2023 RN test 3 NCLEX questions

1. A nurse at a health fair calculates the body mass index (BMI) of a person who weighs 68 kg and is 165 cm (1.65 m) tall. How will the nurse document the BMI? a. 25 kg/m2 b. 46 kg/m2 c. 68 kg/m2 d. 165 kg/m2

Example: Weight = 68 kg, height = 165 cm (1.65 m), Calculation: 68 ÷ (1.65)2 = 24.98

1. When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse received in shift report that the patient has consistently refused pain medication. To help promote comfort, which additional data will the nurse gather? Select all that apply. a. Patient's understanding of or fear of taking prescribed analgesics b. Assessment of any current pain c. Presence of anxiety or additional stressors d. Assessment of the surgical incision for infection e. What the patient has eaten to this point Whether the patient is using the incentive spirometer

a, b, c, d. While it seems the patient's immediate problem is unrelieved pain because the patient refuses to take pain medication, through further assessment, the nurse can plan to address fears of medication, teach about use of the pump, determine if anxiety is interfering with pain, or an infection is causing increased pain. While decreased oral intake may be a response to pain, the patient's dietary intake will not uncover the underlying reason for refusing medications. Use of the incentive spirometer is not included in pain assessment; rather, it is an intervention to prevent atelectasis.

1. A nurse in the intensive care unit is preparing a patient's family for terminal weaning from mechanical ventilation. What nursing actions would facilitate this process? Select all that apply. a. Offering the family information about the advantages and disadvantages of continued ventilatory support b. Explaining to the family what will happen at each phase of the weaning and offer support c. Validating orders for sedation and analgesia to promote comfort and dignity d. Explaining that death occurs quickly after the patient is removed from the ventilator e. Teaching the family that the decision for terminal weaning must be made by the primary care provider f. Arranging mandatory counseling for the patient and family to assist them in making this end-of-life decision

a, b, c. A nurse's role in terminal weaning is to assist patients and families in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation. The nurse teaches what to expect if terminal weaning is initiated, including the use of sedation and analgesia for patient comfort. Supporting the patient and family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they want to discontinue their ventilatory support; more often, the surrogate decision makers determine that continued ventilatory support is futile. The nurse would not predict the time until death. Once removed from the ventilator, a patient may not resume spontaneous breathing or may breathe on their own, living for hours, days, or rarely, longer. Counseling may be arranged if requested but is not mandatory for decision making.

As part of interprofessional rounds, a nurse in a skilled facility assesses for sleep deficits. Patients with which health problems would the team identify as higher risk for sleep disturbances? Select all that apply. a. Uncontrolled hypothyroidism b. Anxiety c. GERD d. HIV e. Arthritis Urinary tract infection

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. Worries and anxiety can interfere with sleep, as can pain. A patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

1. A nurse midwife is assisting a patient whose birth plan states she is firmly committed to natural childbirth. When informed the infant is in distress and a cesarean delivery is necessary, the pregnant patient sobs inconsolably, calling herself a failure. The nurse offers emotional support based on what likely types of losses? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational

a, b, c. The losses experienced by the pregnant patient are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt emotionally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

A nurse is caring for an older adult who is having trouble falling asleep at night. What nursing interventions are appropriate for this patient? Select all that apply. a. Assess the patient for depression. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage the patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.

a, b, d, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions.

1. A nurse in the intensive care unit is reviewing diagnostic studies to evaluate a patient's nutritional status. What findings consistent with inadequate nutrition require follow-up by the nurse? Select all that apply. a. Decreased hemoglobin b. Low prealbumin level c. Increased transferrin d. Anemia e. Elevated lymphocytes

a, b, d, e. Test results for hemoglobin (normal = 12 to 18 g/dL): decrease indicates anemia. Results for hematocrit (normal = 40% to 50%): decrease indicates anemia; increase indicates dehydration. Serum albumin and prealbumin tests for malnutrition and malabsorption will be decreased, as will transferrin and blood urea nitrogen. Elevated lymphocytes may indicate infection.

1. A nurse in the obstetrics clinic is teaching pregnant patients techniques to manage pain during labor. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery

a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet, but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches.

A nurse recommends that a patient with a sleep disorder keep a sleep diary. Which data will the nurse ask the patient to document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is typically kept in the graphic record.

1. During interprofessional rounds, the charge nurse and health care provider evaluate patients to determine their need for parenteral nutrition (PN). Which patients will be identified as candidates for this type of nutritional support? Select all that apply. a. Patient with irritable bowel syndrome and intractable diarrhea b. Patient with celiac disease not absorbing nutrients from the GI tract c. Patient who is underweight and needs short-term nutritional support d. Patient who is comatose and needs long-term nutritional support e. Patient who has anorexia and refuses to take foods via the oral route f. Patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access, motility disorders, intractable diarrhea, impaired absorption of nutrients from the GI tract, and when oral intake has been or is expected to be inadequate over a 7- to 14-day period. PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet with an increased need for calories and nutrients. Oral intake is the best method of feeding; the second-best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

1. A hospice nurse who cared for a dying patient and their family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow.

a, b, f. Mourning refers to the actions and expressions of grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life) that make up the outward expressions of grief. It is a period of grief and acceptance, as the person learns to deal with their loss. A diagnosis of cancer and the coroner's pronouncing the patient's death are not behaviors of the family during a period of mourning. Arranging for hospice care precedes a patient's death.

1. A nursing student caring for older adults in a skilled nursing facility is completing an assignment identifying physical changes that are part of normal aging. What changes will the student include in this assignment? Select all that apply. a. Fatty tissue is redistributed. b. Skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases (sarcopenia), and hormone production decreases, causing menopause or andropause.

1. A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply. a. Cradling a wrist that was injured in a car accident b. Moaning and crying from abdominal pain c. Increasing pulse following a myocardial infarction d. Striking out at a nurse who attempts to provide a bath e. Acting depressed and withdrawn while experiencing chronic cancer pain f. Pulling away from a nurse trying to give an injection

a, b, f. Physiologic responses are involuntary body responses; behavioral responses reflect body movements; affective responses reflect mood and emotions. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.

1. A nurse is assessing a patient who reports their migraines have become "unbearable." The patient states, "I got laid off from my job last week, and I have two kids in college. I don't know how I'm going to pay for it all." Which effects of physiologic effects of stress would the nurse expect to find in this patient? Select all that apply. a. Increased or decreased appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors

a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

1. When caring for an older adult in a geriatric practice who seems anxious and inattentive, the nurse plans to discuss stressors particular to the older adult. For which stressors will the nurse assess? Select all that apply. a. Concern over memory loss b. Acting as the designated driver for friends c. Death of spouse last month d. Inappropriate use of alcohol e. Successful cataract surgery f. Recent mobility issues

a, c, d, f. Stressors of the older adult include declining physical and/or mental capabilities; invasive or health-related tests, examinations, or surgeries (even those with a positive outcome can produce stress, especially related to declining vision); alcohol abuse; diagnosis of chronic illnesses; loss of spouse or significant other; retirement; increased social isolation; loss of independence in living arrangements, driving, or activities of daily living; and chronic pain. The ability to still drive is not considered a stressor.

