Exam 2 -- Fundamentals

The herbal product Valerian is effective in what sleeping disorders?

Mild insomnia and RLS p.1008

Interventions to promote a dying patients dignity

1. Providing respect 2. Viewing patients as a whole 3. Showing interest 4. Being presence 5. Using a preferred name

Which of the following is not an individual risk factor that can pose a threat to a person's safety? A) Age B) Lifestyle C) Impaired mobility D) Sensory or communcation impairment E) Lack of safety awareness

A) Age

Includes all of the physical & psychosocial factors that influence the life and the survival of the patient. A) Environment B) Relationships C) Education D) Finanical stability

A) Environment

The effects of immobility on the cardiac system include which of the following? (Select all that apply).

1. Thrombus formation. 2. Increased cardiac workload. 3. Weak peripheral pulse. 4. Irregular heartbeat. 5. Orthostatic hypotension. 1, 2, and 5

The nurse's second action after discovering an electrical fire in a patient's room is to: A) Activate the fire alarm. B) Contain the fire by closing all doors and windows. C) Remove all patients in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher.

A) Activate the fire alarm.

An older-adult patient had been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?

1. Loss of appetite. 2. Gum soreness. 3. Difficulty swallowing. 4. Left ankle joint stiffness. 4

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:

1. Myoclonus. 2. Pathological fractures. 3. Pressure Ulcers. 4. Pruritus. 3

Name the 2 stages of sleep

1. NREM Sleep (non rapid eye movement) 2. REM Sleep (rapid eye movement)

What should nurse caution patients about regarding the use of Herbal compounds?

1. Not regulated by U.S Food and Drug Administration 2. May interact with prescribed medications

Which assessment finding would the nurse associate with a problem with bowel elimination? A bowel movement every 5 days 2 Loose appearing abdominal skin 3 Bowel sounds every 5 to 15 seconds 4 Absence of peristaltic waves on the abdomen

1 A bowel movement every 5 days indicates constipation, which is an abnormal finding, thus a problem with bowel elimination. Abdominal distension, indicated by taut and stretched abdominal skin, may be seen in patients with altered bowel elimination, as opposed to loose appearing abdominal skin. The occurrence of bowel sounds every 5 to 15 seconds and the absence of peristaltic waves on the abdomen are expected/normal findings and therefore not indicative of a problem with bowel elimination.

A patient complains that he is not able to pass urine completely. Even after voiding, the patient does not feel that the bladder is empty. Which tests can be done to assess the postvoid residual (PVR) in the patient? Portable noninvasive bladder ultrasound device 2 Cystoscopy 3 X-ray of the abdomen 4 Intravenous pyelogram (IVP)

1 Postvoid residual can be assessed using a portable noninvasive bladder ultrasound device, which helps to determine the amount of urine left in the bladder after voiding. A cystoscopy helps to visualize the structures of the urinary tract. An x-ray exam of the abdomen may show the condition of abdominal organs but is not helpful in determining the residual urine left in the bladder. An intravenous pyelogram may help to determine the function of the kidneys but does not help in determining postvoid residual.

What are the characteristics associated with overflow urinary incontinence? Select all that apply. Nocturia 2 Fecal impaction 3 Altered mobility Correct4 High post void residual volume Correct5 Distended bladder on palpation

1 4 5 The characteristics associated with overflow urinary incontinence, or urinary incontinence associated with chronic retention of urine, are nocturia (waking up during the night to urinate), a high post void residual volume (the amount of urine left in the bladder after urination), and a distended bladder on palpation. Fecal impaction is usually associated with transient incontinence. Altered mobility is associated with functional incontinence. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply).

1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake." 1, 2, and 3

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply).

1. B/P= 128/84. 2. Respirations 26/ min on room air. 3. HR 114 4. Crackles over lower lobes heard on auscultation. 5. Pain reported as 3 on scale of 0 to 10 after medication. 2, 3, and 4

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply).

1. Bruising. 2. Pale yellow urine. 3. Bleeding gums. 4. Coffee ground-like vomitus. 5. Light brown stool. 1, 3, and 4

List the 3 types of sleep apnea

1. Central sleep apnea 2. Obstructive sleep apnea 3. Mixed sleep apnea

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?

1. Cream of broccoli soup, with whole wheat crackers, cheese and tapioca for dessert. 2. Hot dog on whole wheat bun with a side salad and an apple for dessert. 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert. 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert. 1

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:

1. Decreased perstalsis. 2. Decreased heart rate. 3. Increased blood pressure. 4. Increased urinary output. 1

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?

1. Encouraging use of an overhead trapeze for positioning and transfer. 2. Frequent family visits. 3. Assisting the patient to a wheelchair once per day. 4. Ensuring that there is an order for physical therapy. 1

Place the following options in the order in which elastic stockings should be applied:

1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg. 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size. 1, 5, 7, 4, 6, 3, and 2

Which of the following are physiological outcomes of immobility?

1. Increased metabolism. 2. Reduced cardiac workload. 3. Decreased lung expansion. 4. Decreased oxygen demand. 3

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply).

1. Initial patient measurement is made around the calves. 2. Inflation pressure averages 40 mm Hg. 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning. 2 and 3

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?

1. Isometric exercises. 2. Administration of low-dose heparin. 3. Suctioning every 4 hours. 4. Use of incentive spirometer every 2 hours while awake. 4

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?

1. Turn, cough, and deep breathe every 30 minutes while awake. 2. Ambulate patient to chair in the hall. 3. Passive range of motion 4 times a day. 4. Immobility is not a concern the first postoperative day. 2

Factors that influence a persons approach to death

1.culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Degree of social support

The nurse is caring for a patient who exhibits slow movements associated with Parkinson's disease. For which type of urinary incontinence should the nurse assess in this patient? Transient incontinence 2 Functional incontinence 3 Reflex urinary incontinence 4 Overflow urinary incontinence

2 Functional incontinence is a loss of continence with a cause outside the urinary tract, usually related to functional deficits such as altered mobility and manual dexterity. Parkinson's disease alters a patient's mobility, which can result in functional incontinence. Transient incontinence is caused by medical conditions that in many cases are treatable and reversible. Parkinson's disease and its associated problems of mobility are not reversible. Reflex urinary incontinence is related to spinal cord damage between C1 and S2; it is not associated with mobility problems caused by Parkinson's disease. Overflow urinary incontinence is related to bladder outlet obstruction or poor bladder emptying because of weak or absent bladder contractions, not Parkinson's disease.

