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

The client with GERD needs to sit up after eating or have the head of the bed elevated to avoid reflux.

Thus, choices 1 and 4 are incorrect. Choice 2 is incorrect because the client needs to eat small, frequent meals.

Reduction of Risk Potential

Recent research reveals that 83% of all persons in the United States, age 12 or older, report using alcohol sometime in their lives. Use of alcohol and illicit drugs appears to increase into the mid-20s, and then levels off and decreases with age. Both lifetime prevalence and intensity of alcohol use are greater in males. Caucasians report higher levels of alcohol use than African Americans or Hispanics. Those with more education are more likely to use alcohol, but heavy use is more common among the less educated and the unemployed.Psychosocial Integrity

The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence

that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something

doesn’t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether

they are lying beside the paper, stacked on the paper or moved to the paper.Centrationis the ability to concentrate

on one feature of a situation while neglecting all other aspects.Causalityis based on the sequence of events, one

event ordinarily following another.Nonreversibilityrefers to the inability of preschoolers to reverse their

operations. They are only able to think forward, not retrace or reverse their thought processes.Health Promotion

and Maintenance

Active transport is a process requiring energy to transport ions against a concentration gradient, as is needed

in the sodium-potassium pump. Choices 2, 3, and 4 are other regulatory mechanisms involved in fluid and

electrolyte balance.Physiological Adaptation

Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Conversion involves the transformation of anxiety into a physical symptom. Introjection involves intense unconscious identification with another person. Rationalization involves the unconscious process of developing acceptable explanations to justify unacceptable ideas, actions, or feelings.Psychosocial Integrity

The nurse must be aware of cultural practices that resemble child abuse. These practices include coining, cupping, and fallen fontanella. Coining and cupping are thought to draw infections from the body. Coining involves rubbing a heated coin on the chest and torso and might cause bruising. Cupping uses heated glasses that can produce erythematous and ecchymotic rounded lesions or linear streaks on the body from the suction. Fallen fontanella involves turning a child upside down to correct a depressed fontanelle; it can cause vomiting, diarrhea, and dehydration in infants. Retinal hemorrhages can also occur, and sometimes Shaken-Baby Syndrome is erroneously diagnosed.Psychosocial Integrity

A high bilirubin level is found with hepatic immaturity in newborns, from which jaundice results. The other

choices are not.Reduction of Risk Potential

Tobacco use is a predisposing factor for cancer of the tongue; the other choices are not.Reduction of Risk

Potential

Many cultures (including the Hispanic and Native-American cultures) are sometimes hesitant to discuss sexuality. Some Navajos, Hispanics, and Orthodox Jews view the postpartum period as a state of impurity and might seclude women as long as they are bleeding. The seclusion is usually ended with a ritual bath. Many white teenage girls approve of the prevention of pregnancy, and many African-American teenage girls value pregnancy. Many Native-American women believe in the importance of monthly menstruation to maintain physical wellbeing and harmony.Health Promotion and Maintenance

All nurses should be concerned with preventing the transmission of microorganisms to themselves as well

as to others. One way to accomplish this goal is by asepsis. Nursing practice focuses on providing a safe and

therapeutic environment to protect clients, family members, and health care providers from acquiring infections.

Safety and Infection Control

A pattern of behavior known as the cycle of abuse has been described in the literature. It involves a honeymoon stage, followed by a buildup of stress, an angry outburst that might involve beating, reconciliation, and another honeymoon phase. Clients who do not receive help are at increased risk of harm, which might include homicide.

Psychosocial Integrity

Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not

enough time to remove secretions. The remaining choices are too long and could lead to hypoxia and tissue

trauma.Reduction of Risk Potential

The troponin level is the first to rise in a client who has had a myocardial infarction, followed by CPK, SGOT,

and LDH.Reduction of Risk Potential

For the client with an NG tube who begins vomiting, the nurse should check the tube placement because

it might be displaced, thereby leading to vomiting. The other responses are not appropriate.Reduction of Risk

Potential

Folic acid should not be used if pernicious anemia is suspected because it does not protect the client from

CNS changes common to this type of anemia. Folic acid is usually given with Vitamin B12. Both are part of the

Vitamin B complex and are essential for cell growth and division. Folic acid is sometimes used as a rescue drug

for cells exposed to some toxic chemotherapeutic agents. The nature of the anemia must be confirmed to ensure

that the proper drug regimen is being used.Physiological Adaptation