[태그:] NCLEX

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Fundamentals
basic care & comfort 65
1. A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3
(0.45 ×109/L). What information contained in the admission history of this client will need to be addressed during discharge education? Gardens as hobby
Absolute Neutrophil Count ANC 2200-7700 normal <500 neutropenia O cooked/ steamed/ grilled, protein (meat, seafood), bathe daily & applies moisturizer X raw/ unwashed, gardening (soil > 병원균 多), flower, plant, standing water raw 날것 gardening 원예 standing water 고인 물 absolute neutrophil count 절대호중구수
2. A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence?

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Mental health
1-6. disturbance 방해, 소란 conscious 의식, 의도 disheveled 헝클어진 shove 밀치다 interrupted 중단 escalating 확대
grandiosity 당당함, 과장 exaggerated 과장된 empathy 공감 reckless 무모한. 난폭한 spending 지출 impulsivity 충동
Flight of ideas 사고비약 admiration 감탄, 존경 intrusive 거슬리는 impulses 충동, 자극 disruptive 지장을 주는
strange 이상한, 낯선 shadow 그림자 forth 앞으로 rocking 흔들리는 constant=fixed involuntary 비자발적
– immediate follow-up > Violence 폭력 상황 먼저 완화
escalating agitation 심해지는 불안 and aggression 공격 징후 (eg, shoving chair 의자 밀치기, yelling 소리지르기)
– Bipolar I characterized manic episode,
– bipolar II characterized by episodes of major depression and hypomania 경조증 (but not mania)
– Manifestations
Distractibility 산만함
Grandiosity 과장 (ie, exaggerated sense of self-importance)
Talkativeness 수다스러움/pressured speech 강압적인 말
Reckless behaviors 무모한 행동 (eg, impulsivity, high-risk behaviors [eg, spending, sexual])

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Adult Health Visual/Auditory
1. Proper use and care of hearing aids
To adjust to new hearing aids 새로운 보청기 적응을 위해,
clients can wear them for a short time (eg, 20 min) before gradually increasing 점진적으로 늘리기 전에 the length of wear
pull the ear up and back before insertion 위로 당기고 뒤로 당기기
삽입 전 볼륨 꺼져 있는지 확인
high-pitched whistling sound (indicate volume is too high) 휘파람 소리들리면 불륨 낮추기
cleaned with alcohol wipes or a soft cloth, 물에 담그면 손상될 수 있음
착용하는 동안 High heat (eg, hair dryers, heat lamps) 피하기
침대 옆 탁자 위 상자 보관
사용하지 않을 때 배터리 제거
2-7.
*Farsighted vision (eg, hyperopia) 원시는 안경으로 쉽게 교정할 수 있는 일반적 상태
*Bilateral lens opacity 수정체 혼탁 (eg, cataracts 백내장) > 노화된 렌즈 교체 필요
*Acute prostatitis 전립선염
– Signs of infection (eg, leukocytosis) and a markedly tender prostate. Treat > antibiotics
2-7.
– Tachycardia and elevated blood pressure, 통증 심한 경우 > 통증 먼저 해결 후 improve vital

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Adult Health Urinary/Renal
1. (BPH) 양성 전립선 비대증
– Manifestations
urinary urgency, frequency, hesitancy 주저, dribbling urine after voiding 배뇨 후 소변 흘림, nocturia, urinary retention
– Treatment
Administering tamsulosin (alpha-adrenergic blocker) > 평활근 이완시켜 소변흐름 도움
> S/E erectile dysfunction 발기부전 and orthostatic hypotension
Performing urinary catheterization > stagnant 정체된 urine 은 감염 多
techniques to increase urine flow > urinating sitting down, relaxing for few minutes, and then trying to urinate again
*cystitis 방광염
– urgency, frequency, pelvic pain
– Phenazopyridine > urinary analgesic
> S/E cause discoloration > wear eyeglasses to avoid staining contact lenses
*Prostate cancer
– prostate nodules 결절, induration 경결 (eg, hardening), or asymmetry 비대칭 on digital rectal examination
with elevated prostate-specific antigen levels 전립선 특이항원
– Treatment > surgery and/or brachytherapy 방사선 근접치료

