356 FINAL EXAM

Before being transferred home, Mrs. Allison changes her mind and is not considering curative treatment; however she would still like to receive hospice care. How could the nurse respond to Mrs. Allison?

"It sounds like palliative care might be an option you want to consider. The philosophy is similar to hospice in that it is patient and family centered, improves quality of life, and manages symptoms." Palliative care is appropriate both for patient still receiving aggressive treatment with hope of achieving a cure and for those who have forgone any life extending treatment.

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (select all that apply) 1. Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes 2.Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 4. Nurses appreciate the cultural aspects of care and recognize the may of these complementary strategies are part of a patient's life. 5. Nurse play an essential role in the safe use of complementary therapies 6. Nurses learn how to provide all of the complementary modalities during their basic education

1, 2, 3, 4, 5 All of the statements are true except that nurses do not learn how to provide all of the complementary modalities during their basic education. Nurses play an essential role in the safe use of complementary therapies in our emerging health care system. They have an appreciation for many types of interventions and can understand the patient's need to become more involved in his or her health care decisions and choices. They also understand the patient's desire to take a more active role in his or her healing and health promotion processes. Culturally relevant care that uses a full complement of intervention strategies that are supported with evidence is a central tenet of contemporary nursing practice.

The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply._ 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. " I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

1, 3, 4, 5 Screening after each new sex partner is the most effective method to detect and manage STIs. One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in males or females. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Older adults may engage in risk sexual behaviors because of lack of knowledge about STIs and condom usage. Research indicates that older adults are remaining sexually active longer than previous believed and the incidence of STI and human immunodeficiency virus (HIV)infections has steadily increased for the past 12 years.

Most recent national daily intake for adults include (select all that apply) 1. Fruits, vegetables, whole-grain products, seafood, and fat-free or low-fat milk 2. Desserts are okay to have after every dinner 3. Limit added sugar or sweetness so that less than 10% of calories are from added sugars 4. Consume less than 2300 milligrams (mg) of sodium per day 5. foods with little salt and potassium high 6. limit alcohol to moderate use (1-2 drinks a day) 7. Limit saturated fats and trans fats, consuming less than 10% of calories per day from saturated fats 8. Eat a variety of proteins, including lean meats, seafood, poultry, eggs, legumes, notes, seeds, and soy products.

1, 3, 4, 5, 6, 7, 8

The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3."most of the normal changes in function are related to alteration in circulation and hormone levels." 4."Many medications can interfere with sexual function"

1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual function and desire." Pathological processes can interfere with sexual function and desire. Changes in circulation, neurological pathways, and hormone levels account for many of the normal physiological change that occur with the aging process. Common medications such as diuretics, antihypertensives, anti anxiety medications, and antidepressants can contribute to sexual dysfunction. Older males and females take longer to reach orgasm, and the refractory period lengthens.

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (NP) informs her that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." How should the NP respond? (select all that apply). 1. "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, but you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

1. "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 have the highest incidence of STIs." Serious complications can result from untreated STIs in pregnancy such as preterm labor, rupture of membranes, and premature delivery of the newborn. The risk of untreated STIs is in any female is pelvic inflammatory disease, which, if untreated can cause serious problems such as infertility. Routine screening for chalmydia is recommended for all sexually women up to age 25. Many people do not know they are infected because they do not experience symptoms.

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage 1 2. Category/stage 2 3. Category/stage 3 4. Category/stage4 a. nonblancable redness of intact skin. discoloration, warmth, edema, or pain may also be present b. full-thickness skin loss; subcutaneous fat may be visible. may include undermining. c. full thickness tissue loss; muscle and bone visible. May include undermining d. partial-thickness skin loss or intact blister with serosanguinous fluid

1. A 2. D 3. B 4. C Category/stage 1 pressure ulcer does not have a break in the skin but has a redness that does not blanch. Category/stage 2 ulcer has a shallow open ulcer (partial-thickness wound). it may also have an intact fluid -filled blister. Category/stage 3 is full-thickness damage with out visible fat; however, bone, tendon, and muscle are not exposed. Category/stage 4 has full-thickness damage with visible bone, tendon, or muscle exposed.

The school nurse is counseling an adolescent male who is retiring to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages then nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this age-group 3. Lesbian, gay, bisexual, and transgender (LGBT) youth often experience stress from identification with sexual minority group 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance

1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 3. Lesbian, gay, bisexual, and transgender (LGBT) youth often experience stress from identification with sexual minority group 4. Knowledge about normal changes associated with puberty and sexuality can de erase stress and anxiety. Adolescents are establishing their identify and exploring their sexual preference. Those who identify with a sexual minority group often experience stress and isolation from peers. They need clear and accurate information about physiological and emotional changes occurring gin their body. Peer influence is high during this time, but support from family and health care professionals is equally important to adolescents.

The nurse is teaching a program on health nutrition at the senior community center. Which points should be included in the program for older adults? (select all that apply.) 1. Avoid grapefruit and grapefruit juice, which impair drug absorption 2. Increase the amount of carbohydrate for energy. 3. Take a multivitamin that includes vitamin D for bone health 4. Cheese and eggs are good sources of protein. 5. Limit fluids to decrease the risk of edema

1. Avoid grapefruit and grapefruit juice, which impair drug absorption 3. Take a multivitamin that includes vitamin D for bone health 4. Cheese and eggs are good sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bones fractures and falls. Grapefruit and grapefruit juice can interfere with warfarin (Coumadin) (anticoagulant), preventing its breakdown. This would lead to an increased risk of bleeding.

The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question asked by the nurse demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?