1. A nurse in a medical practice has assessed a patient reporting abdominal pain, diarrhea, and anxiety. With no identifiable cause for the pain, which actions to reduce stress would the nurse recommend? Select all that apply. a. Keeping a diary identifying sources of stress b. Sleeping 4 hours per night c. Considering previous strengths and coping mechanisms d. Asking whom the patient relies on for support e. Asking if their partner is abusive f. Assessing for prior psychiatric conditions

a, c, d. Keeping a diary of sources of stress can help identify the problem, which is the first step in stress management. The nurse can help the patient identify supports and their strengths. The nurse should recommend sleeping 7 to 9 hours nightly. The nurse would not infer there is a problem of abuse or a psychiatric condition as a cause of their symptoms. Abuse is assessed for routinely, often at the start of the interview, but not in the context of this situation.

1. A nurse caring for older adults in a provider's office researches aging theories to help determine why some people age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. a. Immunosenescence likely promotes the increase in infections in the older adult. b. Free radicals have adverse effects on adjacent molecules. c. Decreases in size and function of the thymus result in more infections. d. Nutrition likely plays an important role in maintaining the immune response. e. Lifespan depends to a great extent on genetic factors. f. Organisms wear out from increased metabolic functioning.

a, c, d. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, resulting in more infections. Vitamin supplements (such as vitamin E) may improve immune function. The cross-linkage theory proposed that a chemical reaction produces damage to the DNA and cell death. The free radical theory states that free radicals—molecules with separated high-energy electrons—formed during cellular metabolism can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors.

1. A nurse in a medical practice has assessed a patient reporting abdominal pain, diarrhea, and anxiety. When the health care provider finds no identifiable cause for the symptoms, which actions would the nurse recommend? Select all that apply. a. Keeping a diary identifying sources of stress b. Sleeping 4 hours per night c. Considering previous strengths and coping d. Asking whom the patient relies on for support e. Asking if the patient's partner is abusive f. Assessing for prior psychiatric conditions

a, c, d. The sympathetic nervous system reacts to stress with the fight-or-flight response. This response causes increased the heart rate, muscle strength, cardiac output, blood glucose levels, and mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest.

A nurse works in a facility stating they support a culture of safety. What will the nurse expect to find operationalized in this culture? Select all that apply. a. Support for reporting errors and near misses without blame b. Nurses being the employees responsible for safety in the organization c. Commitment of resources to address actual/potential safety issues d. Emphasis placed on individuals, their departments, and resources e. Promotion of teamwork and collaboration throughout the organization f. Administrators' and managers' commitment to safe operations

a, c, e, f. The key features of a culture of safety include: (1) acknowledging the high-risk nature of health care and the commitment to safe operations, (2) maintaining a blame-free environment where reporting is protected and expected, (3) promoting teamwork and collaboration to prevent and seek solutions to patient safety issues, and (4) valuing safety as a focus in all health care facilities, the home, workplace, and community.

1. After administering an enteral feeding, a nurse evaluates the patient's tolerance of the feeding. Which findings suggesting intolerance require collaboration with the dietician and health care provider? Select all that apply. a. Nausea and/or vomiting b. Weight gain c. Bowel sounds 20/min d. 200-mL gastric residual e. Absence of diarrhea and constipation f. Slight abdominal pain and distention

a, c, e. Criteria to consider when evaluating patient feeding tolerance include absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.

1. A nurse in the emergency department receives a patient rescued from a building fire. The firefighter giving the handoff report tells the nurse the building collapsed immediately after they removed the patient from the building. The nurse notes the patient is experiencing the alarm phase of the fight-or-flight response. What assessment findings support the nurse's observation? Select all that apply. a. Rapid breathing b. Hypotension c. Restlessness d. Withdrawn demeanor e. Tachycardia

a, c, e. The sympathetic nervous system initiates the fight-or-flight response, preparing the body to fight a stressor or run from it. This phase of the alarm reaction, called the shock phase, is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. During the second phase, called the countershock phase, there is a reversal of body changes. Hypotension and withdrawn demeanor represent the countershock phase.

At an annual health and wellness visit, the parent of an adolescent reports a teacher's concerns that their child is sleepy at school during class time. Which information will the nurse share with the parent and child? Select all that apply. a. Adolescents typically need 8 to 10 hours of sleep each night. b. Demands on the adolescent's time causes them to sleep longer hours. c. Insufficient sleep can lead to daytime sleepiness. d. Adolescents require reduced sleep in the teen years. e. The adolescent could benefit from a sleep study for insomnia.

a, c. Adolescents require 8 to 10 hours of sleep nightly; however, demands on their time cut into the needed sleep. Insufficient sleep can lead to daytime sleepiness.

During a nursing staff meeting to discuss delayed documentation, the nurses unanimously agree that they will ensure all vital signs are reported and charted within 15 minutes following assessments. This decision is consistent with which characteristics of effective communication? Select all that apply. a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness

a, d, e, f. Solving problems involves group decision making; ascertaining the task is important and agreeing to complete the task on time is characteristic of group identity. Group patterns of interaction involve honest communication and member support; cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and appropriately used to accomplish group outcomes.

1. A nurse in a rehabilitation facility is evaluating patients with chronic pain to develop an interprofessional plan of care. Which patients would the nurse identify who could benefit from a multimodal approach to pain management? Select all that apply. a. Patient receiving chemotherapy for bladder cancer b. Adolescent who had an appendectomy c. Patient who is experiencing a ruptured aneurysm d. Patient with fibromyalgia requesting pain medication e. Patient having back pain related to an accident that occurred last year f. Patient experiencing pain from second-degree burns

a, d, e. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and grunting sounds. Based on these nonverbal cues, what action will the nurse take next? a. Assess for pain and the need for analgesia. b. Ask the patient if they feel anxious. c. Offer to sit with the patient and listen to their feelings. d. Suggest the patient increase their fluid intake to prevent constipation.

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and grunting sounds is most likely communicating pain. The nurse should clarify this nonverbal behavior.

1. A nurse in a long-term care facility is caring for patient with a spinal cord injury affecting their sensory and motor reflexes below the waist. Based on the patient's condition, what would be a priority intervention for this patient? a. Taking care with hot beverages to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Offering meals high in carbohydrates to promote healing

a. A patient with a damaged neurologic reflex arc has a diminished pain reflex response. This diminished sensation and motor response places the patient at risk for burns. All patients should be provided adequate pain relief, but this is not a priority. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a well-balanced diet.

1. A home health care nurse has been caring for a patient with advanced AIDS who is working through the stages of death and dying. The nurse documents the patient has entered the acceptance phase of death when the patient makes which statement? a. "I've made peace with everyone, and I'm actually ready to move on." b. "God cannot possibly be good if He allows people to get this horrible disease." c. "I just want to get better. A friend of mine had success with a plant-based diet." d. "The test results must be mixed up with someone else's; I feel better now."

a. According to Kübler-Ross, when the patient reaches the stage of acceptance, they feel tranquil. This patient has accepted the reality of death and is prepared for the transition to death.

1. A nurse at the university health clinic has assessed a student reporting an inability to concentrate and a pounding heart. The student states, "my boyfriend just dumped me out of the blue. They were supposed to be my date at my sister's wedding this weekend. How can I go now?" Which response would the nurse make? a. "Can you tell me what part of this is most problematic right now?" b. "What alternatives can you think of at this late date?" c. "You might start by evaluating your relationship." "It may be best to not think about this person until after the wedding."

a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified.