A nurse is preparing an enema. Which enema helps to treat local infections? 1. Isotonic enema 2. Medication enema 3. Carminative enema 4. Oil-retention enema

2. Medication enema Medication enemas may contain antibiotics that help to treat local infections. Isotonic enemas expand the colon to promote peristalsis. Carminative enemas stimulate peristalsis and provide relief from gastric distention. Oil-retention enemas lubricate the rectum and colon to make the feces softer and easier to pass.

Which type of sleep apnea is the most common? 1. Central sleep apnea 2. Obstructive sleep apnea 3. Mixed sleep apnea

2. Obstructive sleep apnea

Q.) Which factor influencing urinary elimination in older adults does the nurse know to be true? 1 Older adults have an increased bladder capacity. 2 Older adults generally experience decreased bladder irritability. 3 Older adults have an increased frequency of bladder contractions during bladder filling. 4 Older adults have an increased ability to hold urine between the initial desire to void and an urgent need to void.

3 Older adults have an increased frequency of bladder contractions during bladder filling. They also often have a decreased bladder capacity and an increase in bladder irritability. The ability to hold urine between the initial desire to void and an urgent need to void decreases in older adults.

A patient reports a burning sensation and pain while passing urine. What should the nurse include in the assessment? Ask if other family members are sick. 2 Determine height and weight. Correct3 Look for presence of blood in the urine. 4 See if the patient has a history of hypertension.

3 Pain and a burning sensation during urination are symptoms of a lower urinary tract infection. Irritation to the bladder mucosa by bacteria frequently causes hematuria (blood in the urine), so presence of blood in the urine is another sign of a urinary tract infection. Urinary tract infections are not contagious, so asking if any other family members are sick will not help. Assessing the patient's height and weight is important but not relevant to a urinary tract infection. Whether or not the patient has a history of hypertension is irrelevant to urinary tract infections. Test-Taking Tip: Notice that the correct answer for this question corresponds directly to the question set-up. The burning sensation while urinating correlates directly with checking urine. It is not a hidden or tricky answer—just a direct correlation.

Patients with which type of urinary incontinence can be at risk for severe elevation of blood pressure, pulse rate and diaphoresis? Functional incontinence 2 Stress urinary incontinence Correct3 Reflex urinary incontinence 4 Urge urinary incontinence

3 Patients with reflex urinary incontinence are likely to be at risk for autonomic dysreflexia, a life-threatening condition that causes a severe elevation of blood pressure and pulse rate and diaphoresis. Functional incontinence, stress urinary incontinence, and urge urinary incontinence are not associated with an increased risk for autonomic dysreflexia.

The nurse is caring for a patient with a colostomy. Which intervention is most important? Cleansing the stoma with hot water 2 Inserting a deodorant tablet in the stoma bag Correct3 Selecting a bag with an appropriate-size stoma opening 4 Wearing sterile gloves while caring for the stoma

3 The opening of the appliance should be no larger than 0.15 to 0.3 cm (1/16 to 1/8 in) surrounding the stoma to ensure that the skin around the stoma is protected from the enzymes present in the effluent without impinging the stoma.

How many sub-stages are in the stage of NREM sleep?

4

Which may be recommended for a patient in whom fecal impaction is suspected? Gastroscopy 2 Barium swallow 3 Fecal occult blood test Correct4 Digital examination of the rectum

4 Digital examination of the rectum may be recommended for a patient in whom fecal impaction is suspected. Gastroscopy is used to gain direct visualization of the upper gastrointestinal tract. A barium swallow is a radiographic examination using an opaque contrast medium (barium, which is swallowed) to examine the structure and motility of the upper gastrointestinal tract. The fecal occult blood test is a stool test to measure microscopic amounts of blood in the feces. These examinations may not be recommended for a patient in whom fecal impaction is suspected. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse is preparing to administer erythropoietin to a patient who presents with a deficiency. The nurse knows that the patient needs this medication because of dysfunction in which organ? Liver 2 Bone Correct3 Kidney 4 Spleen

4 Kidneys produce erythropoietin. Patients with chronic renal failure require exogenous erythropoietin supplementation for red blood cell production. The liver, bones, and spleen are not involved in the synthesis of erythropoietin. Study Tip: If you didn't know the answer to this question, you might be tempted to choose bone, because you know that red blood cells are formed in bone. You might also be tempted to choose spleen, because the spleen recycles senescent red blood cells. Or you may have wanted to choose liver, because it performs so many functions. Your job is to devise a way to remember the kidneys for erythropoietin production. What mnemonic would you create? You could write the word erythropoietin and have a kid's knee (kid-ney, get it?) sticking into the word. Or you could draw a kidney and use the word erythropoietin to write over and over to form the outline of the kidney. You should use whatever will help you recall the connection, even if it's silly!

Which of the following statements by the parent of a child indicates that further teaching by the nurse is required? A."Now that my child is 2 years old I can let her sit in the front seat of the car with me." B."I make sure that my child wears a helmet when he rides his bicycle." C."I have spoken to my child about safe sex practices." D."My child is taking swimming classes at the community center."

A) "Now that my child is 2 years old I can let her sit in the front seat of the car with me."

Which is not an example of a Procedure-related accident? A) Fall B) Medication administration errors C) IV therapy error D) Improper use of external devices E) Improper performance of procedures (IV insertion, NG insertion, Foley insertion).

