hello Clinic review family I've got a special treat for you today we're doing a prioritization video something you absolutely have to know for the enclex so let's go ahead and get [Music] started hello Clinic review family it's Dr Sharon with Clinic reviews and today we're going to be doing one of my favorite prioritization strategies is what I call the unexpected finding you know that this YouTube channel is a part of the greater climic review organization and the climic review organization offers enlex reviews they're phenomenal y'all Mark climi does those he is the most phenomenal teacher he's taught me everything I know about enlex so um I recommend those we also have monthly packages for small group tutoring and a streaming service so you can go to climic reviews.com for that today I'm going to be talking about one of my favorite prioritization strategies this prioritization strategy you use it very consistently in many ways the enlex is highly predictable so if you don't know this what the National Council State Boards of Nursing does is they bring in people who've applied to be test writers they've applied they've accepted them they bring them in they teach them how to write questions recently I received an email asking me to apply this was just last week I think so I went and I'm like oh I'll apply to be Beyond this and I went through it and it said if you get EX got through the whole application got to the end said if if you're accepted for this you have to agree not to do any enclex preparation with anybody for three years like well I can't agree to do that y'all I got a YouTube channel I can't do that so I had to not submit my application anyway the point I'm trying to make is that they bring people in and they teach them how to write questions and then they write questions in that way okay and the reason they teach them how to write questions is because they have to be written in a specific way so that the answers are object itively correct okay they have to be objectively correct which means there has to be a rule that you follow now sometimes it's just a fact but you might be surprised how many nursing professors and nursing experts disagree on what the highest priority is unless there's a rule that they're supposed to follow and so what we do in clinic reviews is we teach you that rule now what I'm doing with this prioritization strategy is I'm teaching you this one it's not as part a part of the clinic review uh Prep course and so I can teach it to you because I'm not giving away you know know uh Insight or information on this so what I'm doing is I'm going to teach you this one I call it unexpected finding this is when you have a question it's a very short question stem very very short they give you very little information about the patient they tell you that they have a client you have their diagnosis their medical diagnosis and then they may tell you something else about them like a medication that they're taking or they're wearing oxygen or they have a chest tube but what they don't do is they don't give you any assessment data Okay so it's a very short question here's the client here's their medical diagnosis and then they say what are you most concerned about and y'all you're always most concerned about the unexpected finding so in other words all the assessment data is in the answers and three of those are going to be expected and consistent with the medical diagnosis that's why they have to give you a medical diagnosis so you know what to look for so they give you that and you go well a b and d are all expected C is totally not expected so that's the one I most concerned about that's the one I'm going to report to the health care provider that's the one that I'm going to intervene immediately or that's the one I'm going to report to the next shift all of those things mean the same thing you're going to report the unexpected finding to the next shift you're going to report the unexpected finding to the healthcare provider you're going to be most concerned about the unexpected finding you're going to be um intervening immediately with the unexpected finding and so you have to understand how these questions are written so that you know the rule to use when you're answering them and if you don't use this rule while you're answering your practice questions you're not going to use it during the enlex so you have to use it even when you're practicing with your database whatever database you're using of questions you have to use this rule even then and I'll tell you um identifying the unexpected finding is just a really good strategy because they want to know if a nurse can do that right that's one of the clinical reasoning strategies that they're testing to see if you have all right let's go ahead and get started a client with COPD is receiving oxygen therapy two lers via nasal canula which assessment finding is most concerning the client has a productive cough with thick white sputum is that expected with COPD maybe y'all I want you to know I put question marks next to things sometimes maybe it is so I'm putting a question mark next to it could be uh client has a respiratory rate of 28 maybe that's pretty high but it could be with COPD so I'm going to put a question mark next to it the client has clubbing of the fingernails all right that one I'm really confident is consistent with the diagnosis of COPD clubbing of the fingernails is where the fingernail flattens out and it happens with chronic hypoxia and so I can especially if they're wearing oxygen I can see that they could be chronically hypoxic so C is definitely expected so I'm not going to pick that one the client becomes drowsy and difficult to arouse okay that one I know is unexpected I know D is unexpected and I am not going to choose the answer I'm not sure about over the answer I am sure about I may not be sure about A and B remember I put question marks next to them but I know for sure that D is unexpected if you're like why would that be unexpected well first of all it's unexpected pretty much with anybody unless I'm giving him a med to make him drowsy but it's probably a