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org

NCLEX/CGFNS REVIEW BULLETS 3

• Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI) antidepressant.
The client needs to be instructed to avoid foods that require bacteria or mold
for their preparation or preservation or those that contain tyramine. These
food items include cheese, sour cream, beer, wine, pickles herring, liver, figs,
raisins, bananas, avocados, soy sauce, yeast extracts, yogurt, papaya, broad
beans, meat tenderizers, or excessive amounts of caffeine such as in coffee,
tea, or chocolate. The client is also instructed to avoid over-the-counter
preparations used for hay fever, colds, or for weight reduction. The client
should also avoid alcohol.

• When a client is experiencing an auditory hallucination, it is important initially

to understand what the voices are saying or telling the client to do. Suicidal
or homicidal messages, if heard by the client, necessitate implementing
priority measures.

• The therapeutic maintenance range of lithium is 0.6 to 1.2 mEq/L.

Early signs of lithium toxicity include nausea and vomiting, slurred
speech, muscle weakness, thirst, and polyuria. Advanced signs of
toxicity (1.5 to 2.0 mEq/L) would include hand tremors and muscle
incoordination (option 4). Severe toxicity (greater than 2.0 mEq/L) is
present if the client exhibits ataxia, hypotension, oliguria, and
confusion (options 2 and 3). Seizures, coma, and death can also
result.

• Levels of mania may be labeled as hypomania, acute mania, and

delirious mania. The client in the acute state experiences relative
sleeplessness, which over time decreases cognitive functioning,
concentration, and judgment. The client is continuously active and
does not take time to eat. The client’s mood may alternate rapidly
between periods of good humor and irritability. In hypomania, the
client experiences feelings of euphoria and sociability. Judgment is
often poor in this level. In delirious mania, the client is out of touch
with reality.

• Blood levels are drawn weekly in many cases when a client is beginning
lithium therapy. The literature varies somewhat and states that blood levels
may be drawn initially from 3 times a week to biweekly during this phase.
After therapeutic levels are achieved, blood level draws may be reduced to
monthly. If levels are stable after 6 to 12 months, the frequency may be
further reduced to every 3 months.

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• Amitriptyline is a tricyclic antidepressant used to treat the client experiencing
a mood disorder. It takes an average of 10 to 14 days for the client to begin
feeling medication effects. The nurse should give the client information about
the medication, and should encourage the client to continue the medication
as prescribed.

• Memory loss is an expected temporary effect of ECT. The client should be

told that this might occur, and that memory usually returns within a few
weeks. Occasionally clients have memory loss that lasts up to 6 months. The
nurse uses therapeutic communication techniques that will focus on the
client’s concerns and do not block further communication.

• Fluoxetine (Prozac) is a selective serotonin uptake inhibitor used in the

treatment of depression. The medication is effective if the client experiences
relief of symptoms of depression.

• The client taking a MAOI medication should be advised to avoid eating foods
that are high in tyramine. The tyramine in foods reacts with the medication,
causing a hypertensive crisis, which could prove to be fatal. Most fruits and
vegetables are naturally low in tyramine, with the exception of figs, bananas
(in large amounts), avocados, soybeans, and sauerkraut.

• Clients with a histrionic personality disorder are overly concerned with

impressing others, and they are often preoccupied with their appearance.
Their emotional responses are often shallow and changeable, although they
are also intense. Clients who have a borderline personality tend to have
intense needs that they seek to fulfill in relationships. Clients with a
narcissistic personality disorder have a great need for admiration, exploit
others to meet their own needs and desires, and have a lack of empathy for
others. The client with an avoidant personality disorder is often preoccupied
with a fear of rejection and criticism.

• Clients with cluster A personality disorders often behave in a

manner that is odd or eccentric. Suspicion of others is particularly
typical in paranoid personality disorder, a cluster A disorder.
Manipulative and dramatic behaviors are typical of some of the
cluster B disorders. Anger, anxiety, and fearfulness are typical of
clients with cluster C disorders.

• The nurse should avoid getting into power struggles with the manipulative
client, such as arguing with the client or making accusations.