A) Fall

Which of the following could be part of the plan of care for a patient who has a "high risk for falls" diagnosis? (Select all that apply) A) Occupational &/or Physical Therapy B) Safety at home C) Referral to social services D) Recovery from current heatlh issues E) Placement in skilled nursing facilit

A) Occupational &/or Physical Therapy B) Safety at home D) Recovery from current health issues

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A) Place a bed alarm device on the bed. B) Place the patient in a belt restraint. C) Provide one-on-one observation of the patient. D) Apply wrist restraints.

A) Place a bed alarm device on the bed.

For those over 65 years old, falls account for 1.8 million visits to emergency departments each year. What are some causes of these falls? (Select all that apply) A) Poor eyesight B) Weakness C) Slippery Floors D) Pets E) Environmental hazards

A) Poor eyesight B) Weakness E) Environmental hazards

Which precautions would be used for seizures? (Select all that apply) A) Remove surrounding clutter B) Provide a specially trained dog C) Pad edges of furniture &/or bed rails D) Provide presence during a seizure event E) Provide privacy

A) Remove surrounding clutter C) Pad edges of furniture &/or bed rails D) Provide presence during a seizure event E) Provide privacy

The nurse is caring for a patient who suddenly becomes confused and tries to remove an IV fusion. Which priority action will the nurse take? A. Assess the patient B. Gather restraint supplies C. Try alternatives to restraints D. Call the health care provider for a restraint order

A. Assess the patient

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? A. Normal B. Complicated C. Chronic D. Disenfranchised

A. Normal

To best assist a patient in the grieving process , what is most helpful to determine A. Previous experiences with grief and loss B. Religious affiliation and denomination C. Ethnic background and cultural practices D. Current financial status

A. Previous experiences with grief and loss

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

A. These are normal symptoms of grief.

Q.) A patient is admitted with diarrhea caused by Clostridium difficile (C. difficile). Which question should the nurse ask to obtain the most helpful information about the cause of the dysentery? A.) "Are you taking any antibiotics?" B.) "Do you ever go barefoot outside your home?" C.) "Have you traveled to any foreign countries lately?" D.) "Does anyone else in your family have bowel problems?"

A.) "Are you taking any antibiotics?" * Reasoning: Infection with C. difficile is bacterial dysentery. It often occurs in patients who have been receiving large doses of antibiotics or who have taken antibiotics over a long period of time. One cannot contract the C. difficile infection by walking barefoot outside the home, because it does not enter the skin. Traveling to foreign countries is not a risk factor, because the bacteria is already present in the intestines. Not all bowel problems indicate a C. difficile infection.

6. The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action should the nurse take next? a. Notify the primary care provider to place a coudé catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage.

ANS: A Coudé catheters are a special type of double-lumen, indwelling catheters that are slightly stiff and bent at the end, allowing the catheter to pass more easily through a partially constricted urethra. They are used mostly in men experiencing prostate enlargement or BPH. Coudé catheters may need to be placed using a metal wire introducer. Placement using an introducer typically is performed by a physician or the patient's urologist, to avoid damaging urethral tissue.

4. Nursing interventions for the patient who suffers from stress incontinence include a. kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.

ANS: A Kegel exercises also are known as pelvic floor exercises. They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence.

7. The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation.

ANS: A Patients on tube feedings often experience diarrhea, not constipation.

2. A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet

ANS: A The patient with diarrhea is susceptible to dehydration. Checking the patient's weight daily will monitor fluid status.

Which organism is responsible for the majority of urinary tract infections in female patients? a Escherichia coli b. Nesseria gonorrhea c. Candida albicans d. Haemophilus influenza

ANS: A Urinary tract infections (UTIs) are the result of bacteria in the urine. Infection occurs when bacteria from the digestive tract, usually Escherichia coli, invade the urethra and multiply.

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury? a. Risk for falls b. Body image disturbance c. Social isolation d. Fear

ANS: A A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

10. A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation? a. Perceptual b. Cognitive c. Affective d. Social

ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is socializing with the home health nurse, so isolation is not a problem.

18. The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action? a. Places colored stickers on faucet handles to indicate temperature and keeps a thermometer near the tub b. Asks the nurse to test the temperature of the water before entering the bath c. Replaces all lace-up shoes with Velcro ones and purchases shampoo caps d. Dispenses all medications onto a plate for easy access in the morning

ANS: A By placing color-coded stickers and other reminders about dangerous stimuli, the patient is able to safely keep up hygiene. Asking the nurse to test the water does not promote independence, although it does promote safety. Zipper and Velcro clothing is easier for a patient with a tactile deficit to wear, and shower caps allow the patient to stay well groomed with minimal effort. Leaving the lids off of medications can be dangerous, as can placing all medications out at once. It may be difficult for the patient to sort through mixed medications and select the correct types and numbers of pills.

14. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds." b. "Blend foods together in interesting flavor combinations." c. "Eat soft foods that are easy to chew and swallow." d. "Avoid adding spices or aromatic ingredients to food to prevent nausea."

ANS: A Good oral hygiene is important to stimulate and hydrate taste buds. Having an unpleasant taste in the mouth discourages the patient from eating. Avoid blending foods together because this confuses the ability to discriminate flavors and taste. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable.

5. Which of the following sensory changes are normal with aging? a. Impaired night vision b. Difficulty hearing low pitch c. Increase in taste discrimination d. Heightened sense of smell

ANS: A Night vision becomes impaired as physiological changes in the eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.

12. Which nursing assessment best measures cognitive functioning? a. Administer a Mini-Mental Status Exam (MMSE). b. Ask the patient his name, where he is, and what month it is. c. Ask the patient's family if the patient is behaving normally. d. Evaluate the patient's ability to read the newspaper.

ANS: A The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. Reading a paper is not a means of comprehensive assessment; in addition, a patient may be high cognitive functioning and not know how to read English.

26. A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance? a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance. b. Instruct the patient to yell at the top of his lungs to get the attention of the staff. c. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. d. Share cell phone numbers with the patient so he can call the nurse if he needs her.