1. Can you tell me your sexual orientation? A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Using a term such as sexual orientation allows the patient to identify his or her sexual preference.

Which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Age 3. Spirituality 4. Personal beliefs 5. Previous experiences with death 6. Gender 7. Level of education 8. Degree of social support

1. Culture 3. Spirituality 4. Personal beliefs 5. Previous experiences with death 8. Degree of social support Culture, spirituality, personal beliefs and values, previous experiences with death, and degree of social support influence how a person approaches death.

What diet includes clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy? 1. Dysphagia stages, thickened liquids, pureed 2. Mechanical soft 3. Full Liquid 4. Low sodium

1. Dysphagia stages, thickened liquids, pureed

State whether Enteral feeding or Parenteral feeding 1. Cancer of head, neck upper GI _____ 2.Paralytic ileus _____ 3. Parkinson's disease_____ 4. GI disorders such as: Enterocutaneous fistula, inflammatory bowel disease, and mild pancreatitis _____ 5.Anorexia nervosa ___ 6. Respiratory failure with prolonged intubation ____ 7. Sever malabsorption _____ 8. Extended bowel rest: Enterocutaneous fistula, inflammatory bowel disease exacerbation, severe diarrhea, moderate-to-severe pancreatitis______ 9. Neurological and muscular disorders: bran neoplasm, cerebrovascular accident, Dementia, Myopathy _____ 10. Massive small bowel resection/GI surgery/ massive GI bleed _____ 11. Critical illeness/ trauma ____ 12. Preoperative bowel rest ____ 13. Treatment for co-morbid severe malnutrition_____ 14. Intestinal obstruction _____ 15. Difficulty swallowing _____

1. Enteral 2. Parenteral 3. Enteral 4. Enteral 5. Enteral 6. Enteral 7. Parenteral 8. Parenteral 9. Enteral 10. Parenteral 11. Enteral 12. Parenteral 13. Parenteral 14. Parenteral 15. Enteral

What kind of feeding includes NG tubes, jejunal, gastric, and needs to be placed by an X-ray? 1. Enteral Nutrition 2. Parenteral Nutrition

1. Enteral Nutrition Includes: - GI tract -Preferred route -keeps the gut working which prevents bacteria from leaking into surrounding tissues -must verify tube placement by xray -variety of tubes -complications

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? 1. Have the patient perform a valsalva maneuver 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line 3. Have the patient take a deep breath and hold it 4. Notify the health care provider immediately

1. Have the patient perform a valsalva maneuver Turn the patient on his or her left side to prevent air from entering the left side of the hear. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down")

Which of the following best explains the actions of therapeutic touch (TT)? 1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipients bitfield 2. Intentionally heals specific disease or corrects certain symptoms 3. is overwhelmingly effective in many conditions 4. Is completely safe and does not warrant any special precautions

1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield TT is focused on healing the whole person and providing energy to the body that supports innate healing responses. The research literature is a questionable; systematic analyses claim that the research designs are too weak for any conclusive evidence to be identified with confidence. Although TT is relatively safe and there have been very few negative events associated with its use, all therapies (complementary or conventional) should be used with caution in certain populations.

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. which type of grief is she experiencing? 1. Normal 2. Complicated 3. Chronic 4. Disenfranchised

1. Normal It is normal for anniversaries to prompt feelings of sadness and grief.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply). 1. Notify the surgeon 2. Allow the area to be exposed to air until all drainage has stopped 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately 5. Cover the area with sterile gauze and apply an abdominal binder

1. Notify the surgeon 4. Cover the area with sterile, saline-soaked towels immediately If a patient has an opening in the surgical incision and a part of the small bowel is noted, this evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist

A 42-year old sexually active female is being assessed by a nurse during her annual physical. The woman states that she has not had a period for the last 2 months. The nurse knows that the most likely cause of this occurrence is: 1. Pregnancy 2. Illicit drug use 3. Chlamydia infection 4. Early-onset menopause

1. Pregnancy Half of the pregnancies in the United States are unplanned, with women ages 18-24 and over 40 accounting for the highest incidence. Chlamydia often causes the cervix to be friable and bleed easily, resulting gin irregular bleeding and spotting versus amenorrhea. Menopause is defined as the absence of cyclic bleeding for 12 consecutive months.

To best assist a patient in the grieving process, which of the following is most helpful to determine? 1. Previous experience with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status

1. Previous experience with grief and loss Previous experiences with loss and grief help individuals develop coping skills and set a pattern of response to future episodes of loss and grief.

What are the 6 categories of the Braden Scale?

1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear

Which diet includes low-fiber foods, and easily digested such as pastas, casseroles, moist tender meats, and desserts, cakes, cookies with out nuts or coconut? 1. Soft/Low Residue 2. Low Sodium 3. Low Cholesterol 4. Mechanical Soft

1. Soft/Low Residue

Knowing that Mrs. Cooper is on a fixed income, you need to develop a plan to help her decrease her risk for complicating her present disease processes. Using your knowledge of medical nutrition therapy (MNT), summarize three points that you will include in a plan to help hermit her nutritional needs while living a budget.

1. Teach Mrs. Cooper to choose fresh fruits such as apples in bulk to lower cost 2. Explain that process food contains little nutritional value and is high in sugar and salt. 3. Provide a written copy of the AHA nutritional guidelines for Mrs. Cooper

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (select all that apply) 1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 2. we can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. 3. The fat emulsion will help control hyperglycemia during periods of stress 4. The parenteral nutrition will help your wounds heal 5. Since we just started the parenteral nutrition, we will only infuse it at 50% of our daily needs for the next 6 hours

1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids 3. The fat emulsion will help control hyperglycemia during periods of stress 4. The parenteral nutrition will help your wounds heal Sometimes adding intravenous fat emulsions to parenteral nutrition supports the patient's need for supplemental kilocalories, prevents essential fatty acid deficiencies, and helps control hyperglycemia during periods of stress. Parenteral nutrition is administered at 50% of the patients daily needs for the first 24 hours to asses how he or she is tolerating the infusion.