buildup of CO2 that's my concerns they're becoming hypercapnic so um that's why that's unexpected a client with heart failure is being treated with diuretics and ACE inhibitors which assessment finding requires immediate intervention so I do have to keep in mind they're taking they're taking diuretic and ACE inhibitors a client with heart failure is being treated with diuretics and ACE inhibitors okay so I'll keep that in mind a client reports a dry cough well if you don't know this a dry cough is the most common side effect of ACE inhibitors so that's expected it's irritating they may not want to take the med because of it but it's still expected with an Ace inhibitor the client has bilateral crackles in the lung bases that's pretty expected with heart failure y'all not everybody with heart failure may have it and you might go well they're taking a diuretic they shouldn't have bilateral crackles in the bases I mean their heart failure that's kind of consistent with the diagnosis of heart failure so I'm keeping it I'm going to say it's expected unless nothing else is is unexpected client's pottassium level is 5.5 well that's high 3.5 to five is normal so that's definitely unexpected and there's nothing about the meds or about the diagnosis that would make me think it should be high so that's unexpected client was pitting a demon the lower extremities very consistent with the failure diagnosis so I'm going to have to pick C that's unexpected and and y'all don't say but if they're pitting a Dema and bilateral crackles that means the diuretics aren't working y'all you're saying if if if okay instead of just objectively looking at what we have we have a client who's being treated with two of the typical medications that are used for heart failure and B and D are consistent with typical symptoms of a patient with heart failure they didn't tell me that their O2 sat is low they didn't tell me that their heart rate is up they didn't tell me their blood pressure was low they didn't tell me any of that they just said they gave me two physical assessment findings that are actually consistent with heart failure so I have to call those expected a client with pneumonia is receiving IV antibiotics which assessment finding is most concerning all right the client has a temperature of uh 100.8 which is a little high but that's sort of consistent with pneumonia uh client reports a rash on the chest and arms that's not consistent with pneumonia that's not consistent with antibiotics client reports shortness of breath during activity again that's expected with pneumonia the client's white blood cell count is elevated well that's consistent with bacterial pneumonia probably would even be up with viral pneumonia I don't know if it'd be up as much but it would still be up with a viral pneumonia so that's consistent now B is the only unexpected finding and y'all I'm glad this question is here because I can almost guarantee you you're going to get a question on the enlex that asks if you can recognize what an allergic reaction looks like and you don't want to miss that question and here's one way they can ask you that so you need to be prepared for that allergic reaction question okay hives wheezing rash those kinds of things allergic reaction and and those are always a serious serious concern so you me need to make sure that that you recognize those when when you see them client with liver ceros is being managed conser conservatively uh which assessment finding requires immediate intervention so C liver curosis the client has JIS and reports itching well that's actually pretty consistent with aerosis diagnosis client is disoriented and has asterixis asterixis is hand flapping that is actually consistent with hepatic en sephy apathy which is a confusion it's a buildup of ammonia that occurs with liver curosis and so B is unexpected and it's not expected y'all because I don't expect them to develop hepatic incopy that's a complication it's not an expected finding it's a complication so yeah B is a problem the client has abdominal distension due to atis again that's a expected finding with liver ceros the client has peripheral edema expected finding with liver curosis both the aites and the peripheral edema is due to the loss of plasma proteins that is seen with therosis because um the the liver is uh responsible for making sure we have enough plasma proteins and when we lose plasma proteins then the water can third space including into the abdominal cavity and uh into the third spacing into the tissues in the in the lower extremities so uh the only one that's unexpected is b a nurse admits a client with hyperthyroidism which assessment data should be reported to the next shift hyperthyroidism think of it as hyper metabolism hyper metabolism is like you're burning hot you're burning hot burning off all the calories that you take in so it's like a fast running engine so think of the the car being in neutral and you're revving the engine and you put your hand on it and it kind of feels like it's trembling under your hand and it gets warm really fast right and it's it's using up a lot of gas you're not going anywhere but it's using up a lot of gas so that's hyper metabolism it's a hyper fast running engine the client reports a sore throat and fever well actually I expect the body temperature to go up but I don't expect a sore throat that's not consistent with hyperthyroidism client experiences weight loss despite increased appetite very classic hyperthyroidism okay you're fastr running engine you're using a lot of calories but you're still losing weight uh the client has tremors and heat intolerance Tremors think of that fast running engine you can feel it tremoring under your hand and heat intolerance because you're hot your body temperature is going up and so you feel hot all the time and you're like oh I don't want it to be I need it colder in here the client has a heart rate of 100 be per minute actually I'd be okay with it even if it was 110 uh because it's a fast running engine so the heart rate is at the higher end for sure so the only unexpected finding here is a sore throat