ANS: A The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Yelling at the top of the lungs is stressful for the patient and for surrounding patients. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch with her at any time. Sharing personal phone numbers with the patient is inappropriate.

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patient's plan of care? a. Teach the patient about special devices used to assist patients with eating meals. b. Order the patient food that does not require utensils. c. Place a consult for a home health nurse. d. Obtain an order for antidepressant medications.

ANS: A The nurse should include implementations that help the patient adapt to his deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for himself. Changing the type of food the patient eats may not work for every culture, where touching food with fingers is unacceptable, or the patient may not enjoy eating foods that do not require utensils. A home health nurse is not necessary as long as the patient is able to care for himself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.

4. The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Disequilibrium c. Cataracts d. Peripheral neuropathy

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns.

1. Prior to discharge, the nurse teaches the patient the proper techniques for applying an ostomy pouch. When evaluating the teaching, the nurse observes the patient apply a new ostomy pouch without cleansing the skin underneath. What action(s) should the nurse implement following this patient's return demonstration? (Select all that apply.) a. Repeat the demonstration to show the patient how to clean the ostomy site. b. Document that the patient performed the initial return demonstration accurately and safely. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. e. Notify the health care provider that a repeat demonstration of the ostomy appliance procedure is needed.

ANS: A, C, D The initial return demonstration was not performed accurately, and since it is the nurse's responsibility to complete the needed teaching, the health care provider does not need to be notified. Discomfort and damage to the skin can result from not washing the site; therefore, the nurse should repeat the demonstration, emphasizing the importance of cleansing. Positive reinforcement and the provision of written instructions are valuable teaching strategies.

5. Average urine pH is a. 4 b. 6 c. 7 d. 9

ANS: B Urine normally is slightly acidic, with an average pH of 6. Urine with a pH of 4 is very acidic. A pH of 7 is neutral, and a pH of 9 is very alkaline.

3. A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit? a. The patient frequently cleans out his ears with a cotton swab. b. The patient turns one ear toward the nurse during conversation. c. The patient isolates himself from social situations. d. The patient asks the nurse to speak loudly during conversations.

ANS: B Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit? a. Assessing the patient's level of consciousness and documenting every 4 hours b. Keeping a day-by-day calendar at the patient's bedside and having the patient manage it c. Placing a patient observer in the patient's room for safety d. Informing the patient that she cannot be discharged unless she is awake, alert, and oriented

ANS: B Keeping a calendar in the patient's room helps to orient the patient to the dates and gives the patient a sense of control over her environment. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.

16. The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia. a. Expressive b. Receptive c. Broca's d. Wernicke's

ANS: B Receptive aphasia occurs when patients have difficulty understanding spoken and written word. Expressive aphasia is seen when the patient has difficulty speaking or writing words. Broca and Wernicke refer to areas of the brain where language is processed.

22. The nurse is aware that which patient is most at risk for sensory deprivation? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage brain cancer

ANS: B Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation is at risk for sensory deprivation because he has limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke or with brain cancer may have difficulty with tactile sensation and may have sensory deficits, but is not at risk for sensory deprivation.

27. The nurse is developing a plan of care for a patient who is having a prosthetic eye placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care? a. Self-care deficit b. Risk for injury c. Anxiety d. Body image disturbance

ANS: B The patient with a prosthetic eye will require a period of adjustment to new depth perception and visual sensation. Until the patient adapts, preventing injury should be the nurse's priority. The other options are not directly related to the safety of the patient for eye surgery.

23. What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli? a. Placing a "Do not disturb" sign on the patient's door b. Offering the patient a back rub c. Asking the patient if he would like a newspaper to read d. Placing the patient in the room farthest from the nurses' station

ANS: B The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-human interaction and promote further social isolation.

17. The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking in a loud voice, enunciating every syllable b. Having direct conversation with the patient in his affected ear c. If the patient does not understand what the nurse is saying, repeating the phrase again d. Speaking with hands, face, and expressions

ANS: D Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.

11. Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability? a. "Have you stopped reading books or switched to books on audiotape?" b. "Are you able to prepare a meal or write a check?" c. "How do you protect yourself from injury at work?" d. "How does your vision impairment make you feel?"

ANS: B To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit, but not its impact on activity of daily living. Assessing whether the patient is taking measures to protect himself is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.

1. To best determine the patient's competency in changing an ostomy appliance, what should the nurse ask the patient to do? a. Verbalize the procedure. b. Identify the supplies needed. c. Perform the procedure. d. List the steps in the procedure.

ANS: C Repeat performance is the best way to ensure competency.

4. Which discharge instruction should the nurse provide to the patient following a colonoscopy? a. Some discomfort and bleeding is normal postprocedure. b. Return to the emergency room if you experience mild abdominal cramping. c. Do not drive or operate heavy machinery for 12 hours postprocedure. d. Return to your normal bowel pattern immediately postprocedure.

ANS: C Since sedation is given for the procedure, the patient should not drive or operate heavy machinery.

6. What should be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his or her routine d. Knowing the difference between laxatives and cathartics

ANS: C The patient who is discharged on laxatives should still be instructed on the nonpharmacological methods to decrease constipation and promote normal bowel patterns. Laxatives are contraindicated in patients with nausea, vomiting, or undiagnosed abdominal pain. Ongoing use of laxatives is associated with harmful side effects, such as an increase in constipation and impaction, predisposition to colorectal cancer, dependency, and electrolyte imbalance and should not be encouraged. Knowing the difference between laxatives and cathartics will not help the patient in this case.

19. Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment? a. Screen young children early for visual impairments. b. Instruct parents to report reduced eye contact from their child immediately. c. Include rubella and syphilis screening in the preconception care plan. d. Administer prophylactic antibiotics to all newborns.

ANS: C Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible. Prophylactic antibiotics are not appropriate for all newborns. Reporting reduced eye contact is recommended but is not a preventative measure.

8. Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? a. Self-care deficit b. Risk for falls c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.