Because of the foul-smelling tan-colored drainage from Mrs. Stein's hip incision, the staples were removed by the health care provider, and an order was written for most saline gauze dressing to the area 3 Tims a day. When the dressing is removed, which factors are critical to assess?

1. The type of tissue in the wound (granulation, eschar, slough 2. The wound dimensions (length, width, and depth) 3. The presence of odor 4. The description of the wound exudate 5. Periwound condition including maceration, warmth, pain, and edema

A grieving patient complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? 1. These are normal symptoms of grief 2. There is a need for pharmacological support for insomnia 3. The patient is experiencing complicated grief 4. These are common complaints of the admitted patient

1. These are normal symptoms of grief symptoms of normal grief include a variety of feelings, thought patters, physical sensations and behaviors

What are the physical changes that occur as death approaches? (select all that apply) 1. Unresponsiveness 2. Erythema 3. Mottling 4. Restlessness 5. Increased urine output 6. Weakness 7. Incontinence

1. Unresponsiveness 3. Mottling 4. Restlessness 6. Weakness 7. Incontinence Patients experience physical changes that accompany the body shutting down.

Which of the following are measures to reduce tissue damage from shear? (select all that apply.) 1. Use a transfer device (e.g. transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Rase head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g. transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduce shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her form sliding. The head of bed is higher position causes patient to slide down, causing shear.

What is the removal of devitalized tissue from a wound called? 1. debridement 2. pressure reduction 3. negative pressure wound therapy 4. sanitization

1. debridement debridement is the removal of nonliving tissue, cleaning the wound to move toward healing

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (select all that apply). 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointments and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1. frequent position changes 4. using an incontinence cleaner 6. applying a moisture barrier ointment skin that is in contact with stool and urine can become moist and soft, allowing it too become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin-care and moisture barriers use also be used with frequent position changes to help reduce the risk for pressure ulcers.

When planning care for the dying patient, which interventions promote the patient's dignity? (select all that apply) 1. providing respect 2. viewing patients as a whole 3. providing symptom management 4. showing interest 5. being present 6. using a preferred name

1. providing respect 2. viewing patients as a whole 4. showing interest 5. being present 6. using a preferred name A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, feeling valued by others, and the way one is treated by caregivers.

When is an application of warm compress to an ankle muscle sprain indicated? (select all that apply.) 1. to relieve edema 2. to reduce shivering 3. to improve blood flow to an injured part 4. to protect bony prominences from pressure ulcers 5. to immobilize area

1. to relieve edema 3. to improve blood flow to an injured part warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

What role do the patients have in complementary and alternative therapies? 1. Submissive to the practitioner 2. Actively involved in treatment 3. Allow practitioner to experiment 4. Total believer in what is being taught

2. Actively involved in treatment One of the characteristics of complementary therapy users is that they want to be more involved in their care and decision making about the types of treatments that are used. Complementary therapies are one way to provide the patient with increased control of the health care.

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? 1. Use therapeutic techniques when communicating with the patient 2. Allow the patient to determine timing and scheduling of interventions. 3. Encourage family to only visit for short periods of time. 4. Provide the patient with private room close to the nurses station

2. Allow the patient to determine timing and scheduling of interventions Providing the opportunity for patients to have control of decisions concerning care allows them to maintain autonomy and dignity

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? 1. Denial 2. Anticipatory grief 3. Yearning and searching 4. Dysfunctional grief

2. Anticipatory grief Family members often grieve the impending loss of companionship, control, and sense of freedom, and the mental and physical changes to be experienced by their loved one. Ultimately they grieve the impending death.

The nurse is completing an admission history on a patient and says, "As a routine part of your medical history, it's important to include the sexual aspects of your life. Would it be alright if we discussed this?" this is an example of the nurse using the PLISSIT model to: 1. Place the patient in control of the situation. 2. Ask permission to discuss sexuality issues. 3. Provide the patent with limited information about sexual issues 4. Ask the patient to provide sensitive information.

2. Ask permission to discuss sexuality issues According to the PLISSIT assessment of sexuality, the nurse should first ask for permission to discuss sexual issues with the patient, followed by open-ended questions to determine the patient's concerns.

A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (Select all that apply.) 1. Always fail and cause illness and disease 2. Causes negative response over time 3. React the same way for all individuals 4. Protect an individual from harm in the short term

2. Cause negative responses over time 4. Protect and individual from harm in the short term In the beginning stress responses serve as a warning and physiological "alarm" of sorts, preparing the person to respond to harm. In this way they can be a protective mechanism. However, stress that continues unmitigated for long period of time creates states of "exhaustion" that translate ultimately into negative physiological and psychological events.

A patient is receiving total parenteral nutrition (TPN). what is the primary intervention the nurse should follow to prevent a central line infection? 1. Institue isolation precautions 2. Clean the central line port through which the TPN is infusing with antiseptic 3. Change the TPN tubing every 24 hours 4. Monitor glucose levels to watch and asses for glucose intolerance

2. Clean the central line port through which the TPN is infusing with antiseptic Use either alcohol or an alcoholic solution of chlorhexidine gluconate to clean the injection port or catheter hub 15 seconds before and after each time it is used to reduce the risk of central line infection

What is included in a high fiber diet? 1. Pastas, casseroles, moist tender meats, cooke fruits and vegetables 2. Fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits 3. Scrambled eggs, mashed potatoes and gravy, cottage cheese, rice, peanut butter 4. refined cooked cereals, cream soup, custard, canned fruits and vegetables.