1. After validating an autopsy is not planned, a new graduate nurse provides postmortem care. Which action requires the preceptor to correct the graduate? a. Leaving the patient in a sitting position at the family's request b. Placing identification tags on both the shroud and the ankle c. Removing soiled dressings and tubes, while washing the body d. Ensuring a death certificate is issued and signed

a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

1. An older adult who has had multiple strokes is refusing artificial nutrition and hydration against medical advice and in opposition to their daughter. The patient's nurse advocates for the patient, stating which party is the most appropriate decision maker? Electronic Health Record (EHR), Consultations Tab Psychiatric Consult: Patient is competent, understands the consequences of her actions, no depression noted. Patient persists in refusing treatment. Suggest ethics consultation. a. Patient b. Patient's daughter c. Health care provider Ethics consult team

a. Because this patient is competent, they have the right to refuse treatment felt to be disproportionately burdensome, even if this hastens their death. Neither her daughter nor her doctor has authority to assume decision-making responsibilities unless appointed as surrogates. The ethics consult team is not a decision-making body; they can make recommendations but have no prescription authority.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What should be the focus of this education? a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to age 2 years (or the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children age older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to age 2 years (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than age 6 years should still be in a booster seat.

1. A college student visits the school's health center reporting extreme fatigue and slight restlessness. The student states, "Exams are right around the corner, and all I feel like doing is sleeping." There are no abnormal physical assessment findings. How does the nurse best help the student frame their desire to sleep? a. Asking the student if they are worried about failing exams b. Telling them they must strive to sleep 7 to 9 hours nightly c. Evaluating their use of recreational drugs d. Explaining that some people use sleep as a coping mechanism

a. Fatigue and mild anxiety are often handled without conscious thought through the use of coping mechanisms, such as sleeping. These coping mechanisms are protective behaviors used to decrease stress and anxiety.

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which is the best action for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics. The nurse discourages napping during the day, decreases fluids at night, and dispenses diuretics in the morning (or early evening when necessary).

1. A nurse receives information in a shift report that a patient who has rapidly progressing terminal illness is in the denial phase of death and dying. The nurse expects a patient in this stage to make which statement? a. "I can't wait to get out of the hospital and plan next year's beach vacation." b. "I've chosen my favorite music and readings for my memorial service." c. "The people in this hospital are so incompetent, what a bunch of idiots!" d. "I cry every time I wonder how my children will get along when I'm gone."

a. In the denial phase, the patient denies the reality of death and may repress what is discussed. The patient may think, "They made a mistake in the diagnosis" or "they mixed up my records with someone else's." Planning a vacation for the following year indicates the patient is not ready to take in the information. When the stage of acceptance is reached, the patient feels tranquil and has accepted the reality of and is prepared for death. The patient may think, "I've tied up all the loose ends." In the anger phase, the patient expresses rage and hostility and may adopt a "why me?" attitude. During the depression phase, the patient goes through a period of grief before death. The grief is often characterized by crying and not speaking much.

A nurse observes involuntary muscle jerking in a sleeping patient. What action will the nurse take next? a. No action is necessary; this is normal in stage 1 sleep. b. Report the neurologic deficit to the health care provider. c. Lower the temperature in the patient's room. d. Awaken the patient, as this is an indication of night terrors.

a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. No further actions are needed for this patient.

A nursing student is caring for an older adult with arthritis who states she did not sleep well and was "up all night to use the bathroom." To help promote sleep, the student plans to discuss re-timing which medication with the primary nurse? a. Furosemide (diuretic) 10:00 AM, 10:00 PM b. Melatonin 9:00 PM c. Acetaminophen 10:00 AM, 10:00 PM d. Artificial tears every 8 hours, 8:00 AM, 2:00 PM, 8:00 PM

a. It is best to administer diuretics in the morning or early evening to prevent nocturia. Melatonin promotes sleep and rest. Acetaminophen can relieve arthritis pain and help promote rest. Artificial tears, used for dry eyes, will not affect sleep.

A nurse in a rehabilitation facility develops a plan to help promote patients' sleep. What interventions will the nurse include in the plan? Select all that apply a. Maintain a consistent bedtime and time to awaken. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.

a. Keeping a consistent bedtime and awakening schedule, even when up late, helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

A patient experiencing menopause tells the nurse at the medical clinic that she would like to try a CAH hormonal sleep aid like her friend uses. What information can the nurse give the patient? a. Melatonin, an over-the-counter hormonal sleep aid, has varied effectiveness. b. Lavender is a hormonal scented sleep aid. c. Lorazepam, a naturally occurring benzodiazepine, is recommended for sleep. d. Valerian is a natural hormonal sleep aid.

a. Melatonin, used as a complementary or alternate to traditional pharmacologic agents, is a hormone thought to regulate the sleep-wake cycle. Valerian is an herb; lavender is a plant used for aromatherapy and relaxation. Benzodiazepines are pharmacologic medications used to decrease anxiety and promote sleep and relaxation.

1. A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? a. Older adult on bedrest following cervical spine surgery b. Patient with a severe sunburn being treated for dehydration c. Industrial worker who has burns caused by a caustic acid d. Patient experiencing cardiac disturbances from an electrical shock

a. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores is a mechanical stimulant. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. An electrical shock is an electrical stimulant.

The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene? a. "I am sure everything will be fine; you have nothing to worry about." b. "When you return from surgery, you'll need to cough and deep breathe." c. "Many people on this unit have had that procedure with good success." d. "You seem fearful, can I answer any questions about the procedure?"

a. Telling a patient that everything will be fine is a cliché. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.

1. A group of nursing students in a leadership course are studying the ANA position regarding assisted suicide. The professor asks the students for the best response to a note written by a ventilator-dependent patient "help me end my suffering, I don't want to live anymore." Which nursing response is consistent with the ANA's position? a. "I will do everything possible to keep you comfortable but will not administer medication to cause your death." b. "Being removed from the ventilator is a form of active euthanasia, which is not supported by the nurses' code of ethics." c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "Let's talk about when and how you want to die." d. "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Removing mechanical ventilation or other life support at the patient's request or request of the surrogate when treatment is futile is not performed with the sole intent to end life but to promote dignity and comfort. Nurses should be prepared to respond to the request: "Nurse, please help me die...."

1. The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES b. COMFORT c. FLACC d. FACES

a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES Scale is used for children who can compare their pain to the faces depicted on the scale.

An experienced nurse and new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse? a. Raising all four side rails to keep the patient in bed b. Performing documentation in the patient's room c. Suggesting obtaining a patient "sitter" d. Using a bed alarm to alert staff the patient leaving the bed

a. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. People of small stature are more likely to be injured slipping through or between the side rails. A history of falls from a bed with raised side rails carries a significant risk for a serious incident. The nurse uses creative measures while promoting safety and respect for the patient's dignity.

1. A nurse is feeding a patient who reports feeling nauseated and unable to eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore why the patient does not want to eat the food. d. Offer high-calorie snacks such as pudding and ice cream.

a. The first action of the nurse when a patient has nausea is to remove the tray, which may have noxious odor, from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.

1. A nurse is receiving report on a patient with alcoholism who will be transferred to the medical-surgical unit. Due to long-term alcohol exposure, the nurse plans for administration of which nutrient? a. B vitamins b. Lipids c. Fluids d. C vitamins

a. The need for B vitamins is increased in alcoholism because these nutrients are used to metabolize alcohol, thus depleting their supply. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

1. A patient with end-stage breast cancer has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that his wife was very clear about not wanting aggressive treatment that would merely prolong her dying. Which type of order could the nurse suggest the husband discuss with his wife's health care provider? a. Comfort Measures Only b. Do Not Hospitalize c. Living Will d. Slow Code Only

a. The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order in which the goal of treatment is a comfortable, dignified death, and further life-sustaining measures have been declined. A Do-Not-Hospitalize order is often used for patients in long-term care and other residential settings who refuse hospitalization for further aggressive treatment. A living will is a document in which the patient provides specific instructions about the kinds of health care that should be provided or foregone in particular situations in which they are unlikely to recover. A Slow Code refers to a delay in calling a code and beginning resuscitation efforts until these measures will be ineffective. This is not consistent with current best practice and may be forbidden in certain facilities. A nurse could be charged with negligence in the event of a Slow Code and resulting patient death.