6. A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic? a. "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk." b. "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident." c. "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go." d. "No, instead you should see your ophthalmologist and get some glasses to help you see better."

ANS: C Part of the normal aging process is an inability to see colors. Much as with a younger adult who is color blind, the nurse should teach the patient new ways to adapt to his deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

1. A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as a. Sensation. b. Reception. c. Perception. d. Reaction.

ANS: C Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Reaction is how a person responds to a perceived stimulus. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms.

28. A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo? a. Increasing fluid intake to 3 liters a day b. Watching television instead of reading books c. Avoiding riding in vehicles and making sudden motions d. Placing several antiemetic patches on the patient

ANS: C Sudden motions and motorized travel can worsen vertigo; avoiding these will lessen the severity of the vertigo. Increasing fluid intake, avoiding reading books, and using antiemetic patches do not affect vertigo.

9. A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit

ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. This disequilibrium can cause nausea and vomiting. The other options would not result in nausea based on movement.

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospital's physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a "Do not disturb" sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate? a. Allowing the physician to enter because he has higher authority than the nurse b. Calling for security to remove the visitor c. Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room d. Scolding the physician for not obeying the signs on the door and respecting the patient's wishes.

ANS: C The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the visitor to leave regardless of position in the hospital. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle herself with professionalism when addressing the visitor; scolding the visitor is not appropriate.

3. The patient is ordered an ultrasound to determine the size, shape, and location of the kidneys. The nurse knows that prior to the test the patient will a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.

ANS: D An ultrasound scan may be performed to assess the size, shape, and location of the kidneys. Ultrasound studies may be safely conducted in patients who have allergies to contrast media, because no radiation or contrast dyes are used. No patient preparation such as fasting or sedation is required.

2. A patient is experiencing acute renal failure. What is the most common cause of this critical illness? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction

ANS: D Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure.

5. Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. The patient will return to previous elimination pattern. b. The patient will increase intake of grains, rice, and cereals. c. The patient will discontinue antibiotic use and contact the health care provider. d. The patient will increase fluid intake.

ANS: D The patient will increase fluid intake since diarrhea can lead to dehydration.

3. A patient is scheduled for an upper GI series. Which information is most important to obtain from him before the procedure? a. Allergy to lasix b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing

ANS: D The patient will need to drink barium for this x-ray; therefore, swallowing ability should be assessed prior to the start of the procedure

29. A nurse is caring for a patient with right-sided weakness following a stroke. Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit? a. Placing the patient's belongings on the affected side b. Approaching the patient from the affected side c. Teaching the patient how to create a safe environment d. Completing sentences that the patient cannot finish

ANS: D Completing the patient's sentences is not beneficial to the patient; instead provide the patient with plenty of time and opportunity to begin speaking. Creating a safe environment is important to reduce risk of injury. Placing objects on the patient's affected side and approaching the patient from the affected side cause the patient to be aware of the affected side and to learn to adapt and incorporate the affected part of the body. If the patient does not acknowledge the affected side, it will become neglected, and risk of injury will increase.

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient? a. Provide the patient with a therapeutic back rub. b. Turn off the alarms on the monitoring devices. c. Administer an opioid medication to help the patient sleep. d. Provide the patient with earplugs.

ANS: D Giving the patient control over stimuli helps to decrease the frustration that results from sensory overload. Adding additional stimuli such as a back rub can increase sensory overload. Turning off monitors and alarms is unsafe; the nurse needs to be aware of critical situations. Opioid medications should not be the first option; however, antianxiety medications and sleep aids may be considered.

21. The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care? a. Patient will recover full use of speech vocabulary in 1 week. b. Patient will carry a pen and a pad of paper around for communication. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally.

ANS: D Patients with expressive aphasia may take a prolonged time to regain speech function, depending on the cause of the incident. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. A patient who has expressive aphasia may not be able to speak or write words. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

2. What is the involuntary motion of retracting the body from painful stimuli? a. Sensation b. Reception c. Perception d. Reaction

ANS: D Reaction is how a person responds to a perceived stimulus. Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Sensation is the combination of all three combined.

13. The nurse would utilize the Snellen chart for assessment of which patient? a. A patient who is having difficulty remembering how to perform familiar tasks b. A patient who turns the television up as loud as possible c. A patient who holds his newspaper 2 inches from his face d. A patient who frequently reports the incorrect time from the clock across the room

ANS: D The Snellen chart is used to assess vision using a distance of 20 feet. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental status. Turning the television up louder indicates the need for a hearing assessment. Holding a newspaper 2 inches from the face indicates the need for assessment of near vision.

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. A) Explain what you plan to do. B) Wrap a limb restraining around wrist or ankle with soft part toward skin and secure. C) Determine that restraint alternatives fail to ensure patient's safety. D) Identify the patient using proper identifier. E) Pad the patient's wrist.

All

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger-gauge catheter. d. Notify the primary care provider (PCP).

Answer: a Checking the position and patency of the catheter first will determine whether the problem is mechanical or physiologic in nature. At times, the end of the catheter may become lodged up against the side of the bladder preventing the flow of urine into the tubing. Telling the patient that is impossible to void while catheterized is erroneous. Catheterizing the patient with a larger-gauge catheter is unnecessary at this point, as is contacting the PCP.

The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

Answer: a Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help to form the stools so should be increased. Whole-grain products contain fiber.

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider

Answer: b The wound ostomy continence nurse (WOCN) is the most important person to contact to schedule teaching sessions and follow-up care. This nurse specialist is certified in the treatment of patients who have a bowel or bladder diversion. Although team input is important, the contribution of the WOCN is paramount to help the patient achieve competence and comfort with self-care before discharge.

The nurse is placing an indwelling catheter in a female patient. She inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the PCP. b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

Answer: b By leaving the first catheter in place in the vagina, the nurse can more accurately identify the urethra for insertion of the new catheter. This prevents misplacing the new catheter into the vagina during the second catheterization attempt. The catheter that was placed in the vagina is no longer sterile, so it should not be reused and should be discarded after the new catheter is properly placed. It is impossible to get a urine sample from the catheter placed in the vagina. Only after experiencing difficulty with proper placement of the new catheter may the nurse wish to ask for assistance from another nurse.