• The client with a dependent personality disorder exhibits an unusually strong

need to be cared for, and has difficulty making personal choices and making

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 everyday decisions. An appropriate goal would be for the client to use the
problem-solving process effectively in everyday situations.

• The nurse who is preparing a treatment plan for a client in prison must
employ a framework that integrates the built-in realities and limitations of the
correctional setting and the compulsory regimen that has been created for
the offender. The incidence of suicide in correctional settings is higher among
inmates than it is in the general population. The prison nurse’s ability to
assess for self-violence and suicide is critical.

• One of the criteria that the Parole Board will investigate is the client’s ability
to engage in strategic planning. The fact that the client has plans for
employment and regaining custody of the children will be viewed in a positive
way as an example of changed behavior.

• Codependence involves overly responsible behavior, that is, doing for

another person what that person could be doing for himself or herself.

• The least helpful strategy by the nurse is to demand that the client stop
taking drugs. This blocks further communication, and does not affect
behavior change on the part of the client. If client health maintenance is the
goal, it is helpful for the nurse to instruct the client about aseptic conditions
for drug use to reduce the risk of human immunodeficiency virus and
hepatitis. It is also useful to educate the client about the short- and long-term
effects of the substance being abused. Since many clients who use drugs are
malnourished, it is also helpful to teach the client the elements of basic
nutrition.

• In larger organizations such as hospitals, there are often employee assistance

programs that offer services such as information, counseling, and referral for
employees who experience a wide variety of problems, including substance
abuse.

• Bradykinesia is described as decreased speed and spontaneity of movement.

The client appears to slow down.

• Hypertensive crisis, a potentially fatal problem that occurs when the

norepinephrine levels are excessively elevated, produces severe
occipital headache, stiff or sore neck, palpitations, increase or
decrease in heart rate, nausea, vomiting, hypertension, and an
increase in temperature.

• Tricyclic antidepressant agents produce an enhanced mood, an increase in

activity level, and an improvement in appetite. In addition, sleep patterns
become more like that of the client’s baseline normal sleeping pattern

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• Employing a hopeful attitude that is not excessively cheery will combat the
negative and gloomy affect that is intrinsic to depression. The client can
interpret an excessively cheerful approach as belittling. A matter-of-fact
approach will be more reassuring to the client and avoid any regressive
struggles that might emerge.

• In addition to the 4 weeks required to establish maximum therapeutic effects,

tricyclic antidepressants have significant adverse effects. Most notable are
their effects on the heart

• The use of TCAs in individuals with second-degree and third-degree heart

block can be fatal. Therefore, the nurse is responsible to ensure that the
psychiatrist orders a baseline ECG before treating the client with TCAs. This
will enable the psychiatrist to determine if there are any preexisting cardiac
abnormalities, which would necessitate eliminating this group of medications
from the treatment protocol.

• Establishment of a trusting nurse-client relationship is the foundation for

giving effective nursing care to the client with a mental health disorder.

• Alprazolam is an antianxiety agent (benzodiazepine) used in the short-term

management of panic disorder. Central nervous system side effects include
disorientation, drowsiness, and clumsiness, among others.

• BuSpar is classified as a nonbenzodiazepine antianxiety agent. It

does not appear to cause either physical or psychological
dependence in clients who use it. Clonazepam, oxazepam, and
lorazepam are benzodiazepines that may cause dependence.

• The client with post-traumatic stress disorder is not treated with behavior
therapy. It may be treated with psychotherapy, family or group therapy,
relaxation techniques, and vocational rehabilitation as needed.

• Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of

dizziness, vertigo, and nausea and vomiting that accompany motion sickness.

• Zollinger-Ellison syndrome is a hypersecretory condition of the

stomach. The client should avoid taking medications that are
irritating to the stomach lining. Irritants would include aspirin and
nonsteroidal antiinflammatory medications (Naprosyn and
ibuprofen). The client should take acetaminophen for pain relief.
Medication includes lansoprazole (Prevacid).

• A client who has a long history of antisocial and acting-out behavior needs to
demonstrate the motivation to change behavior, not just verbalization that

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 change will occur. The nurse would be therapeutic by assisting the client to
look at the behaviors that indicate the motivation to change.

