Gold standard for nclex Exam 10 2024

RILE - -Right-sided heart murmurs are louder on Inspiration. -Left-sided heart murmurs are louder on Expiration. Normal findings in tympanic membrane - translucent, shiny, light gray, taut disk; free from tears or breaks too small a cuff - too large a cuff - cuff wrapped too loosely - - too small a cuff - can lead to false readings of elevated blood pressure too large a cuff - may lead to falsely low readings cuff wrapped too loosely - produces a false high reading R E A L - Real - accept that the loss is real Experience- the emotions associated with the loss Adjust- or re-adjust to life and activities Let- go and move on with one's own life Physiologic Indicators of Stress - Increased Blood Pressure Tachycardia Tachypnea Sweaty palms Cold hand and feet Decreased urine output Dilated pupils Change in appetite Nausea, vomiting, diarrhea Headache Restlessness Insomnia Muscle tension NI Mania - -offer high protein, high calorie finger foods, -supplements for weight loss/malnutrition -set limits on manipulative behavior -positive reinforcement for appropriate behavior -reduce stimuli sodium - -needed to maintain water balance, transmit nerve impulses, and contract muscles; used to control blood pressure and blood volume -regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney -sodium is regulated by salt intake, aldosterone, and urinary output -normal lab value for serum sodium is 135-145 mEq/L (135-145 mmol/L) -large changes may occur with minimal clinical findings -low levels of 125 mEq/L (125 mmol/L) or less result in mental confusion, hostility, hallucinations -excess levels may result in hypertension or generalized edema, called anasarca