Islamic

Buried as soon as possible after death. The eyes and mouth are closed, the face of the deceased turn towards Mecca, Muslims of the same gender prepare the body for burial.

A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis showing negative results on testing for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

Answer: b Contraindications tor IVP include an allergy to iodine, which is similar in nature to the contrast material injected during the intravenous pyelogram. Knowing this information would be critical to providing safe patient care. Frequency of urination may be an indication to perform an IVP; however, this is not critical to know before performing an IVP. The results of a urinalysis and history of a recent thyroid scan would not affect a scheduled IVP.

A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Altered Skin Integrity b. Risk for Imbalanced Fluid Volume c. Acute Pain d. Self-Care Deficit: Toileting

Answer: b Diarrhea can cause dehydration with loss of fluids and electrolytes. There is no statement of problems with the skin, although this patient may be at risk for skin breakdown if the diarrhea continues. In addition, no self-care deficit is stated for this patient. Although the patient has experienced cramping and the pain needs to be addressed, the main consideration would be correction of any fluid and electrolyte problems, followed by determination of the cause of the diarrhea.

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider (PCP). b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

Answer: b The next action by the nurse should be to check the patency of the catheter tubing. At this point there is no need to aspirate any urine or call the PCP. The catheter should not be changed unless absolutely necessary, owing to the possibility of causing an infection.

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

Answer: b Urine specimens for culture and sensitivity testing must be collected in sterile containers using the clean-catch, midstream method whenever possible. All voided urine specimens should be collected directly into the specimen container, not transferred from another potentially contaminated vessel. Discarding the entire first void and saving urine in a chilled, opaque container are both procedures for conducting a 24-hour urine collection.

Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

Answer: c Fiber is encouraged in patients with diarrhea to add bulk to the stools. Fluid intake and exercise should be encouraged. Cathartics would not be used because they are strong laxatives used to soften the stool and evacuate the bowels.

A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

Answer: c The patient will be on a clear liquid diet for 1 to 3 days before the procedure. The patient should not eat or drink anything immediately before the procedure. Drinks with red or purple dye are contraindicated because they could interfere with the exam findings. Patients are given medications during the procedure that alter the sensorium and therefore need to have someone else drive them home.

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

Answer: d The most important item in preadministration assessment data is a history of surgery to the anus or rectum, which may contraindicate enema administration. The nurse needs to know the proper patient position for an enema and must observe for signs of intolerance to the procedure, but these are done during the procedure. Vital signs are not routinely obtained before an enema.

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, and the stoma is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy

Answer: d An ascending colostomy meets the description of fecal output of liquid consistency and with a pungent odor, as well as location of the stoma in the upper right quadrant of the abdomen. Descending colostomies produce increasingly formed stool. An ileostomy will produce liquid stool but with less odor because enzyme activity is not present. Ureterostomies drain urine, not stool.

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing

Answer: d Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using whole-grain products.

What symptom is most likely to be exhibited by the patient who complains of voiding small amounts of urine in relation to his fluid intake? a. Nocturia b. Polyuria c. Anuria d. Oliguria

Answer: d Oliguria is reduced urine volume. Nocturia is excessive urination at night. Polyuria is an excessive amount of urine excreted each day, and anuria is excretion of 50 to 100 mL or less of urine each day.

A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use bubble bath when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

Answer: d Wiping the female perineal area from front to back after voiding is crucial in the prevention of microorganisms, which lead to infection, being transferred from the rectum or vagina to the urethral meatus. Limiting fluid intake, using bubble bath, and wearing tight-fitting clothing all may contribute to the promotion of urinary tract infections, rather than their prevention.

When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine (Pyridium) b. A diet that includes a large amount of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake

Answers: a, b, c, d Urine may appear orange when a patient is taking phenazopyridine. Urine can appear red or pink with a diet including beets or blackberries and if blood is present in the urine, which may be secondary to an enlarged prostate or kidney stones. Urine often has a brownish appearance when liver disease such as hepatitis or cirrhosis is present.

3. To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

Answers: a, c, d, e Administering stool softeners, increasing the fiber and fluids in the diet, and increasing physical activity are all early interventions to prevent constipation. Although used to treat constipation, an enema would not be an early intervention for prevention.

When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Perform hand hygiene and apply sterile gloves. c. Add room-temperature solution to enema bag. d. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. e. Raise container, release clamps, and allow solution to flow to fill tubing. f. Hang solution bag 45 to 60 cm (18 to 21 inches) above anus and instill rapidly. g. Clamp tubing after solution is instilled.

Answers: a, e, g The patient should be assisted to the left side-lying (Sims) position. The container release clamps must be released and the solution allowed to flow for fill the tubing. After the solution is instilled, the tubing should be clamped. Gloves for this procedure do not need to be sterile. Solution should be warmed to slightly warmer than body temperature (or 100° to 105° F) to prevent cramping. The tip of the rectal tube should be lubricated 6 to 8 cm (3 to 4 inches). If the enema bag is hung too high and the solution is instilled too rapidly, cramping may occur.