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1. postictal state 발작 후 상태
– Lamotrigine > 다른 항경련제 (eg, valproate) 에 비해 선천성 기형 발생 낮아서 childbearing 가임기에 처방
갑자기 중단 후 Preseizure auras (eg, blurred vision, tinnitus 이명, nausea) and sudden loss of consciousness
> indicate breakthrough seizure activity 돌발성 발작 나타냄
약물을 중단하는 위험보다 지속적 항경련제의 이점이 더 큼 > 약물 교육 강화, prescription for lamotrigine
*Eclampsia 자간증 > 임신 20 주 이후 hypertension, hyperreflexia, seizures
> Magnesium sulfate reduces the risk of seizures
*Migraine headaches 편두통 > photophobia, visual changes, nausea/vomiting
> treat, Butalbital-acetaminophen-caffeine
Epilepsy 뇌전증 tinnitus 귀울림 childbearing 출산, 분만
2-7.
– immediate follow-up
Cranial bruising 두개골 타박상 > Ecchymosis 반상출혈 behind the ear (ie, Battle sign)
basilar skull fracture 기저 두개골 골절 및 underlying brain injury 근본적인 뇌 손상의 강력한 지표
> CSF otorrhea
Pupil assessment > 뇌부종은 안구 운동 신경 (cranial nerve III) 압박하여 동공 변화 (eg, size, reactivity) 유발
Glasgow Coma Scale (GCS) score > 신경학적 손상의 중증도 추정

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Adult Health Musculoskeletal
1-6.
– Concerning findings in a client with lower back pain (LBP)
Diminished or unilateral lower extremity sensation > herniated disc or impaired circulation (ie, peripheral neuropathy)
heaving lifting or prolonged sitting Occupations
> disc herniation or pain exacerbation from a prior injury 이전 부상으로 인한
Radicular LBP (ie, radiating down one or both legs)
> spinal nerve root (eg, from L2-S2) compressed or inflamed 염증 시 발생
> 관리되지 않은 급성 통증 > negative psychosocial effects (eg, withdrawal, depression)
Absent or diminished lower extremity reflexes 하지반사 (ie, Achilles) > disc herniation
Positive straight-leg raising test
> 신경근 자극 나타냄, acute lumbar disc herniation or disc prolapse
Obesity (ie, BMI >30 kg/m2) > increases lower back strain 부담 and increases the risk for LBP
– Acute lumbosacral strain (LSS) 급성 요천추 염좌
신체 역학의 부적절한 사용, 무거운 물건으로 유발되는 back pain

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Adult Health Cardiovascular
1-6. Heart failure (HF)
– immediately follow up
dyspnea, inspiratory crackles, weight gain, peripheral edema > acute HF exacerbation 로 인한 체액 과부하
treated > diuretics, such as furosemide (ie, “water pill”)
Respiratory findings (ie, SpO2 90%, inspiratory crackles, tachypnea, dyspnea, labored respirations)
> pulmonary edema (Crackles > alveoli 폐포 체액으로 인한 폐부종의 징후)
– planning care > 12-lead ECG, chest x-ray, current weight, Serum electrolyte levels
X orthostatic 기립성 vital signs > 탈수, dizziness or syncope on standing 유발하는 약물 부작용과 관련
– Hyper- or hypokalemia
– Treatment for hyperkalemia
Drives potassium from blood into cells > albuterol nebulizer and IV insulin 일시적 감소
Promotes potassium excretion > loop diuretics (ie, furosemide)
Stabilizes myocardial cell membranes > calcium gluconate antagonizes potassium (칼륨 효과 차단, 심근 과민성 감소)

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