• A client in prison is knowledgeable about the rules for behavior in the

correctional setting. Many clients will test the nurse’s capacity to be
victimized and will make inappropriate statements. These behaviors need to
be verbally confronted directly and then carefully documented in the client’s
chart.

• Acute toxicity of MAO inhibitors is manifested by restlessness,

anxiety, and insomnia. Dizziness and hypertension may also occur.

• The nurse working with chronically mentally ill clients in crisis should focus on
the client’s strengths, modify and set realistic goals with the client, take an
active role in assisting the client in the problem-solving process, and provide
direct interventions that the individual might be able to do.

• Methylphenidate hydrochloride (Ritalin) is a central nervous system (CNS)

stimulant and can cause insomnia. Its usually prescribed to clients with
ADHD. Taking the medication at breakfast and lunch and avoiding taking the
medication in the evening can prevent insomnia. It is taken orally 30 to 45
minutes before breakfast and lunch.

• When depressed, a client sees the negative side of everything. Neutral

comments such as :You are wearing a new dress this morning" will avoid
negative interpretations.

• In psychomotor agitation, it is best to provide activities that involve the use

of hands and gross motor movements. These activities include Ping-Pong,
volleyball, finger-painting, drawing, and working with clay. These activities
provide the client a more appropriate way of discharging motor tension than
pacing or ringing the hands.

• When a client is manic, solitary activities requiring a short attention

span or mild physical exertion activities are best initially. These
include writing, painting, finger-painting, woodworking, or walks
with the staff. Solitary activities minimize stimuli, and mild physical
activities release tension constructively. When less manic, the client
may join one or two other clients in quiet, nonstimulating activities.
Competitive games should be avoided because they can stimulate
aggression and cause increased psychomotor activity.

• An inappropriate affect refers to an emotional response to a situation that is

not congruent with the tone of the situation. A flat affect is an immobile facial
expression or blank look. A blunted affect is a minimal emotional response
and expresses the client’s outward affect. It may not coincide with the

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 client’s inner emotions. A bizarre affect such as grimacing, giggling, and
mumbling to one’s self is marked when the client is unable to relate logically
to the environment.

• Poverty of speech is speech that is restricted in amount and ranges

from brief to monosyllabic one-word answers. Poverty of content of
speech is speech that is adequate in amount but conveys little
information because of vagueness, empty repetitions, or use of
stereotypes or obscure phrases. Thought blocking is when the client
stops talking in the middle of a sentence and remains quiet.

• When caring for a paranoid client, the nurse must avoid any physical contact
and not touch the client. The nurse should ask the client’s permission if touch
is necessary, because touch may be interpreted as a physical or sexual
assault. The nurse should use simple and clear language when speaking to
the client to prevent misinterpretation and to clarify the nurse’s intent and
actions. A warm approach is avoided because it can be frightening to a
person who needs emotional distance. Anger and hostile verbal attacks are
diffused with a nondefensive stand. The anger a paranoid client expresses is
often displaced, and when a staff member becomes defensive, anger of both
the client and staff member escalates. A nondefensive and nonjudgmental
attitude provides an environment in which feelings can be explored more
easily.

• In a paranoid client, The nurse should arrange solitary noncompetitive

activities that take some concentration such as crossword puzzles, picture
puzzles, photography, and typing. When the client feels less threatened,
games such as bridge or chess or playing cards with another client may be
appropriate. When the client is extremely distrustful of others, solitary
activities are best and activities that demand concentration keep the client’s
attention on reality and minimize hallucinatory and delusional preoccupation.

• Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic

medication that decreases gastrointestinal secretions. It should be
administered 30 minutes prior to meals.

• The nurse would most appropriately assess the client’s eating patterns and
food preferences and concerns about eating. Assessing previous and current
coping skills is most appropriately related to a nursing diagnosis of Ineffective
Coping. Assessing the client’s feelings about self and body weight is most
appropriately related to a Disturbed Body Image. Assessing the client’s lack
of control about the treatment plan is most closely related to the nursing
diagnosis of Powerlessness.

