HYPERLINK "http://www.nursereview.org/2008/08/free-nclex-review-questions-10.html" Free Nclex Review Questions 10 (Nclex Answers)
The endotracheal tube is moved from one corner of the mouth to the other at least every day to minimize the risk of necrosis of the mouth and pharynx due to pressure from the tube. Doing this every 6 hours is excessive. The nurse suctions the oropharynx above the endotracheal tube frequently to prevent accumulation of secretions above the endotracheal tube cuff. Products with lemon or alcohol are not used because they dry the oral mucosa. For the same reason, the lips are lubricated as needed.
Unresolved sexual trauma occurs when the following conditions are present: development of a persistent phobia such as that of being alone or going out; retreat from sexual themes and possessing low self-esteem and guilt feelings; reoccurrence of the symptoms of rape trauma triggered by seemingly minor events; reoccurrence of the symptoms of rape trauma triggered by the anniversary date of the rape trauma; avoidance of contact with members of the opposite sex; and negatively altered relationships with family and friends, such as withdrawal, unusual anger, or silence.
A power rapist wants to place a woman in a helpless controlled situation where she cannot resist or refuse him. In this situation, the power rapist is provided with a reassuring sense of strength, mastery, security, and control. He uses these feelings to compensate for his feelings of inadequacy. Although the power rapist usually does not consciously intend to hurt his victim, he does aim to have complete control over her. As the power rapist's behavior becomes repetitive and compulsive, his need to achieve feelings of power, control, and adequacy may lead him to increase the aggression over time.
The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and thinking of the client is unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. Isolating the client in a private room would intensify the client's feelings of worthlessness. Placing the client in charge of the morning chess game is a premature intervention that can overwhelm and cause the client to fail. This can reinforce the client's feelings of worthlessness. Distances of 18 inches or less between two individuals constitutes intimate space. Invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness.
Caring for a child in traction includes ensuring that the child's body is in proper alignment. Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin care to prevent infection.
An adolescent with juvenile rheumatoid arthritis may be dealing with issues related to disturbed body image. To plan care appropriately, the nurse would initially assess the adolescent's perception of the chronic illness.
In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red color.
Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and appears as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and must be reported.
Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs approximately 1 fingerbreadth or approximately 1 cm/day.
Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down; wearing a supportive well-fitting bra at all times; taking a warm shower just before feeding or applying warm compresses; and alternating the breasts during feeding.