2. Fresh, uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation , control bleeding and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2. Ice bag An ice bag helps to contract excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (select all the apply.) 1. Palliative care and hospice are the same thing 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment 5. Palliative care selects home health care services.

2. Palliative care is for any patient, any time, any disease, in any setting 4. Palliative care relieves the symptoms of illness and treatment. Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. It can also include, but is not solely, care of the dying. The primary goal of palliative care is to help patients and families achieve the best possible quality of life.

What type of feeding uses an infusion pump? 1. Enteral 2. Parenteral

2. Parenteral Includes: - intravenous: CVN/PPN -asepsis -lipids/fat emulsions -do not connect any other IV lines (fluids/medications) to the PN IV line -multiple lumens label the lumen for PN and only use for that -always use an infusion pump -weaning -complications

The nurse would delegate which of the following to nursing assistive personnel (NAP)? 1. Repositioning and reaping a patient's nasogastric tube 2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours 4. Administering enteral feeding bolus after tube placement has been verified 5. Hanging a new bag of enteral feeding.

2. Performing glucose monitoring every 6 hours on patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours The skills of measuring blood glucose level after skin puncture (capillary puncture) and writing down the amount the patient ate can be delegated to NAP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nasogastric tube should never be repositioned by the NAP for risk of causing injury to the patient.

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? 1. Fastening tube to the gown with new tape 2. Placing patient supine while giving a bath 3. Hanging a new container of enteral feeding 4. Ambulating patient with enteral feedings still infusing

2. Placing patient supine while giving a bath A patient receiving continuous enteral feeding should never be placed supine because it increase the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feeding should be stopped and restored when the head of the bed is at 45 degrees.

People who are vegetarian are at risk for _________ deficiencies? (select all that apply) 1. Vitamin C 2. Protein 3. B12 4. carbohydrate

2. Protein 3. B12

When providing postmortem care, which action is a priority for the nurse? 1. Locating the patient's clothing 2. Providing culturally and religiously sensitive care in body preparation 3. Transporting the body to the morgue as soon as possible 4. Providing postmortem care to protect the family of the deceased from having to view the body

2. Providing culturally and religiously sensitive care in body preparation Various cultures and religions have specific postmortem care practices. Honoring these practices is important for the family as they prepare to mourn their loved ones.

What does the Braden scale evaluate? 1. skin integrity oat bony prominences, including any wounds 2. risk factors that place the patient at risk for skin breakdown 3. the amount of reposition that the patient can tolerate 4. the factors that place the patient at risk for poor healing

2. Risk factors that place the patient at risk for skin breakdown The Braden scale measures factors in six sub scales that can predict the risk of pressure ulcer development. It does not assess skin or wounds

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (select all that apply) 1. Heart disease 2. Sepsis 3. Pleural effusion 4. Cardiac arrhythmias 5. Diarrhea

2. Sepsis 3. Pleural effusion 4. Cardiac arrhythmias patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, pleural effusions, sepsis, or hemorrhage during hospitalization

The nurse reviews the health history of a 48-year old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands: (Select all that apply) 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected negatively by some medications 3. Sexually transmitted infections (STIs) can cause complication such as erectile dysfunction. 4. It is not unusual for men with health issues to experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

2. Sexual function can be affected negatively by some medications. 4. It is not unusual for men with health issues to experience erectile dysfunction Nurses should complete a holistic assessment on all patients to be able to personalize a plan of care. Nurses who are not comfortable discussing sexual concerns of patients should seek training and resources to develop this skill. Many drugs and illnesses can affect sexual function. Antidepressants can alter sexual functioning by blocking neurotransmitters. Antihypertensives can affect sexual function by altering circulation. Erectile dysfunction occurs more frequently in older men but can occur in men as young as 40. STIs may affect sexual functioning but are less likely than medications or illness to be the cause of erectile dysfunction.

Which patients are at high risk for nutritional deficits? (select all that apply.) 1. The divorced computer programmer who eats precooked food from the local restaurant 2. The middle-age female with celiac disease who does not follow her gluten-free diet 3. The 45-year-old patient with type 2 diabetes who monitors her carbohydrate intake and exercises regularly 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not vitamins or iron supplements 5.The 65-year-old patient with gallbladder disease who electrolyte, albumin, and protein levels are normal

2. The middle-age female with celiac disease who does not follow her gluten-free diet 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements Patients suffering from celiac disease or Crohn's disease need to take vitamin and iron supplements regularly because they have a deficit resulting from malabsorption.

In addition to an adequate patient assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? 1. The family has provided permission 2. The patient has provided permission and consent 3. The health care provider has given approval or provided orders for the therapy 4. He or she has documented that the patient has a complete understanding of complementary and alternative medicine.

2. The patient has provided permission and consent Nurse-accessible therapies are independent nursing interventions. As long the Scope of Practice identified by the nurse's State Board of Nursing permits this activity, you do not need to obtain permission from the patient's primary provider or his or her family members unless the patient is underage. An adult cant provide consent. Complete understanding of any procedure or intervention is impossible to ensure; therefore documenting that the patient has a complete understanding of the complementary and alternative medicine is inaccurate.

The nurse is gathering a history from a 72-year old male patient being admitted to a nursing home. The patient request a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.