Which of these is not an example of a physical hazard? (Select all that apply). A) Motor Vehicle Accidents B) Allergies C) Poison D) Falls E) Fire F) Communicable diseases G) Depression H) Security I) Pollution J) Terrorism

B) Allergies G) Depression

Select all that apply to Carbon monoxide. A) Comes only from automobile exhaust. B) Colorless and odorless gas C) Low concentration cause N/V, h/a, dizziness D) Low concentrations are not noticable in adults E) High concentrations cause death after 1-3 mins

B) Colorless and odorless gas C) Low concentration cause N/V, h/a, dizziness E) High concentrations cause death after 1-3 mins

Which is not an example of Client-inherent accidents? A) Self-induced cut, injury, or burn B) Domestic violence injuries C) Self-induced Ingestion/injection D) Self-mutilation E) Setting fires F) Sometimes may be caused by seizures

B) Domestic violence injuries

The nurse found a 68-year-old female patient wandering in the hall. The patient ways she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) A) Insert a urinary catheter. B) Leave a night light on in the bathroom. C) Ask the physician to order a restraint. D. Keep the bed in a low position with upper and lower side rails up. E) Assign a staff member to stay with the patient. F) Provide scheduled toileting during the night shift. G) Keep the pathway from the bed to the bathroom clear

B) Leave a night light on in the bathroom. F) Provide scheduled toileting during the night shift. G) Keep the pathway from the bed to the bathroom clear

Health care agency injuries are the 8th leading cause of death in the USA. Which of the below are not a risk to patients in a health care agency? (Select all that apply) A) Medical errors B) Loneliness & Depression C) Chemical use D) Sexually transmitted diseases E) Falls F) Procedure-related accidents (administration errors, IV therapy, improper use of external devices, or improper performance of procedures G) Patient privacy violations H) Equipment-related accidents

B) Loneliness & Depression D) Sexually transmitted diseases G) Patient privacy violations

Which of the below are examples of chemicals that must be safeguarded and used according to protocol & procedures in a healthcare setting? (Select all that apply) A) Alcohol B) Mercury C) Hand sanitizer D) Anesthetic gases E) Cleaning solutions

B) Mercury D) Anesthetic gases E) Cleaning solutions

The best overall rule for avoiding accidents with equipment in the hospital is for the nurse to: A.Always lock wheels on movable equipment B.Never operate equipment without prior instruction C.Always unplug equipment when moving the client D.Never use equipment without a person to assist you

B) Never operate equipment without prior instruction

What are the "Basic needs"? (Select all that apply) A) Water B) Oxygen C) Nutrition D) Shelter E) Temperature

B) Oxygen C) Nutrition E) Temperature

A substance that impairs health or destroys life when ingested, inhaled or absorbed by the body. A) Carbon Monoxide B) Poison C) Pollution D) Cheerios

B) Poison

What does Safety in health care settings not provide? A) Reduces the incidence of illness and injury B) Solves domestic problems the patient will have when they go home. C) Prevents extended length of treatment/stay D) Improves or maintains functional status E) Increases client's sense of well-being

B) Solves domestic problems the patient will have when they go home.

A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the past. Which of the following is the most appropriate nursing intervention? A.A loose abdominal restraint should be placed on the client during sleeping hours. B.The caregivers should check the client frequently during the night. C.A radio should be left playing at the bedside to assist in reality orientation. D.Reassign the client to a room that is close to the nursing station.

B) The caregivers should check the client frequently during the night.

A nurse has the responsibility of managing a deceased patient's postmortem care. Which of the following is the proper order for postmortem care? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed. A. 9, 1, 2, 4, 3, 5, 7, 8, 6 B. 6, 9, 2, 5, 7, 3, 1, 4, 8 C. 8, 4, 1, 3, 5, 2, 6, 7, 9 D. 2, 1, 5, 3, 7, 9, 4, 8, 6

B. 6, 9, 2, 5, 7, 3, 1, 4, 8

Which patient will the nurse see first? A. A 56 year old patient with oxygen with a lighter on the bedside table B. A 56 year old patient with oxygen using an electric razor for grooming C. A 1 month old infant looking at a shiny, round battery just out of arms reach D. A 1 month old infant with a pacifier that has no string around the baby's neck.

B. A 56 year old patient with oxygen using an electric razor for grooming

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? A. Use therapeutic techniques when communicating with the patient B. Allow the patient to determine timing and scheduling of interventions C. Encourage family to only visit for short periods of time D. Provide the patient with a private room close to the nurse's station

B. Allow the patient to determine timing and scheduling of interventions

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 A. Denial B. Anticipatory grief C. Yearning and searching D. Dysfunctional grief

B. Anticipatory grief

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

B. Providing culturally and religiously sensitive care and body preparation

A nurse has the responsibility of managing eight to see spacious postmortem care what is the proper order for postmortem care A. Locating the patient's clothing B. Providing culturally and religiously sensitive care in body preparation C. Transporting the body to the morgue as soon as possible D. Providing postmortem care to protect the family of the deceased from having to view the body

B. Providing culturally and religiously sensitive care in body preparation

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? A. the patient refuses to call for help to go to the bathroom B. The patnnet continues to remove the nasogastric tube C. The patient gets confused regarding the time at night D. The patient does not sleep and continues to ask for items

B. The patnnet continues to remove the nasogastric tube

Buddhist

Believe in an afterlife in which humans manifest in different forms. They recommend not touching the body after death

Which of the following questions has the highest priority for the nurse when talking with parents about the safety of a 4-year-old? A."Can you talk to the parents of your child's friend to find out why they are getting in fights?" B."Would the families in your neighborhood share your concern about reporting strangers when they see them?" C."Do you have the kitchen cleaning supplies locked in the cupboard?" D."Does your child have the appropriate protective equipment for the games he plays?"

C) "Do you have the kitchen cleaning supplies locked in the cupboard?"

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) A) Contact the nursing supervisor. B) Restrict the family's visiting privileges. C) Ask the family to stay with the patient if possible. D) Inform the family of the risks associated with side-rail use. E) Thank the family for being conscientious and put the four rails up. F) Discuss alternatives with the family that are appropriate for this patient.

C) Ask the family to stay with the patient if possible. D) Inform the family of the risks associated with side-rail use. F) Discuss alternatives with the family that are appropriate for this patient.

Mrs. Field falls asleep while smoking in bed and drops the burning cigarette on her blanket. When she awakens, her bed is on fire, and she quickly calls the nurse. On observing the fire, the nurse should immediately: A) Report the fire. B) Attempt to extinguish the fire. C) Assist Mrs. Field to a safe place. D) Remind Mrs. Field this a non-smoking facility E) Close all windows and doors to contain the fire.

C) Assist Mrs. Field to a safe place.