A public health nurse is leaving the home of a young mother who has an infant with special needs. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response? a. "New mothers need support." b. "The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation."

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. "How are you today?" is dismissive of the neighbor's question.

The hospital's fire alarm sounds, and an announcement is made that there is a fire in a patient room. What is the priority for nurses on the unit? a. Removing patients from the room or vicinity b. Attempting to put out the fire with water or appropriate extinguishers c. Closing all the doors on the unit to contain the fire d. Running to the closest unit and requesting help

a. The nurse uses the acronym RACE and rescues and/or removes the patient and those in nearby rooms as the safety priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Remaining on the unit allows you to assist patients and is more appropriate; assistance can be summoned by phone.

A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship? a. "Let's review the progress you've made in meeting your goals." b. "I'd like to review your medication schedule with you." c. "I need to document today's teaching session in the electronic health record." d. "Should we include your family in today's session?"

a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed.

1. A nurse is feeding an older adult patient with dementia. What intervention will best promote nutritional intake? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

1. A nurse plans to administer a bolus tube feeding for a patient but is unable to aspirate gastric contents due to a clogged tube. What action will the nurse take next? a. Use warm water or air, applying gentle pressure to remove the clog. b. Use the tube's stylet to unclog the tubes. c. Administer a cola beverage to remove the clog. d. Replace the tube with a new one.

a. To remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. The stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and, if unsuccessful, the tube should be replaced.

1. A nurse caring for an older adult living in a long-term care facility uses reminiscence to help the patient adapt to the changes of aging. The nurse uses which question to encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday? d. "Why don't you want to talk about your feelings?"

a. Use of life review or reminiscence encourages reflection; the older adult can restructure life experiences and better adapt to life circumstances. Asking about a recent event, upcoming plans, or feelings would be unlikely to encourage reminiscence.

1. A nursing student is caring for a patient who had a gastrostomy tube placement 12 hours ago. Which action by the student is correct? a. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site b. Washing the area surrounding the tube with a wet washcloth and with soap and water. c. Adjusting the external disk every 3 hours to avoid crusting around the tube. d. Taping a gauze dressing over the site after cleansing it. e. Assessing the gastric residual every 4 hours. f. Discontinuing feedings when gastric residual volume is 120 mL.

a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air. If drainage is present, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

1. A nurse specializing in care of older adults speaks to a group of nursing students about that population's challenge with obtaining sufficient nutrition. Which points will the nurse include in the discussion? Select all that apply. a. An increase in BMR and physical activity require additional calories. b. Tooth loss and periodontal disease may make chewing more difficult. c. Decreased peristalsis can result in constipation, requiring additional fiber and fluid. d. Loss of taste between sweet and salty occurs with a preference for sweets. e. Older adults express an increase thirst sensation. f. Caloric needs decrease, and the need for nutrients increases, especially protein.

b, c, d, f. Due to age-related changes, caloric needs of the body decrease; however, the need for nutrients, including protein, calcium, vitamin B12, and vitamin D increase. If tooth loss and periodontal disease occur, adequate nutritional intake may become more difficult. An increase in fiber and fluid intake can relieve constipation related to decreased peristalsis. Older adults are also prone to dehydration related to loss of thirst sensation. Loss of taste between sweet and salty occurs with a preference for sweets. Dietary restrictions related to chronic illness, limited income, isolation, and age-related physiologic changes place persons in this age group at risk for malnutrition.

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. Patient taking iron supplements for anemia b. Patient with Parkinson's disease who is taking dopamine c. Older adult taking diuretics for congestive heart failure d. Child taking antibiotics for an ear infection e. Patient taking antidepressants f. Patient taking low-dose aspirin prophylactically

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

1. During postconference, nursing students are exploring definitions of pain and its nature. Which statements should be included in this discussion? Select all that apply. a. "It is whatever the health care provider treating the pain says it is." b. "Pain exists whenever the person experiencing it says it is present." c. "It is an emotional and sensory reaction to tissue damage." d. "Pain is a simple, universal, and easy-to-describe phenomenon." e. "When a cause cannot be identified, pain is psychological in nature." f. "It is classified by duration, location, source, transmission, and etiology."

b, c, f. Nurses must respect patients' reports of pain and consider the patient an expert on their pain experience. An accepted definition of pain is that pain is whatever the patient says it is, existing whenever the person says it does, even if the cause is not clearly established." Pain is a complex, unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

The nurse manager and nurses in an acute care hospital are participating in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine require follow-up? Select all that apply. a. Age >50 years b. History of falling c. Taking antibiotics d. Presence of postural hypotension e. Nausea from chemotherapy f. Transferred from long-term care

b, d, f. Risk factors for falls include age >65 years, documented history of falls, postural hypotension which can cause dizziness, and unfamiliar environment. A medication regimen that includes diuretics creating urinary urgency and tranquilizers, sedatives, hypnotics, or analgesics causing altered mental status and impaired judgment are also risks. Chemotherapy or antibiotics are not included as factors leading to falls.

1. Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S—Senility b. P—Problems with feeding c. I—Irritability d. C—Confusion e. E—Edema of the legs f. S—Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S—Sleep disorders P—Problems with eating or feeding I—Incontinence C—Confusion E—Evidence of falls S—Skin breakdown

A nurse caring for patients on a surgical unit should implement which recommendation to promote sleep? Select all that apply a. Keep the room light dimmed during the day. b. Maintain a cool temperature in the room for sleep. c. Keep the door of the room open for fresh air. d. Offer a hypnotic to patients on a regular basis. e. Offer pain medication prior to sleep, as needed. f. Provide earplugs if the patient agrees.

b, e, f. The nurse should keep the room cool and provide earplugs and eye masks if desired. The nurse should maintain a bright room environment during daylight hours and dim lights in the evening, keeping the door of the room closed to keep out extraneous noise. Sleep aid medications should only be offered as prescribed with the knowledge that they can become habit forming.

1. A patient tells a nurse that their daughter has been appointed to make decisions for them should they become incapacitated. What follow-up question would the nurse ask? a. "Did the health care provider complete a Physician Order for Life-Sustaining Treatment (POLST) form?" b. "Do we have a copy of your durable power of attorney for health care?" c. "Have you prepared a living will?" d. "Should I phone your provider for you to sign an Allow Natural Death (AND) form?"

b. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A POLST form is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. The living will is a document whose purpose is to allow people to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. AND on the medical record of a patient indicates the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient.

1. A nurse researcher interviews adults to validate Erikson's theory that middle-aged adults who do not achieve their developmental tasks may be in the stage of stagnation. Which patient statement will the nurse correlate to this theory? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. According to Erikson (1963), the middle adult is in a period of generativity versus stagnation. The tasks are to establish and guide the next generation, accept middle-age changes, adjust to the needs of aging parents, and reevaluate goals and accomplishments. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs.