2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest. Sometimes sexual health is not addressed by the nurse, but it is important to include a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Long-term care facilities need to make arrangements to allow for continuation of sexual experiences of residents as long as no health risks are involved.

Traditional chines medicine (TCM) is used by many patients. Which statement most accurately describes intervention(s) offered by TCM providers? 1. Uses acupuncture as its primary intervention modality 2. Uses many modalities based on the individual's needs 3. Uses primarily herbal remedies and exercise 4. Is the equivalent of medical acupuncture

2. Uses many modalities based on the individuals needs TCM practitioners use a variety of interventions that are based on individual patient assessment findings and needs. Modalities include herbal therapies, acupuncture, moxibustion, cupping, prescribed exercise such as tai chi or qi gong, and lifestyle changes. Although acupuncture is often confused with TCM, when used alone acupuncture is not a whole system of medicine. Rather the National Insitutes of Health/National Center for Complementary and Alternative Medicine (NIH/NCCAM) considers it to be a mind-body technique that is often referred to as medical acupuncture. Although herbal therapies and exercise are considered to be part of the treatment repertoire of the TCM providers, these modalities are not considered to be primary interventions

According to Healthy People 2020, certain ethnic groups in the United States are disproportionately affected by sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). What are the likely causes of this issue? (Select all that apply.) 1. The large percentage of lesbian, gay, bisexual, or transgender individuals in the culture 2. Values and expectations about sexual behavior by the men or women in the culture 3. Religious beliefs and cultural attitudes toward the use of contraceptives 4.Educational background and knowledge of health risks associated with sexual behaviors 5. The higher incidence of sexual abuse in the affected ethnic groups

2. Values and expectations about sexual behavior by the men or women in the culture 3. Religious beliefs and cultural attitudes toward the use of contraceptives 4. Educational background and knowledge of health risks associated with sexual behaviors Factors such as gender, education, socioeconomic status, religion, language, and values influence the use of the health care system and health care practices. Each cultural group has their own set of norms that determine acceptable sexual behavior. Contraception choice is influenced by age, ethnicity, marital status, income, sexual orientation, and previous pregnancies. Populations who are at increased risk for HIV are people who are intravenous drug users, those who practice unprotected sex, and men who have sex with men. According to Healthy People 2020, Hispanic, African-American, and American Indian/Alaska Native populations experience higher rates of STIs than whites.

A 53-year-old female being treated for breast cancer tells the nurse that she has no interesting sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) 1. Sexual issues are expected in a woman this age. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. It is not unusual for medical conditions such as cancer to contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning.

2. Women experience sexual dysfunction more frequently than men 4. It is not unusual for medical conditions such as cancer to contribute to HSDD. 5. Disturbance in self-concept affect sexual functioning Women of all ages (not just older women) can experience HSDD. Biological, organic, or psychosocial factors; pain, depression; and body image concerns can result in sexual problems in men and women. Sexual dysfunction is estimated to occur in 40% of men and 60-80% of women. Self-concept issues, including changes in body image, self-esteem, and role performance, can impact sexual functioning.

What kind of diet does the American Diabetes Association recommend? 1. focus on mainly carbohydrates and sugars 2. focus balance intake of carbohydrates, fats, and proteins 3. focus on proteins and dairy products 4. focus on carbohydrates and fats only

2. focus balance intake of carbohydrates, fats, and proteins Nutrition recommendations by the American Diabetes Association: focus on total energy, nutrient and food distribution; include. balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient's metabolic demands

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "children are able to receive palliative care."

3. "only people who are dying can receive palliative care." Palliative care is available to all patients regardless of age, diagnosis, and prognosis.

What is a health BMI? 1. 17 2. 26 3. 18.5 4. 30

3. 18.5 NORMAL BMI RANGE 18.5 -24.9

What is the recommended amount of mg/day for a low cholesterol diet to reduce serum lipids? 1. 500 mg/day 2. 1000 mg/day 3. 300 mg/day 4. 250 mg/day

3. 300 mg/day Recommended by the American Heart Association guidelines

A 17-year-old girl asks for more information about birth control methods and says that she does not want her parents to know she is using birth control. The nurse informs the patient that the most effective option for her situation would be: 1. An effective long-term method such as a subnormal implant. 2. A hormonal method such as birth control pills or the transdermal patch 3. A long-acting hormonal injection given every 12 weeks 4. Abstinence during her most fertile time.

3. A long-acting hormonal injection given every 12 weeks The progesterone (Depo-Provera) injection is an effective method of birth control in which the patient receives an injection of progesterone every 12 weeks. Although the transdermal patch or sub-dermal implant is an effective method, it would be easier for others to see it in place on the skin. The use of latex condoms is recommended in addition to hormonal methods to decrease the risk for sexually transmitted infections. Any birth control method that must be used consistently with each occurrence of intercourse is a less reliable method (because of the margin for human error) than longer-acting methods that are not required with each act of sex.

A cardiac nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but doesn't feel comfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply). 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge 2. Avoid discussing the topic unless the patient brings it up and learn from the example. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training in the near future on how to discuss such issues

3. Ask a more experienced nurse to cover this with the patient and learn from the example 4. Plan to attend conferences or training in the near future on how to discuss such issues Nurses often avoid discussing sexual issues with patients because they are uncomfortable, lack knowledge, or have personal values in conflict with the patients. Nurses who have difficulty addressing sexual issues need to seek education and experiences to increase knowledge and explore their personal values.

