Long terms of care

Community resources

Other coping means aside from denial

Personal responsibility for not drinking

Isolation

Nutrition Vitamin B & C, CHO diet

Group therapy

Nursing diagnosis: Ineffective individual coping

Principles of Nursing Care:

1. Well-lighted room
2. DAT
3. Monitor vital signs
4. Administration of glucose
5. Vitamins

Drug of choice: Disulfiram (Anti-abuse) – delays the metabolism of alcohol

Avoid:

Mouth wash

Over the counter cold remedies

Food sauces made up of wine

Fruit flavoured extracts

Aftershave lotion

Vinegar

Skin products

Commonly Abused Substances

Substance Physical signs Withdrawal Effect

a. Stimulants

Amphetamine (shabu) Weight loss, hyperactivity depression

Euphoria

Cocaine perforated nasal septum psychomotor agitation

b. Narcotics

Heroin pinpoint pupils, drowsiness piloerection & runny nose

c. Hallucinogens

LSD dilated pupils & hallucinations none

Nursing Diagnosis:

Ineffective individual coping

Nursing interventions for substance abusers:

Behavior Modification (Firmness-matter of fact)

Detoxification

Antihypertensive; anti-anxiety- administered to patients who are abusing stimulants

Anti-anxiety; anti-depressants- administered to patients who are abusing depressants

Anti-anxiety (Librium), disulfiram (anti-abuse);- administered to patients who are abusing alcohol

XVII. Concept of Loss

Grief/Grieving-George Engel

1. Shock, Numbness, Disbelief- Searching behaviour
2. Yearning and Protest – anger towards God
3. Anguish, Disorganization, and Despair – reality of the loss is accepted
4. Identification stage- a family member imitates some characteristics of the dead person.
5. Reorganization/restitution- life normalizes

Death/Dying: Elizabeth Kubler-Ross

Stages:

Denial – “No, Not me!”

Anger - “Why me?”

Bargaining- “If only…”

Depression – silence

Acceptance – “Yes, it’s me.”

Nursing Diagnosis: Ineffective individual coping

Nursing Care:

1. Be physically present
2. Be non-judgmental
3. Encourage verbalization of feelings
4. Allow the patient to cry
5. Recognize your own thoughts about death and dying