1. A patient is admitted to the acute care medical center with change in mental status, dehydration, and electrolyte imbalances. Which of these reflects a reversible cause of the changes in mental status? a. Alzheimer's disease b. Delirium c. Dementia d. Delirium superimposed on dementia

b. Delirium, an acute syndrome of brain failure, can last from hours to weeks, has a specific cause, and resolves with treatment of the identified underlying cause. Symptoms of delirium include deficits in attention, awareness, and cognition. Dementia refers to various organic disorders affecting cognitive function that are progressive and irreversible.

1. A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse, "I'm a vegetarian. I'm not the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression

b. Denial, a coping mechanism, occurs when a person refuses to acknowledge the presence of a condition that is disturbing. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness. This patient is not blocking out the fact that the diagnosis was made, but refusing to believe it.

A nurse says to their nurse manager, "I need the day off, and you didn't give it to me!" The manager replies, "I wasn't aware you needed the day off, and it isn't possible since staffing is inadequate." How could the nurse best modify the communication for a more positive interaction? a. "I placed a request to have 8th of August off for a doctor's appointment, but I'm scheduled to work." b. "Could I make an appointment to discuss my schedule with you? I requested the 8th of August off for a doctor's appointment." c. "I will need to call in on the 8th of August because I have a doctor's appointment." d. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. Effective communication involves sending clear, nonthreatening, and respectful information to the receiver. The nurse identifies the subject of the meeting and determines a mutually agreed upon time.

A nurse on a postpartum unit is teaching new parents about newborn safety and sleep patterns. Which comment from a parent indicates further teaching is required? a. "I can expect my newborn to sleep an average of 16 to 24 hours a day." b. "Eye movements or groans during my baby's sleep is an emergency." c. "It is essential that I place my infant on their back to sleep." d. "I will not place pillows or blankets in the crib to prevent suffocation."

b. Eye movements, groaning, grimacing, and moving are normal activities at this age; no emergency exists. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and other items in the crib as they pose a suffocation risk.

1. The nurse in a long-term care facility states in report that an older adult resident is quite frail. The oncoming caregiver prioritizes prevention of what problem? a. Confusion b. Falls c. Delirium d. Dementia

b. Fear of falling, indicators of frailty, and personality traits of high neuroticism and low conscientiousness contribute to falls in older adults. Falling once doubles the chance of the older adult falling again.

1. A patient with COPD is experiencing anorexia and weight loss. Which intervention would be most helpful in stimulating appetite in this patient? a. Administering pain medication after meals. b. Encouraging the patient's family to bring food from home when possible. c. Scheduling respiratory therapy nebulizer treatments before each meal. d. Reinforcing the importance of eating what is delivered to them.

b. Food from home that the patient enjoys may stimulate them to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what they must eat is no guarantee that they will comply.

1. When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced pain sensation b. Inadequate or inconsistent relief of pain is widespread c. Reliable assessment tools are currently unavailable d. Narcotic analgesic use should be avoided

b. Health care personnel are placing awareness of pain relief in children as a priority. The evidence supports the fact that children do indeed feel pain, and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.

1. A nurse is teaching a patient who is experiencing stress how to perform a relaxation technique. Which statement by the patient indicates the need for additional teaching? a. "I must breathe in and out in rhythm." b. "I should expect my pulse to be faster." c. "I can expect my muscles to feel less tense." d. "I will be more relaxed and less aware."

b. No matter what the technique, relaxation involves rhythmic breathing, a slower (not a faster) pulse, reduced muscle tension, and an altered state of consciousness.

1. A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings require follow up with the health care provider? a. Skin pigmentation caused by exposure to sun over the years b. Thin toenails with a bluish tint to the nail beds c. Using a walker while healing from a hip fracture related to brittle bones d. Bruising on forearms due to fragile blood vessels in the dermis

b. Older adults' toenails may become thicker (not thinner), with a yellowish tint (not a bluish tint) to the nail beds; a blue tint may indicate hypoxemia. Exposure to sun over the years can cause older adults' skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura.

After reporting an adult patient's loud snoring and changes in vital signs occurring overnight the patient's health care provider, a nocturnal polysomnography study is prescribed. What teaching will the nurse provide about this test? a. This is a blood test, taken in the evening to evaluate leptin and ghrelin. b. The patient is monitored overnight to evaluate for sleep apnea. c. A patient is evaluated for leg jerking and awakenings during the night. d. Adults, rather than children, can be diagnosed with this test.

b. Polysomnography is an overnight sleep study to determine if an individual has sleep apnea and treatment. Leptin and ghrelin are hormones that regulate nutritional intake. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. Research suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, increasing appetite; however, this does not help diagnose sleep apnea. Jerking legs in the early stage of sleep is expected. Both adults and children can benefit from diagnosis of sleep apnea with this test.

1. A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider? a. A respiratory rate of 11/min with normal depth b. A sedation level of 4 c. Mild forgetfulness d. Reported constipation

b. Sedation levels predict respiratory depression. The sedation scale uses: S = sleep, easy to arouse: no action necessary; 1 = awake and alert; no action necessary; 2 = occasionally drowsy but easy to arouse; requires no action; 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose; and 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone. A respiratory level of 11 with normal depth of breathing is usually not a cause for alarm. Mild forgetfulness or confusion may result from opioids; additional observation is necessary. Constipation is not life threatening; it should be reported to the health care provider but is not the priority.

1. A patient is receiving a multimodal medication regimen as part of the treatment plan for neuropathic phantom limb pain. When the patient reports a bloody bowel movement, which medication prescription requires notification of the provider? a. Acetaminophen b. Nonsteroidal antiinflammatory c. Opioid medication d. Antianxiety medication

b. The NSAIDs are contraindicated in patients with bleeding disorders (their action may interfere with platelet function). The nurse will hold the medication and collaborate with the provider to adjust the patient's prescriptions.

1. A postoperative patient asks the nurse about pain management following surgery. What teaching will the nurse provide? a. "Avoid asking for pain medication often, as it can be addictive." b. "It is better to wait until the pain is severe before asking for pain medication." c. "It's natural to have pain after surgery; it will lessen in intensity in a few days." d. "You will be more comfortable if you take the medication at regular intervals."

b. The gate control theory states that a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate, interfering with pain perception. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory.

A nursing student is preparing to administer morning care to a patient. What question by the student is most important to ask? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"

b. The nurse should ask permission to assist the patient with a bath. This allows for patient preferences and consent for care that involves entering the patient's personal space.

A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice? a. Positioning the patient in the supine position prior to applying wrist restraints b. Ensuring that two fingers can be inserted between the restraint and patient's wrist c. Applying a cloth restraint to the left hand of the patient with an IV catheter in the right wrist d. Tying an elbow restraint to the raised side rail of the patient's bed

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. Restraining the patient in a supine position increases the risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

1. A nurse is caring for terminally ill patients in a long-term care setting. Which nursing action is appropriate during end-of-life care? a. Avoiding disturbing a comatose patient by speaking to them while providing care b. Holding the hand of a dying patient and crying with the patient and family c. Requesting a social work consult for family members with multiple complaints about the care d. Performing hygiene for the patient because it is easier than having the patient help

b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient or family. The sense of hearing is believed to be the last sense to leave the body before death; therefore, the nurse should explain care to comatose or unresponsive patients. The nurse should address caregiver role endurance by actively listening to family members. Encouraging the dying patient to remain active and participate in care for as long as possible is appropriate, rather than taking over self-care measures.