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? 1. Recheck by performing another blood glucose test. 2. Call the primary health care provider 3. Check the medical record to see if there is a medication order for abnormal glucose levels 4. Monitor and recheck in 2 hours

3. Check the medical record to see if there isa medication order for abnormal glucose levels Check the medical record to see if there isa medication order for deviations in glucose level; if not, notify the health care provider. As the nurse you want to get the patient's blood sugar as close to normal as possible.

What kind of diet includes clear fat-free broth bouillon, coffee, tea carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles? 1. Mechanical Soft 2. Full Liquid 3. Clear liquid 4. Soft/Low residue

3. Clear Liquid

What is the palliative care team's primary obligation for the patient with severe pain? 1. Providing postmortem care 2. Teaching about grief stages 3. Enhancing the patients quality of life. 3. Supporting the family after the death

3. Enhancing the patients quality of life Palliative care focuses on enhancing the patient's quality of life

What kind of diet includes clear liquids, with addition of smooth-textured diary product (e.g. ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, and frozen yogurt? 1. Dysphagia stages, thickened liquids, pureed 2. Mechanical soft 3. Full Liquid 4. Low sodium

3. Full Liquid

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (select all that apply.) 1. Improved health among the staff 2. Increased patient safety 3. Improved staff satisfaction 4. Improved staff relationships 5. Fewer overtime assignments

3. Improved staff satisfaction 4. Improved staff relationships Current research has been able to determine that reducing stress by using relaxation strategies in the workplace leads to improved staff relationships, communication, and satisfaction.

What kind of diet includes clear, full, and pureed liquids, with addition of cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)? 1. Soft/Low Residue 2. High fiber 3. Mechanical soft 4. Low Sodium

3. Mechanical Soft

while planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? 1. Disease, spirit, and family interactions 2. Desires and emotions of the patient 3. Mind-body-spirit of patients and their families 4. Muscles, nerves, and spine disorders

3. Mind-body-spirit of patients and their families You could argue that, when you consider the totality of the patient/family, all of these come into play; but AHNA/ANA standards of Holistic Nursing speak specifically to the mind-body-spirit focus of holistic nursing.

A young mother is dying of breast cancer with bone metastasis and tells the nurse, " My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? 1. Spiritual distress related to questioning God 2. Hopelessness related to terminal diagnosis 3. Pain related to disease process 4. Anticipatory grief related to impending death

3. Pain related to disease process Pain control is always the priority

A nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for guided imagery? 1. Pregnant patient 2. Hypertensive patient 3. Patient with post-traumatic stress disorder (PTSD) 4. A pediatric patient

3. Patient with post-traumatic stress disorder (PTSD) Imagery can often recreate the traumatic experience, intensifying the sensations and emotions that accompany the memory of it and bring the PTSD to a crisis level.

Which complementary therapies are most easily learned and applied by a nurse? (select all that apply) 1. Massage therapy 2. Traditional Chinese medicine 3. Progressive relaxation 4. Breath work and guided imagery 5. Therapeutic touch

3. Progressive relaxation 4. Breath work and guided imagery These were identified as nurse-accessible complementary therapies. Massage therapists are licensed by local governmental agencies, and additional education preparation is require to practice. Traditional Chines medicine practitioners also attend training/educational programs, typically accredited by the Accreditation Commission for Acupuncture and Oriental Medicine.

A 16-year old female tells the school nurse that she doesn't need the human papilloma virus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: 1. Latex condoms are the most effective way to eliminate the risk of HPV transmission. 2. Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity. 3. The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts. 4. you are past the recommended age to receive the vaccine.

3. The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses the cause cancer and genital warts. An HPV vaccine that protects both men and women against the types of HPV that causes serious health issues is available and recommended for individuals ages 11-26. The use of latex condoms reduces the risk of contracting and sexually transmitted infection (STI), but abstinence is the only practice that eliminates the risk. Research indicates that vaccination does not increase sexual risk-taking behaviors among youths.

Which statement best describes the evidence associated with complementary therapies as a whole? 1. Many clinical trails in complementary therapies support their effectiveness in a wide range of clinical problems 2. It is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use 3. The science supporting the effectiveness of complementary therapies is early in its development 4. Most of the research examining complementary and alternative therapies has found little evidence, suggesting that, although people like them, they are not effective.

3. The science supporting the effectiveness of complementary therapies is early in its development Science in the field is just beginning. Before the 1990s little attention was paid in the United States at the Nation INsitutes of Health to support funding for studies about complementary therapies. Most of the evidence cited in systematic reviews throughout this chapter indicates preliminary support for the effectiveness of a variety of complementary therapies. Conditions that appear to be particularly responsive include chronic pain, chronic autoimmune disorder, anxiety, depression, impaired well-being and quality of life that accompany cancer and other chronic conditions, and some time-limited acute illnesses and the symptoms that accompany them (e.g.gastrointestinal disturbance, cold/flus)

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage 2 2.Category/Stage IV 3. Unstageable 4. Suspected deep-tissue

3. Unstageable To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

What food foods can a resident with dysphagia eat? 1. ground or finely diced meats, flaked fish, rice, potatoes, cooked or canned fruits, banal, peanut butter, eggs 2. easily digest foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables 3. fat free broth, bouillon, coffee, gelatin, popsicles, custards, refined cooked cereals, scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy 4. uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

3. clear and full liquid diet with addition of scrambled eggs; pureed meats, vegetables, andf fruits

What type of diet for a patient with diverticulitis? 1. Mechanical soft 2. Full Liquid 3. moderate-to-low residue diet 4. Low fiber

3. moderte-to-low residue diet Afterwards a high fiber diet would be prescribed. Diverticulitis is condition that results from an inflammation of diverticula, which are abnormal but common pouch like herniations that occur in the bowel lining.