and fever a client with schizophrenia is receiving anticho medication which assessment finding requires inter immediate intervention all right schizophrenia uh psych diagnosis um unclear Thinking Fast talking uh delusional maybe hallucinating that kind of thing and then anti-yo medication all right client reports dry mouth and blurred vision that's actually a side effect that's an anti-cholinergic side effect associated with any psychotropic drug psychotropic drug is a psych drug whether it's an anti-depressant or an antis psychotic anti-cholinergic side effects are expected with those meds so that's expected L exhibits muscle rigidity and high fever that is not associated with either schizophrenia or anti-yo medication in fact anticho discs can cause nms neuroleptic malignant syndrome it's a very very high temperature very high temperature and that's caused by anti-yo usually in older adults and because they're not metabolizing it as well muscle rigidity is also a symptom of neuroleptic malignant syndrome so that's a problem B is a problem the client has gained five pounds in one week weight gain one of the most common side effects of any psych drug experiences restlessness and pacing that's actually consistent with the schizophrenic frenia so the only one that's unexpected here is B so I'm very concerned about that I have to do something about that immediately in fact you have to stop the medication with that client with eptic ulcers on proton pump inhibitor therapy like protonics PPI which assessment finding should be reported to the healthcare provider so a PPI is expected treatment for peptic ulcer the client reports black tar stools all right um that could indicate the ulcer is bleeding which could be expected it's not that unexpected for a peptic ulcer to bleed but we'll keep a question mark next to it the client has occasional nausea after eating that's not surprising with a peptic ulcer the patient reports epigastric discomfort relieved by an acid very classic peptic ulcer the client test positive for helicobactor pyl okay helicobactor pylori is inconsistent with the treatment that they're getting if he was had a peptic ulcer with H pylori and they knew about it he'd be on an antibiotic because this is a a bacteria that causes a peptic ulcer and you have to be on an antibiotic for seven days for that it's pretty much gets rid of it so I have to notify the healthc care provider about that and I and I put a question mark next to a but a is is fine I mean if they're H if they're all is bleeding and they have some black ter stools that's not that surprising so there's nothing about D that is expected remember I choose the answer I know is is unexpected rather than the one I'm not sure about okay so I have to CH do that client with bipolar disorder is in the manic phase so that's at high phase right active active active delusional hallucinating often very irrational thinking magical thinking is prescribed a mood stabilizer mood stabilizer example of a mood stabilizer is um tricyclic anti-depressants example of a mood stabilizer which assessment data should be reported to the healthc care provider a client sleeps only two hours per night but feels rested very CL that's very classic manic phase they don't sleep much but they have lots of energy talks rapidly and interrupts others very classic Mania the client expresses grandiose thoughts about abilities very classic Mania magical thinking grandio thought thoughts that's sort of magical thinking like I can I can uh jump off a building and survive that's very grandiose thinking client attempts to give away personal belonging so A B and C are classic Mania D is nothing to do with Mania there's nothing about that that would make you think that was consistent with a Mania diagnosis and I don't know if this guy is suicidal but um at least on a testing for testing purposes giving away personal belongings is sort of classic suicidal ideation so I don't know what's going on but that's concerning to me that they're giving away their personal belongings client with major depressive disorders receiving anti-depressant therapy which assessment finding is most concerning the client reports a lack of appetite that's a pretty common side effect of depression the client complains of constipation constipation is an anti-cholinergic side effect so bladder retention blurred vision constipation and dry mouth are your classic anti-cholinergic side effects so B is consistent with the anti-depressant therapy client shows improved energy levels but remains withdrawn so that can happen when you start on anti-depressant therapy the concern is that when your energy levels improve before your mood improves is there at risk for suicide so I'm going to leave a question mark next to C the client experiences occasional headaches so headache is one of the most common side effects nausea and headache are the two most common side effects of just about any oral medication like can any oral medication can cause headaches and and nausea so I'm really not concerned about D so I left a question mark next to C and because I ruled out all the other answers as not concerning then I have to choose C and C is it does concern me because they could become suicidal if their energy levels improve before their mood improves and so I would need to investigate what's going on and how they're feeling all right I hope that was helpful to you and that is it for today thank you for being a part of our family and if you're still here watching I'll just tell you one story I got a um I got a water pick to clean my teeth because my dentist recommended it and y'all did you know that you could spray yourself in the eye with water pick I think I've sprayed myself in the eye like three times I've sprayed it all over the bathroom I don't know how to use this thing it's like it's like really goes really far so pray for me that I'll figure out how to use this water pick on my teeth because apparently I need to use a water pick okay all right we love you thank you for being a part of our family good luck on all your standardized tests that you may be taking see you later