1. A nursing student tells the clinical professor that they hate when they feel anxious before performing new procedures. They state they do not sleep well the night before, feel restless, and have increased alertness. How does the professor best respond to this concern? a. Suggesting the student seems worried about failing clinical and should seek professional help b. Stating that we cannot diagnose students, but these symptoms of mild anxiety can aid in learning and growth c. Suggesting the student is in denial about the need to increase their clinical grade and should meet with the course faculty d. Asking if they have considered speaking to someone about their panic disorder and recommend a provider

b. The professor can normalize the student's experience by explaining that mild anxiety is present in day-to-day living. It can increase alertness and perceptual fields (e.g., vision and hearing) and motivate learning and growth. Although mild anxiety may interfere with sleep, it also facilitates problem solving. Mild anxiety is often manifested by restlessness and increased questioning. The other options call attention to problems that may not exist.

1. A patient tells the nurse it is unfair that they should have to die now when they have finally made peace with their family. Which response by the nurse would be most appropriate? a. "I'm sorry you're feeling this way when death is inevitable." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll come to acceptance soon; no one knows how much time they have." d. "Tell me about your pain. Did it keep you awake last night?"

b. This response by the nurse validates the patient's feelings, saying they have been heard, and invites them to share more of their feelings, concerns, and fears. The other responses either deny the patient's feelings or change the subject.

1. A nurse on an adult surgical floor enters a patient room and observes a family member pressing the button to administer a dose of PCA via the infusion pump. What response by the nurse is most appropriate? a. "That dose will sure be helpful after their type of surgery." b. "Having only the patient use the pump prevents respiratory complications." c. "If the patient asked you to press the button, then it's OK." d. "Since the pump has built in safeguards, you can help with pain management."

b. Unauthorized family members or caregivers (instead of the patient) who administer PCA by pushing the dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death. This is known as PCA by proxy. Institutions should have protocols in place to protect against unauthorized PCA delivery and clear warning labels attached to PCA pumps stating, "WARNING: BUTTON TO BE PRESSED ONLY BY THE PATIENT" (ISMP).

1. A nurse is caring for a terminally ill patient who says, "I just can't sleep. I keep worrying about what my family will do when I am gone." What response by the nurse is most appropriate? a. "You need your sleep for your visitors tomorrow." b. "What seems to be concerning you the most?" c. "Your family told me they will be fine." d. "I suggest you discuss this with your family."

b. Using an open-ended question, such as, "What seems to be concerning you the most?" encourages communication. False reassurances or side-stepping the statement are not helpful. The nurse then would assess the patient's restlessness and consider possible comfort measures.

1. A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial Somatic

b. Visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after hearing the plan of care. How does the nurse best respond? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninterrupted. c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. Appropriate use of silence allows the patient to initiate or to continue speaking; the nurse can reflect on what has been shared while observing the patient without having to concentrate simultaneously on conversation. In due time, the nurse might discuss the meaning of silence with the patient. The nurse considers whether the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to excessive talking by the nurse, displacing focus from the patient. The nurse should not assume silence requires a consult with a counselor.

A school nurse is teaching parents about home and fire safety. What information will be included in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Fire-related injury and death have declined due to the availability and use of smoke alarms. e. Fires are more likely to occur in homes without electricity or gas. f. Fires are less likely to spread if bedroom doors are kept open when sleeping.

c, d, e. Eighty percent of fire deaths in the United States occur in the home. Most fatal home fires occur while people are sleeping, and most deaths result from smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the decline in fire-related injury and death. People with limited financial resources may use space or kerosene heaters, wood stoves, or a fireplace as the sole source of heat if utilities are turned off. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply. a. Choking b. Diving accidents c. Car accidents d. Suicide e. Intimate partner violence f. Cigarette smoking

c, d. Car accidents and suicide are common causes of death in adolescents. Choking is more typical in children younger than age 3 years. While diving accidents can occur in adolescents due to poor judgment, this is not as common. Intimate partner violence is more common in adults. Smoking, while ill advised, takes many years or decades to become a cause of death.

A nurse working the night shift is watching the monitors on a telemetry unit and observes a slight increase in a patient's vital signs during sleep. Which of these points will the nurse correlate to changes in vital signs? Select all that apply. a. They are aware of his surroundings at this point. b. They are in delta sleep at this time. c. It would be most difficult to awaken them at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. In stage IV NREM sleep (delta sleep), the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

1. The charge nurse in a long-term care facility discusses ageism with new nurse employees. Nurses are asked to intervene if they observe which of these examples demonstrating ageism? a. The AP encourages older adults to apply makeup or aftershave to promote positive self-image. b. The activity director explains to an older adult they could learn to use video conferencing to speak to their grandchildren. c. A nurse colleague states that older adult should not think about having a boyfriend or girlfriend after age 70 years. d. A nurse recognizes the patient who lost their partner of 45 years may be experiencing loneliness.

c. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only some of their age group. The other statements are positive, building on the older adults' strengths and resilience.

1. A nursing instructor teaching a gerontology class to nursing students discusses myths related to the aging of adults. Which statement will the students identify as a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Aging results in mental deterioration. d. Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults live in their own homes. Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others.

1. A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. Which type of cognitive impairment is non-reversible? a. Post-stroke speech issues b. Malnutrition c. Alzheimer's disease d. Loss of cardiac reserve

c. Alzheimer's disease causes progressive, irreversible cognitive impairment. It is the most common degenerative neurologic illness and the most common cause of cognitive impairment. With therapeutic intervention, speech therapy, proper diet, and pharmacologic intervention, the other problems can be managed and potentially improved.

1. A nurse who performs preoperative assessments and teaching prepares patients for postoperative discomfort using anticipatory guidance. What interventions would this nurse use to decrease postoperative stress? a. Teaching rhythmic breathing to perform prior to the procedure b. Telling the patient to mentally place themselves in a pleasant place and breathe in and out slowly c. Explaining about expected incisional discomfort or nausea and describing relief methods d. Suggesting the patient create and focus on a mental image during the procedure to be less responsive to the pain

c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient knows what to expect through advanced explanation about discomfort, nausea, or pain and available relief measures, the patient's anxiety can be reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. While these might be addressed, the other options do not reflect anticipatory guidance or focus on postoperative discomfort.

While discussing home safety with the nurse, a patient admits that they smoke a cigarette in bed before falling asleep at night. Which health problem is the priority for this patient? a. Impaired gas exchange: etiology, cigarette smoking b. Acute anxiety: etiology, inability to stop smoking c. Nonadherence: etiology, nonadherence to recommendation to stop smoking d. Knowledge deficiency: etiology, risk for burn and suffocation in a house fire

c. Because the patient is not aware or denies that smoking in bed poses a danger for fire and toxic fumes, education about the risk for burns and suffocation is needed. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

A nursing student is nervous and concerned about working at a clinical facility. Which action would best decrease anxiety and help ensure successful delivery of patient care? a. Determining the established goals of the institution b. Ensuring that verbal and nonverbal communication is congruent c. Engaging in self-talk to plan the day and decrease fear d. Speaking with fellow colleagues about how they feel

c. By engaging in positive self-talk, or intrapersonal communication, the nursing student can plan the day, decrease fear and anxiety, and enhance clinical performance.

1. An older adult who recently moved into a long-term care facility tells the nurse their only son died 20 years ago, and they haven't enjoyed life since. When giving report to the next shift, the nurse tells the oncoming nurse the resident seems to be suffering from which type of grief? a. Somatic b. Anticipatory c. Unresolved d. Inhibited

c. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; it may also describe a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place.