A nursing professor is teaching a nursing student about caring patients who use herbal preparations in addition to prescribed medications. Which of the following statements made by the student indicates that the student understands herbal preparations? 1. "Herbal preparations are regulated by the FDA; therefore, I need to tell patients that they are completely safe." 2. " They are natural products and therefore are safe as long as you use them for the conditions that are indicated." 3. "These preparations are covered by insurance, including Medicare, Medicaid, and private payers." 4. " we need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

4. " We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses" Herbal therapies are derived from plants materials and often contain the same active components as medications. Yet they are viewed as dietary supplements and are not regulated by the FDA. You should always explicitly ask patient whether they are taking supplements or other herbal remedies or vitamins when you ask them about the medications that are currently being used during a health history. Many Patients do not tell you about these products voluntarily because they do not view them as medications, they fear that conventional providers will not approve of these substances and they want to continue taking them, or they do not think that you are interested in a substance that was not prescribed.

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze palmed over a granulating wound 3. A deriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

Meditation may compound the effects of which of the medications? 1. Prednison and antibiotics 2. Insulin and vitamins 3. Cough syrups and aspirin 4. Antihypertensive and thyroid-regulating medications

4. Antihypertensive and thyroid-regulating medications Mind-body techniques, including mediation, create physiological responses in the cardiovascular respiratory systems. These responses may include decreased blood pressure, reduced heart rate, and slowed respirations. They decrease the need for antihypertensive and other cardiac regulators and thyroid regulating medications.

When reposting an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area glances on fingertip touch? 1. A local skin infection requiring anitbiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode When reposition an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area comprises the blood vessels in the area; and. if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? 1. Lupus and diabetes 2. Ulcers and hepatitis 3. Heart disease and pancreatitis 4. Chronic back pain and arthritis

4. Chronic back pain and arthritis Evidence supports the use of many complementary therapies for chronic pain syndromes, particularly pain that is unremitting and unresponsive to conventional allopathic therapies

When obtaining a wound culture to determine the presence of wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4. Cleansed wound Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning gate area before obtaining the culture, the skin flora is removed.

Which statement made by a patient of a 2-month old infant requires further education? 1. I'll continue to use formula for the baby until he is at least a year old 2. I'll make sure that I purchase iron-fortified formula. 3.I I'll start feeding the baby cereal at 4 months 4. I'm going to alternate formula with whole milk starting next month

4. Im going to alternate formula with whole milk starting next month Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies

The nurse evaluates which laboratory values to asses a patients potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance

4. Nitrogen balance Nitrogen balance is important to determining serum protein status. A negative nitrogen balance is present when catabolic states exist. When a patient has decreased protein level, he or she is at risk for delayed wound healing.

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. suction her mouth and throat 2. turn her on their side 3. put on oxygen at 2-L nasal cannula 4.Stop feeding her and place on NPO

4. Stop feeding her and place on NPO Stop feeding and place patient on NPO. If choking persists, suction airway. Notify health care provider

A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback.What is the expected outcome related to using this additional modality? 1. To eat less food 2. To control diabetes 3. To live longer with acquired immunodeficiency syndrome (AIDS) 4. To learn how to control some autonomic nervous system response

4. To learn how to control some autonomic nervous system responses Biofeedback is a mind-body technique that teaches self-regulation and voluntary control over specific physiological responses, including autonomic nervous system responses.

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3.When central line has been in for 10 days 4. When 75% of the patients nutritional needs are met by the tube feedings

4. When 75% of the patients nutritional needs are met by the tube feedings When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? 1. using silence 2. asking, "why are you crying today?" 3. using therapeutic touch 4. stating, "I see that you're crying."

4. stating, "I see that you're crying." stating an observation encourages patients to share without putting the patient on the defensive.

You are assessing Mr. Clements during his 4-week follow-up appointment after discharge from the hospital. You need to include a sexual health history as a routine part of the nursing history. Give examples of nonjudgmental questions you will ask to determine his sexual function.

According to the PLISSIT model, you first ask for permission to discuss sexual health. Then you could ask: Are you sexually active since your myocardial infarction? Can you tell me about any difficulties you are having with your partner? How do you feel about the sexual aspects of your life?

Margaret Thompson is a 76-year-old Catholic woman who was diagnosed with a slow-growing renal tumor. She is scheduled for surgery. You are responsible for the admission assessment and initial care for this patient. Which assessment questions about complementary and alternative therapies will you include during the preoperative period?

Assess for the use of herbal supplements or natural products. Questions can include, "are you taking any dietary supplements, such as calcium, magnesium, vitamin E?" "Are you taking any OTC herbal supplements on a routine basis such as St. John's wort, glucosamine, echinacea?" "Do you use any products such as tea tree oil, lavender, or capsaicin cream?" Many supplements have drug interactions that can be exacerbated during anesthesia and period of physiological stress. For example, the use of St. John's wort increases bleeding times and may interfere with the metabolism of anesthetic agents. It is necessary to counsel this patient to stop the use of these natural products before surgery.

After determining Mr. Clements sexual orientation, how would you establish a therapeutic relationship to put him at was discussing the intimate aspects of his life?

Be sure to conduct the assessment in a confidential; private setting without interruptions. Talking with Mr. Clements before the actual physical examination before he undresses or puts on a gown enhances his comfort. Sit down near Mr. Clements, at his eye level, versus standing above him. You could use an opening statement such as, "It is not unusual for people with cardiac health issues to experience changes in sexual functioning. What questions or concerns do you have about this?" Another option would be to use an open-ended question such as, "People often have questions or concerns about resuming sexual activity after a health issue such as yours. How has your health affected your sexual activity?