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• Repetition of words or phrases that are similar in sound and in no other way
(rhyming) is one altered thought and language pattern used by clients with
schizophrenia. Clang associations often take the form of rhyming. Echolalia is
the pathological repeating of another’s word by imitation and is often seen in
people with catatonia. “Word salad” is a phrase used to identify a mixture of
phrases that is meaningless to the listener and perhaps to the speaker as
well. Thought broadcasting is the belief that others can hear one’s thoughts.

• Whenever a client has been identified as a victim of abuse, priority must be

placed on ascertaining whether the person is in any immediate danger. If so,
emergency action must be taken to remove the person from the abusing
situation.

• A social phobia is characterized by a fear of appearing inadequate or inept in

the presence of others and of doing something embarrassing. Thus, the client
becomes anxious as the center of attention.

• Physical assessment findings such as bruises, along with the other

assessment findings noted in the question, should alert the nurse to the
potential for elder abuse.

• Tertiary prevention involves the reduction of the amount and degree

of disability, injury, and damage following a crisis. Primary
prevention means keeping the crisis from ever occurring, and
secondary prevention focuses on reducing the intensity and duration
of the crisis during the crisis itself. A precrisis level of prevention is
similar to primary prevention.

• Thioridazine hydrochloride (Mellaril), an antipsychotic medication,

has a higher likelihood of producing impotence than other
neuroleptics

• A nurse who is preparing a medication-teaching plan for a client who is

receiving fluphenazine decanoate would be certain to advise the client to
immediately report any clinical manifestations such as a sore throat or fever,
because these signs could signal the onset of agranulocytosis. In addition,
any extrapyramidal symptoms also require the physician’s immediate
attention.

• Trifluoperazine (Stelazine) can cause the client’s urine to turn pink

to reddish-brown. This condition is not harmful; it disappears when
the medication is discontinued. Nevertheless, the nurse will want to
instruct the client to report its occurrence to the nursing staff or the
medical staff.

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• One of the side effects of antipsychotic agents is that they decrease
moisture around the eyes. This can cause difficulty for clients who
wear contact lenses. Because the client has emphasized the
importance of these lenses, it is a potential problem that may occur
and lead to medication noncompliance by the client.

• The most commonly occurring side effects of antipsychotic agents include dry
mouth, blurred vision, nasal stuffiness, and weight gain. Additional side
effects include difficulty in urinating, constipation, risk of infection, decreased
sweating and increased sensitivity to heat, increased sensitivity to sunlight,
yellowing of the eyes (especially the whites of the eyes), and decreased
moisture around the eyes. Painful or interrupted menstruation, vaginal
dryness, dizziness, drowsiness, breast enlargement/lactation, skin rash or
itchy skin, and anhedonia can also occur.

• Lithium and sodium, similar in chemical structure, compete to

occupy sites within the body. Therefore, sodium levels often
decrease, which causes lithium to be reabsorbed. When this
happens, it increases the amount of lithium in the body, causing side
effects. For this reason, the nurse instructs the client to drink 2 to 3
liters of water each day and eat a diet that is adequate in sodium.
Once the client’s lithium level is established (usually within 2
weeks), a blood lithium level will be drawn every 1 to 2 months.

• The most therapeutic response for the nurse to make to effectively teach the
client about lithium is the one that emphasizes the necessity that the client
does not discontinue the medication even if feeling an upset stomach. Clients
who are taking this medicine are instructed to take their medication with
meals to minimize the occurrence of an upset stomach.

• Depersonalization constitutes a symptom that displays disturbance in the

client’s sense of self. A flat affect is a symptom of schizophrenic disturbance
in affect. Magical thinking is a symptom of the content of thought in
schizophrenia. Word salad is a schizophrenic disturbance in the form of
thought.

• Fluphenazine decanoate (Prolixin) can decrease the normal bacteria

in the oral cavity and increase sensitivity to infection. This can be
prevented by instructing the client to avoid high-sugar foods;
increase the frequency of mouth care (brushing, including the
tongue, flossing, and gargling with mouthwash); and frequently
inspect the tongue for a thick, white coating, which signals infection.