1. A nurse plans to promote a patient's natural pain mediators by using a whirlpool following intensive physical therapy to the legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin

c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.

1. The parents of an infant in the neonatal intensive care unit (ICU) for several months also have a 22-month-old child at home. The nurse notes the parents seem chronically fatigued, express guilt about neglecting their child at home, have been short tempered, and express anxiety about their continued ability to manage their family. The nurse plans to address which of these health problems in the plan of care? a. Dysfunctional Grief b. Fear about Being a Burden to Others c. Impaired Ability of Caregiver to Perform Caretaking d. Impaired Health Maintenance

c. Impaired ability of a caregiver to perform caretaking applies to these parents. Even with a positive outcome, the infant in the ICU is likely to be discharged with many needs, which may still impact them and their other child. Grief is an expression of loss, but the focus here is on the parents' exhaustion and coping. The health problem of being a burden refers to a patient's fear, rather than the caregiver. There is no specific information about the health maintenance needs of the child, rather, in this situation, the parents are the focus of care.

A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation? a. A toddler playing with his older brother's wooden blocks b. A 4-year-old eating yogurt and strawberries for lunch c. An infant sleeping in the prone position d. A 3-year-old drinking a glass of juice

c. Infants should be placed on their backs to sleep. A young child may place small or loose parts in the mouth. Anything that will fit through the average toilet paper roll is not safe for a toddler. A 3-year-old and a 4-year-old drinking juice and eating yogurt are developmentally appropriate.

1. A nurse is caring for a patient with ill-fitting dentures. What modification to their diet will the nurse suggest? a. Clear liquid b. Full liquid c. Mechanically altered d. Honeylike liquids

c. Mechanically altered diets provide adequate in calories and nutrients and contain chopped, ground, or soft foods. Liquid diets are generally used as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Clear-liquid diets are inadequate in calories, protein, and most nutrients; progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets include clear liquids plus milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A high-calorie, high-protein supplement is recommended if a full-liquid diet is used for more than 3 days.

1. When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method? a. Providing the highest effective dose of an opioid on a PRN (as needed) basis b. Using nonopioid drugs conservatively c. Applying multimodal nonpharmacologic and nonopioid pharmacologic therapies d. Administering a continuous intravenous infusion on a regular basis

c. Nonpharmacologic and nonopioid pharmacologic therapies (multimodal) are the preferred choices for chronic pain that is unrelated to active cancer, palliative care, or end-of-life care. If progression to opioids becomes necessary, the lowest effective dose of an immediate-release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PRN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. When caring for a patient with acute pain, such as postoperative pain, medication should be offered or requested before pain becomes severe or unbearable. Once pain is adequately treated, such as later in the postoperative course, a PRN schedule may be effective.

A nurse in a pediatric unit notes a school-aged child snores and appears to have labored breathing during sleep. Which assessment question could the nurse ask the patient or parents? a. "Do you have trouble sleeping?" b. "Have you missed a lot of school due to not feeling well?" c. "Have you been wetting the bed lately?" d. "Do you have a history of high blood pressure?"

c. OSA (pediatric) is defined by the presence of snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). Adults, children, and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. Hypertension is a consequence of OSA in adults.

1. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient assessment requires collaboration with the surgeon, as the procedure could need to be postponed? a. 19-year-old patient who is a vegan b. Older adult patient who takes daily nutritional drinks c. 43-year-old patient who takes ginkgo biloba and an aspirin daily d. Infant who is breastfeeding

c. Patients taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have increased risk for excessive bleeding and may requiring surgery to be postponed. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.

1. A nurse notes a hospice patient is increasingly agitated, with noisy, irregular breathing and periods of apnea. The skin of their feet appears mottled. The nurse takes which action? a. Activates the rapid response team to treat shock b. Contacts the respiratory therapist for a nebulizer treatment c. Prepares the patient's family for imminent death d. Inserts an oropharyngeal airway for suctioning

c. Signs of imminent death include difficulty talking or swallowing; urinary or bowel incontinence or constipation; loss of movement, sensation, and reflexes; decreasing body temperature with cold or clammy skin; weak, slow, or irregular pulse and decreasing blood pressure; noisy, irregular, or Cheyne-Stokes respirations; restlessness or agitation and/or; cooling, mottling, and cyanosis of the extremities and dependent areas. The purpose of hospice care is to provide comfort as death approaches rather than invasive interventions. As death approaches, the irregular noisy breathing is expected; nebulizer treatments are not the priority.

1. Students in a leadership class are discussing how social determinants of health affect pain management. Which statement is correct and should be included in the discussion? a. "Outcomes of pain management are generally satisfactory regardless of income." b. "Minority patients often receive excess medication." c. "Patients from minority groups often wait a long time before seeking treatment for pain." d. "Social determinants of health are unrelated to pain management."

c. Social determinants of health greatly impact on pain management outcomes. Patients residing in low-income settings and minority populations are less likely to receive the recommended treatments for pain in health care settings. Minority patients often experience pain for a lengthy period of time before seeking treatment for it. Language barriers, culturally inappropriate pain assessment tools, and prejudice and misconceptions may contribute to unsatisfactory pain outcomes. Initiatives to address health care access and treatment disparities begin at the local and community level.

1. A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? a. Infant who learns to turn over b. School-aged child learning to add and subtract c. Adolescent who is a "loner" d. Young adult who has a variety of friends

c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.

1. A parent bringing their toddler for a visit to the pediatric clinic tells the nurse that after work their partner yelled at the child for dropping a fork. Later the patient learned the partner's supervisor had been angry about the contents of a report that was submitted. The nurse explains it is likely their partner was using which coping mechanism? a. Denial b. Sublimation c. Displacement d. Dissociation

c. The nurse can explain that the patient's partner used the coping mechanism displacement, by transferring (displacing) their anger to a "safe" target. Another example is an angry person kicking a chair or slamming a door. The nurse can encourage the patient to discuss this with their partner.

1. A nurse is performing an assessment of a patient who is 8 months' pregnant. The patient states, "I worry about being able to handle becoming a mother." The nurse plans interventions for which problem? a. Poor coping skills b. Denial about the impending birth c. Uncertainty and anxiety due to change in role d. Low self-esteem and fear of parenting

c. The nurse prepares a care plan focusing on anxiety, which can develop in a situational/maturational crises or changes in role status. There is insufficient data to determine whether the patient is demonstrating poor coping, referring to an inability to appraise stressors or use available resources. The patient is not displaying denial, as she is consciously discussing the anxiety rather than attempting to disavow the knowledge or meaning of the impending birth. There is no indication the patient has feelings of worthlessness (poor self-esteem) but rather expresses concern about the role change as she becomes a mother.

A nurse is providing education in a senior center on sleep and sleep hygiene in older adults. What teaching point will the nurse include? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Eating a bedtime snack high in tryptophan and carbohydrates improves sleep. d. Exercising right before bedtime can hinder sleep.

c. The nurse would teach that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

1. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention will best prevent aspiration? a. Feed the patient solids first and liquids last. b. Place the bed in the semi-Fowler position during feeding. c. Provide a 30-minute rest period prior to mealtime. d. Provide a straw for the patient's beverages and soups.

c.The nurse should provide a 30-minute rest period prior to mealtime to promote better swallowing. The nurse alternates solids and liquids when feeding the patient; sits the patient upright or, if on bedrest, elevates the head of the bed at a 90-degree angle; and initiates a nutrition consult for diet modification and food size and/or consistency. Straws are avoided in patients with dysphagia. Assessing breath sounds will help detect aspiration but not prevent it.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By age 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults, and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the demands of school, activities, and part-time employment. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

1. A visiting nurse is assessing a family that includes a young couple and their infant who has cerebral palsy. The nurse notes that the mother is unkempt, the house is untidy, and the mother states she is "so busy with the baby that I don't have time to do anything else." What priority intervention would the nurse set for this family? a. Arranging to have the infant removed from the home b. Informing other members of the family of the situation c. Increasing the number of visits by the visiting nurse d. Recommending respite care for the parent(s)

d. A person providing care at home for a family member for long periods of time often experiences caregiver burden, manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse could recommend a consultation with a social worker or suggest community resources including possible respite care for the parent(s).