Mrs. Allison will be staying in the hospital for the next week until her family can make the necessary arrangements to transfer her home. Describe ways to ensure that Mrs. Allison is comfortable at home and in her hospital room.

Encourage family and friend to bring items from home such as photographs or small items that bring enjoyment and comfort to the patient. Patients are comforted by their own familiar things. If possible, allow her to wearing her own pajamas or lounging clothes to make her feel less institutionalized. Keep unpleasant sounds and odors to a minimum.

What will you include in your plan of care for MRs. Stein to address the impairment in skin integrity in the sacral area?

Include the following: 1. Assess the type of support surface that the patient is using to determine appropriateness. 2. Institution of turning schedule, which will be used as her condition permits 3. Topical therapy to provide moisture to the area while providing protection such as hydrocolloid or hydrogel dressing 3. regular skin and wound care assessments to assess intact skin for signs of redness and the wound for signs of deterioration or progress toward healing 4. patient education to help Ms. Stein understand the importance of frequent position changes.

Mr. Mrs. Clements both vocalize cancer about initiating sexual activity since his MI, saying they are concerned that it might cause another MI. Mrs. Clements states that he seems less interested in intimacy than before the MI and tires easily.Provide at least three strategies that they. Ould use to enhance their sexual functioning.

Inform the couple that sexual activity can be resumed within 1-2 weeks after an uncomplicated MI and there are several things they could try to minimize their concerns. Plan sexual activity when feeling rested, possibly in the morning versus evening. Avoid heavy meals or alcohol for 2-3 hours before sexual activity. Experiment with different positions to enhance comfort and relaxation. Increase communication and discuss concerns during routine activities such as during meals or on a daly walk.

A head-to-toe skin assessment is done per institutional policy each shift or on a daily basis. At the most recent assessment of Mrs. Stein's ski, blistering was noted over the sacral area; on direct examination it was a small area of denuded tissue with redness around the blistered area. The area was found to have minimal depth and a red, moist, base. How would you describe the impairment in skin integrity in your charting?

The area over the sacrum had partial-thickness skin loss, stage two pressure ulcer, no measurable depth, granulation tissue at wound base, with periwound redness

Name the three important dimensions to consistently measure to determine wound healing.

Width, Length, Depth consistent measurement of the wound using the dimensions of width, length, an depth provide information on the overall change in the wound size that indicates if the wound is moving toward healing.

In the days following surgery you are assigned to care for Ms. Thompson. Although physical she is recovering quite well from the procedure, you note that she is becoming more dependent and depressed. Preparing for discharge, which complementary and alternative medicine (CAM) therapies do you recommend to help her deal with depression and cancer diagnosis?

You need to recommend nursing-accessible therapies that are used to combat cancer, including creative visualization and meditation. Both require additional teaching before discharge and follow-up during the initial period that they are used. You either need to teach her about these therapies beforedischarge or arrange for a home health nurse to teach them after discharge. A training specific therapy that may be helpful is biofeedback to address ongoing depression and chronic anxiety. Therapeutic touch and Reiki have also been found to be effective for people living with cancer.

Mrs. Allison is exhibiting signs of grief over her situation and possible cancer diagnosis. In her withdrawn state how might you encourage her to share her feelings? Provide specific statements that would illicit robust responses from Mrs. Allison.

a. Open-ended questions (open-ended questions invite patients to elaborate on their thoughts and encourage them to tell their stories.) (1) "Tell me how you're feeling today?" (2) "What are you thinking about now that you've talked with the physician?" (3) "What would you like your daughter to know?" b. Empathy (empathizing allows the patient to see that her feelings are normal and that as the nurse you understand) (1) "I would imagine that you must have many feelings about this situation" (2) "I would be having similar feelings." (3) "you have every right to feel what you're feeling" c. Silence (1) silence encourages patients to continue sharing. d. sharing observations (stating an observation invites patients to respond without feeling pressure to answer.) (1) "I saw that you and your daughter were talking." (2) " I noticed that you were crying." (3) "You look sad today."

Six months later, Mrs. Cooper is admitted to the hospital for an exacerbation of her heart failure. She is diagnosed with a viral infection. She has increased weight gain because of fluid retention and decreased urinary output because her kidneys are starting to fail. Her appetite spoor; she has frequent nausea and vomiting. Her abdomen is soft and contender, and bowel sounds are present. the health are provider orders the starting of enteral feedings. a. Which type of tube would be most appropriate for you to select? b. How would you verify tube placement? c. Which measures would you take to make sure that the tube stays in the correct position? d. Which tube-feeding complications would be appropriate for you to include in your patient assessment?

a. a small-bar nasoenteric tube because this decreases the risk of aspiration b. abdominal x-ray is the preferred method c. gastric aspirate pH. Document position of tube each shift. d. you should include your assessment for tube-feeding aspiration and tube dislodgment

During the initial assessment Ms. Thompson asks many questions. " is it cancer? will the surgery result in a disability? what can I expect? will I have to be in the ICU? You conclude that she is afraid of both the surgical procedure and the outcome. Which types of specific nursing-accessible complementary therapies will you offer her during the preoperative period to reduce her anxiety and help her prepare for surgery?

you could use a variety of mind-body therapies, and focused abdominal breathing. They are relatively easy to teach and learn and do not require additional equipment that might be difficult to access during the preoperative period. In addition, they can be used right up until the time she undergoes anesthesia in the operating room. Evidence support the effectiveness of these techniques during times of acute and chronic anxiety responses.