NCLEX NCLEX-PN - National Council Licensure Examination(NCLEX-PN)

An enema could dislodge the placenta and increase bleeding.Physiological Adaptation

The definition ofrapeis sexual intercourse against someone’s will. It is a degrading, brutal crime of violence and can occur between any two persons regardless of their marital status.Psychosocial Integrity

Denial, rationalization, regression, and fantasy are coping mechanisms that protect persons from anxiety.

Psychosocial Integrity

To ensure proper immobilization and increase client comfort when using a rigid splint, pad the spaces

between the body part and the splint.Basic Care and Comfort

A nasopharyngeal airway is measured from the tip of the nose to the earlobe.Reduction of Risk Potential

Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This

hyperpigmentation results from hormonal changes.Health Promotion and Maintenance

Syphilis is an acute and chronic treponemal disease characterized clinically by a primary lesion, a secondary

eruption involving skin and mucous membranes, long periods of latency, and late lesions of skin, bone viscera, the

CNS, and the cardiovascular system. The primary lesion (chancre) appears about three weeks after exposure as an

indurated, painless ulcer with serous exudate at the site of initial invasion. Invasion of the bloodstream precedes

development of the initial lesion, and a firm, nonfluctuant, painless lymph node (bubo) commonly follows.

Infection might occur without a clinically evident chancre; that is, it might be in the rectum or on the cervix. After

four–six weeks, even without specific treatment, the chancre begins to involute, and, in approximately one-third of

untreated cases, a generalized secondary eruption appears, often accompanied by mild constitutional symptoms.

This symmetrical maculopapular rash involving the palms and soles, with associated lymphadenopathy is classic.

Secondary manifestations resolve spontaneously within weeks to 12 months. Again, about one-third of untreated

cases of secondary syphilis become clinically latent for weeks to years. In the early years of latency, infectious

lesions of the skin and mucous membranes might recur. Specific treatment includes long-acting penicillin G

(benzathine penicillin), 2.4 million units given in a single IM dose on the day that primary, secondary or early

latent syphilis is diagnosed. This ensures effective therapy, even if the client fails to return. Serologic testing is

important to ensure adequate therapy. Tests are repeated three and six months after treatment and later as needed.

In HIV-infected clients, testing should be repeated one, two, and three months after treatment, and at three-month

intervals thereafter. Any fourfold titer rise indicates the need for retreatment.Physiological Adaptation

Sex role identification begins during infancy. Infants can identify body parts by the end of the first year. Preschoolers frequently engage in masturbation and sex play with peers. School-age children continue to gain awareness of their sexual identity. During this time they might continue to masturbate and engage in sex play. They might add behaviors such as hugging and kissing members of the opposite sex. Adolescent sex role identification is largely influenced by sexual maturation and trying out or assuming a sex role.Health Promotion and Maintenance

Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless

bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the

uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright

red, painless bleeding. The abdomen might be soft, nontender, and relax between contractions.Physiological

Adaptation

In DIC, many small clots form throughout the body and are immediately broken down. D-dimer measures a

specific fibrin split (or degradation) product and is the most specific test for DIC. Choice 1 is incorrect because

platelets are consumed in DIC, but this is not specific. Choices 3 and 4 are both elevated (because clotting factors

have been used up) but, again, are not specific.Physiological Adaptation

The culturally sensitive response is to notify the physician of the family member’s wishes and to determine whether it is feasible. Ginkgo biloba has been shown to be of some benefit in treating dementia. The other statements are not culturally sensitive.Reduction of Risk Potential

Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age

indicates the need for further developmental or neurological evaluation. Laying the infant on her stomach

promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral

should be the first action. These findings are not normal for a 6-month-old infant. Significant head lag can be seen

in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those

disorders might have mental retardation as a component. However, this child needs to have the referral to

determine the cause of the head lag first.Health Promotion and Maintenance

For lipid fractionation, the client cannot eat for 12 hours prior to the test, but he or she can drink an unrestricted

amount of water. No lipid solution is given. Thus, the other choices are incorrect.Reduction of Risk Potential

Displacement unconsciously transfers emotions associated with a person, object, or situation to another lessthreatening person, object, or situation. The nurse slammed doors instead of striking the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. This choice cannot be considered correct because the slamming of the cupboard doors cannot be considered a constructive activity. Conversion involves unconsciously transforming anxiety into a physical symptom. Reaction formation keeps unacceptable feelings or behaviors out of awareness by using the opposite feeling or behavior.Psychosocial Integrity

Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The

expected outcome is grief resolution. Vital signs monitoring is a nursing intervention classification for deficient

fluid volume in clients with major burns. Medication administration: skin is a nursing intervention classification

for impaired skin integrity for clients with major burns. Anxiety reduction is a nursing intervention classification

for anxiety experienced by clients with major burns.Health Promotion and Maintenance