A nurse is filing a safety event report for a confused patient who fell while getting out of bed. Which action is most appropriate during documentation? a. Including suggestions on how to prevent the incident from recurring b. Providing minimal information about the incident c. Discussing the details with the patient before documenting them d. Recording the circumstances and effect on the patient in the health record

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

1. A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize? a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression

d. An opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening.

A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. Which action does the nurse suggest they prioritize? a. Ensuring proper function of fire alarms b. Preventing exposure to temperature extremes c. Screening for partner or elder abuse d. Maintaining clutter free rooms and hallways

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms and hallways should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

1. Nurses working in a trauma intensive care unit state they experience a high level of stress. Which stressor are they likely to encounter? a. Nurse manager support for equitable assignments b. Health care benefits c. Debriefings after the death of a patient d. Incivility by team members or bullying

d. Incivility encompasses rude or discourteous actions that negatively affect others. Incivility can escalate to bullying, which is defined as repeated, ongoing actions that intend to harm another person. This includes humiliation, offensive speech or actions, or other methods of causing distress. The other options exist in a positive work environment.

1. A nurse providing health services for a community setting for people age 55 years and older considers health problems for these residents. Which of the following problems is most appropriate for many middle-aged adults? a. Adequate nutrition b. Mental health problems c. Abuse d. Caregiver role strain

d. Many middle-aged adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Nutritional issues are more common in the childhood years and possibly in older adults. Mental health issues and abuse can occur in multiple age groups.

1. A patient hospitalized for a stroke has a prescription for continuous tube feedings through a small-bore nasogastric tube. Following tube placement, which action by the nurse best confirms correct tube placement? a. Auscultating the bowel sounds b. Measuring the pH of gastric aspirate c. Measuring the amount of residual in the stomach d. Ensuring validation of tube placement by x-ray

d. Radiographic examination is the most accurate method to validate tube placement in the stomach. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual volume amount does not confirm placement.

Nursing students are invited to participate in the clinical agency's annual disaster drill, simulating the release of an airborne infectious agent and ensuing panic. Which assignment is most appropriate for the students? a. Cleansing and dressing wounds sustained during the panic b. Triaging patients with respiratory symptoms and traumatic injuries c. Providing information to families of missing loved ones d. Ensuring everyone entering and working has an N95 mask

d. Rapid assessment and triage are essential during a disaster. Delegating tasks appropriate to students are based on skill level and ability to complete skills independently. Ensuring masks are worn and the education for this, if needed, are within the educational and clinical skills of nursing students.

1. Which question by the nurse will be most helpful in determining whether a patient who is experiencing a myocardial infarction has referred pain? a. "Did your chest pain last 2 minutes or less? b. "Was the pain on the surface of your chest?" c. "Is this pain in your residual limb shooting or burning?" d. "Are you having any arm or shoulder pain?"

d. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. One example is the pain of MI (heart attack) that can be felt in the shoulder or chest, among other areas. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.

A patient states, "I have been experiencing complications of diabetes." What question will the nurse use to elicit additional information? a. "Do you take two injections of insulin to prevent complications?" b. "Are you using diet and exercise to help regulate your blood sugar?" c. "Have you been experiencing the complications of neuropathy?" d. "Can you tell me about the complications you've experienced?"

d. Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.

During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority? a. Explaining how to use the telephone b. Introducing the patient to their roommate c. Reviewing the hospital policy on visiting hours d. Demonstrating how to operate the call bell

d. Teaching the patient to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the "A" portion of the SBAR communication? Exhibit: Electronic health record (EHR) Past medical history Vital Signs Peptic ulcer T 98.8°F, P 111, RR 20, BP 98/50 Bleeding disorder Pulse oximetry 96% a. Admitted with peptic ulcer and bleeding disorder b. Found vomiting in bathroom c. Anti-ulcer medication recommendation d. Vital signs, oxygen saturation, bright red emesis

d. The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.

The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate? a. "Please speak more quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for shouting." d. "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the AP to see to the patient's safety, then address any concerns privately. The nurse then can discuss appropriate use of therapeutic communication.

1. The family of a patient who has just died asks for privacy and supplies to wash their loved one's body. How does the nurse best respond? a. Inform the family that there is no need for them to wash the body since the funeral home typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient. c. Provide the requested the supplies and maintain a watchful eye to ensure they maintain the patient's dignity. d. Provide the requested supplies, assess if this request is linked to religious or cultural customs, and offer assistance.

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so. This action may reflect caring, the last service to a loved one, or promote acceptance of death.

A nurse enters a patient's room and examines the patient's intravenous (IV) fluids and cardiac monitor. When asked, "who are you?", which response by the nurse is most appropriate? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "I am John Smith, your nurse, and I'll be caring for you until 11 PM."

d. The nurse should identify themselves, ensure the patient knows what will be happening, and the duration of their relationship.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested a toxic substance from under the sink. How will the nurse advise the parents? a. Administer activated charcoal in tablet form and take child to the ED. b. Administer syrup of ipecac and take child to the ED. c. Bring the child in to the primary care provider for gastric lavage. d. Call the PCC immediately before attempting any home remedy.

d. The nurse tells the parents to call the PCC immediately, before attempting a home remedy. Parents may be instructed to bring the child to an emergency facility for immediate treatment. Activated charcoal is not appropriate to use at home but under medical supervision, after the risks and benefits have been assessed. Syrup of ipecac is no longer recommended because vomiting may exacerbate the hazard as it vomited up. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." How will the nurse best communicate a therapeutic response? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "Tell me what feeling so alone is like for you?"

d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A disoriented older resident likes to wander the halls of their long-term care facility but becomes agitated when they cannot find their room. Which action is most appropriate as an alternative to restraints? a. Placing them in a geriatric chair near the nurses' station b. Using the sheets to secure them snugly in the bed c. Keeping the bed in the high position d. Identifying their door with his photograph and a balloon

d. This allows the resident to be on the move and be more likely to find their room when they want to return. Many facilities use this kind of approach, rather than restrict patients' movements. Identifying the patient's door with their photo and a balloon may resolve the issue without restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would likely result in a fall.

1. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on the breakfast tray. b. The patient tells you they are hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast.

d. Tolerance to a diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information? a. "Watching your child vomiting and in discomfort must have been scary." b. "This started yesterday, correct?" c. "Has this child has had anything to drink?" d. Could you tell me the color and approximate amount of the vomiting?

d. Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true.

1. The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by "closing the gate"? a. Encouraging regular use of analgesics b. Applying moist heat to the area at intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication

d. While many analgesics are ordered on a PRN (as needed) basis, patients should be taught that it is more difficult to relieve pain that prevent it. The patient should not wait until pain is severe or unbearable to request pain medication. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time.