• Lithium is contraindicated in pregnancy and for breastfeeding

mothers. The client will be taught that breastfeeding is not possible

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 while taking this medication and will be instructed to notify the
physician immediately if pregnancy is even suspected or is being
planned.

• Tranylcypromine (Parnate), an antidepressant, can cause serious and

potentially fatal adverse reactions if used with other antidepressants. Its use
is avoided within 2 weeks of another antidepressant.

• For clients with somatoform disorder, they are told to exercise because it
helps to release endorphins, which enhance the feeling of well-being.

• If a client who is taking an antidepressant complains of tiredness,

the nurse instructs the client to report the side effect to the
psychiatrist, take medication at hour of sleep (except fluoxetine
hydrochloride [Prozac], which must be taken in the morning), and
avoid alcohol or alcohol-containing foods (even over-the-counter
medications that contain alcohol). The client should also be
instructed to lie down and rest.

• Some of the side effects of benzodiazepines are drowsiness, lethargy and

confusion, dizziness, blurred vision, rash or “itchy” skin, unusual irritability or
nervousness, headache, and nausea.

• The Abnormal Involuntary Movement Scale (AIMS) scale is used to

assist the nurse to recognize tardive dyskinesia. The three areas of
examination are facial and oral movements, extremity movements,
and trunk movement. Tardive dyskinesia can occur from the use of
antipsychotics.

• Abdominal pain is the most prominent symptom of acute pancreatitis. The

main focus of nursing care is aimed at reducing discomfort and pain by the
use of measures that decrease gastrointestinal tract activity, thereby
decreasing pancreatic stimulation.

• A diagnosis of gout is made on the basis of clinical manifestations,

hyperuricemia, and the presence of uric acid crystals in the synovial fluid of
the inflamed joint. Blood studies show an increased serum uric acid level of
more than 7 mg/100 mL. The erythrocyte sedimentation rate and the white
blood cell count may be elevated during an acute episode. T

• Probenecid is a uricosuric medication. The client should be instructed to avoid

alcohol, because it increases the urate levels and to avoid medications that
contain aspirin. Increased fluid intake is encouraged to maintain an adequate
urine output and prevent hematuria, renal colic, and stone development. The
client is instructed to administer the medication with milk or meals to prevent
gastric distress and is also told to limit high-purine foods.

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• Calcium supplements should not be taken with whole grain cereals,
rhubarb, spinach, or bran, because these foods decrease the
absorption of the calcium. Most supplements should be taken on an
empty stomach (1 hour before meals or at bedtime) to promote
absorption, but food might be necessary if gastric irritation
develops. The client should be instructed to drink water while taking
the supplements to prevent renal stones. Side effects include
constipation, gastric irritation, a chalky taste, nausea, and gastric
bleeding.

• Blood glucose levels for an adult normally range between 60 and 120 mg/dL.
A level of 33 mg/dL indicates hypoglycemia. Metabolic disorders can be an
etiological factor of delirium.

• The Romberg test is an assessment for cerebellar functioning

related to balance. The client stands with feet together and arms at
the side and then closes the eyes. Slight swaying is normal, but loss
of balance indicates a problem and a positive Romberg test.

• For the first 12 hours following a laparotomy, the NG tube drainage may be
dark brown to dark red. The drainage should then change to a light yellowish
brown color. The presence of bile may cause a greenish tinge. The physician
should be notified at once of the possibility of hemorrhage if the dark red
color continues or if bright red blood is observed. Due to the presence of
small amounts of blood and the action of gastric secretions, coffee ground
granules might be seen in the NG tube drainage.

• The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of

reactions that are not necessarily a direct result of ineffective coping skills.
The nurse must also know that persons with HIV are living well beyond 1
year. Ignoring the problem will not eliminate the client’s difficulty in
understanding the disease process. The nurse must focus on the knowledge
deficit of a disease process and other psychosocial interventions.

• Sheet grafts are often used to graft burns in visible areas. Sheet
grafts are done on cosmetically important areas, such as the face
and hands, to avoid the meshed pattern that occurs with meshed
grafts.

• The incidence of invasive cervical cancer in situ peaks around age 45 and
occurs twice as often in African American women than in other races. A
classic symptom is painless vaginal bleeding; it can be accompanied by
watery, blood-tinged vaginal discharge that can become dark and foul
smelling as the disease progresses. A Papanicolaou smear is the initial
diagnostic test performed.

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• Organisms present in the synovial fluid are characteristic of a septic
joint condition. Urate crystals are found in gout. Bloody synovial
fluid is seen with trauma. Cloudy synovial fluid is diagnostic of
rheumatoid arthritis.

• Trigeminal neuralgia affects cranial nerve V, causing sudden bursts of electric

current–like pain in the face.

• In atrial fibrillation with rapid ventricular response, the atrial

chambers quiver, do not contract normally, and fill the ventricles
with blood during the last part of diastole. This results in the loss of
an important atrial contribution to cardiac output, called the “atrial
kick.” Loss of the atrial kick and the rapid ventricular rate causes a
reduction of cardiac output by as much as 25%.

• Physical changes in the client's appearance can occur with Cushing's

syndrome. Such changes include hirsutism, moon face, buffalo hump, acne,
and striae. These changes cause a body image disturbance.

• A fasciotomy is a treatment for compartment syndrome.

• The client with unilateral neglect must learn to scan the environment and
gradually come to a realization of the affected side

• Alcohol can precipitate an attack of pancreatitis. Coffee and cola products,

which contain caffeine, stimulate the pancreas. Carbohydrates actually
should be encouraged, since they are less stimulating to the pancreas. Since
smoking can overstimulate the pancreas, teaching is effective when the
client will try to stop smoking.

• Hypercalcemia is a phenomenon associated with multiple myeloma.

Due to the hypercalcemia, pathological fractures are possible.
Ambulation is important, because immobility increases the likelihood
of hypercalcemia. Most clients with multiple myeloma will not
tolerate aerobic exercise because of their anemia.

• Even if testicular cancer is detected in an early stage, the client newly

diagnosed with testicular cancer might be afraid he will be sexually
handicapped, and feelings of sexual inadequacy may occur. An appropriate
nursing diagnosis would be Ineffective Role Performance.

• Ventilators need to be assessed routinely by the respiratory therapist.

Ventilators are machines, and machines can fail.

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• The normal white blood cell count is 5,000 to 10,000/mm3. Chemotherapy
agents cause medication-induced leukopenia, and treatment focuses on this
side effect.

• A fractured femur may require up to 20 weeks for healing in an adult. Full

weight-bearing is permitted as soon as bony union is present. Ambulation
with a cane requires at least partial to full weight-bearing status. Full weight-
bearing is usually restricted until there is radiographic evidence of bony union
of the fracture fragments. Callus formation is too weak, and the fracture site
may refracture with full weight-bearing. The stage of fracture healing dictates
the amount of weight-bearing, not range of motion, muscle strength, or pain.

• Perforation of the gastrointestinal wall is a potential complication of

any endoscopic procedure. Signs of perforation include abdominal
pain, bleeding, and fever. Temperature elevation does not usually
accompany internal hemorrhage. The temperature may be elevated
in both severe dehydration and with a nosocomial infection, but the
potential complication that can occur with this procedure is
perforation of the intestine.

• Clients who test positive for HIV antibody are at risk for
opportunistic infection. The normal CD4+ T cell count is between 500
mcg/L and 1600 mcg/L. As the CD4+ T cell count falls, the client’s
risk for infection increases. Clients with HIV infection or acquired
immunodeficiency syndrome are commonly afflicted with diarrhea,
not constipation.

• Clients with chronic illness often experience feelings of anger and depression.
Manifestations of chronic hepatitis include profound fatigue, resulting in an
inability to pursue normal daily activities. Ineffective coping involves
inappropriate use of defense mechanisms (alcohol consumption). It can also
include the inability to meet role expectations (working). The destructive use
of alcohol will contribute to the client’s illness and rehabilitation time, and
further prolong fatigue and the inability to work.

• Nocturnal attacks of reflux from hiatal hernias are common, especially if the
person has eaten near bedtime. Large meals, alcohol, and smoking can also
precipitate attacks. Therefore, if the client did more entertaining earlier in the
day, attacks might be decreased or eliminated.

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