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A) Give the child milk. B) Give the child syrup of ipecac. C) Call the poison control center. D) Take the child to the emergency department.

C) Call the poison control center.

A 4-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n): A.Wrist restraint B.Jacket restraint C.Elbow restraint D.Mummy restraint

C) Elbow restraint

Federal Agency responsible for regulating the manufacture, processing, and distribution of foods, drugs and cosmetics. A) Internal Revenue Service B) Congress C) Food & Drug Administration (FDA) D) NANDA

C) Food & Drug Administration (FDA)

Select all that apply to "Temperature". A) Normal range: 65° F - 75° F B) Hyperthermia: febrile/ low core temperature C) Hyperthermia: febrile/ high core temperature D) Hypothermia: core body temp falls below 95° F E) Hypothermia: core body temp rises above 95° F

C) Hyperthermia: febrile/ high core temperature D) Hypothermia: core body temp falls below 95° F

Which is not a cause of equipment-related accidents? A) Malfunction B) Disrepair C) Loss of electricity D) Misuse of equipment

C) Loss of electricity

Which of the following is not an actual or potential nursing diagnoses that applies to patients whose safety is threatented? (Select all that apply) A) Risk for fall B) Impaired home maintenence C) Natural disaster victim D) Risk for injury E) Deficient knowledge F) Nutritional imbalance G) Risk for poisoning H) Risk for suffication I) Risk for trauma J) Domestic violence injuries K) Risk for thermal injury L) Risk for contamination

C) Natural disaster victim F) Nutritional imbalance J) Domestic violence injuries

What is the palliative care team's primary obligation for the patient with severe pain? A. Providing postmortem care. B. Teaching about grief stages. C. Enhancing the patient's quality of life. D. Supporting the family after the death.

C. Enhancing the patient's quality of life.

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? A. Spiritual Distress related to questioning God B. Hopelessness related to terminal diagnosis C. Pain related to disease process D. Anticipatory Grief related to impending death

C. Pain related to disease process

The nurse is educating a group of women about measures to reduce the risk of urinary infections. What should the nurse include in the teaching? 1. Decrease fluid intake. 2. Wash hands frequently. 3. Urinate every 8 hours. 4. Wipe from back to front after defecation.

Correct 2. Wash hands frequently. Inadequate handwashing predisposes patients to urinary infections; therefore, frequent handwashing reduces this risk. The nurse should tell patients to increase their fluid intake, not decrease it, to prevent urinary tract infections. Patients should also be taught to empty their bladder as soon as they feel the urge. The longer urine sits in the bladder, the more bacteria can grow and lead to an infection. Wiping has to be done from front to back after defecation to prevent contamination from fecal bacteria.

The nurse is reviewing the urinalysis report for a patient. Which finding indicates possible glomerular injury? 1. White blood cells 2. Casts 3. Large proteins 4. Glucose

Correct 3. Large proteins The presence of large proteins in the urine is suggestive of glomerular injury, as they are not normally able to filter through the glomerulus. White blood cells and casts can indicate a urinary tract infection. Glucose in the urine may be indicative of diabetes mellitus.

A primary healthcare provider prescribes a normal saline enema for a patient. What does the nurse understand about the effects of this enema? Select all that apply. A. It can aid in the removal of impacted feces. B. It will distend the colon. C. It will stimulate peristalsis. D. It will irritate the colonic mucosa. E. It will lubricate the colonic mucosa.

Correct A, B, C A normal saline enema is a cleansing enema. The normal saline used as enema solution aids in the removal of impacted feces and distends the colon, thereby stimulating peristalsis. A soapsuds enema irritates the colonic mucosa, which stimulates peristalsis. An oil retention enema lubricates the colonic mucosa and facilitates easy passage of stools.

A stool culture is used to: Select all that apply. A. Detect parasites. B. Help determine the cause of diarrhea. C. Verify that a previous pathogenic bacterial infection has been resolved. D. Detect blood in the stool.

Correct A, B, C A stool culture is used along with other tests to detect parasites in the stool and to help determine the cause of diarrhea. Stool cultures are ordered if the patient complains of diarrhea for several days or when blood or mucus is noted in loose stools. Stool culture may be performed if the history suggests that the patient may have consumed food contaminated with bacteria associated with undercooked meat or raw eggs, or the same food that has made others ill. Recent travel outside the United States may suggest possible food contamination. If the patient has had a previous pathogenic bacterial infection of the GI tract that has been treated or resolved, additional stool cultures may be performed to verify that the pathogenic bacteria are no longer detectable. Testing for the presence of blood in the feces is performed using a fecal occult blood test.

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagonses indicates an understanding of the assessment findings? A) Activity intolerance B) Impaired bed mobility C) Acute pain D) Risk for falls

D) Risk for falls

A nurse, along with unlicensed assistive personnel (UAP), is catheterizing a patient with neurogenic bladder. What are the responsibilities of the UAP? Select all that apply. A. Focus lighting. B. Provide comfort measures. C. Assist in positioning the patient. D. Insert catheter into the urethral meatus. E. Inflate the balloon fully as per the manufacturer's direction.

Correct A, B, C In some settings, UAPs may be permitted to insert a urinary catheter, but it is not routine practice. The UAP may assist with positioning the patient, focusing lighting, maintaining patient position, and providing comfort measures. Inserting the catheter into the urethral meatus and inflating the balloon of the catheter are skilled activities that should be performed by the nurse

Which foods does the nurse teach the patient to refrain from eating to prevent flatulence? Select all that apply. A. Beans B. Spicy foods C. Fresh fruit D. Cauliflower E. Whole grains

Correct A, B, D Beans, spicy foods, and cauliflower are gas-producing foods and should be eliminated from the patient's diet to reduce flatulence. Fresh fruits and whole grains are highly nutritious and are not gas-producing foods; therefore, these foods may be included in the patient's diet.

A patient has constipation. What are the signs and symptoms of constipation? Select all that apply. A. Abdominal pressure B. Abdominal distention C. Stoma "budding" D. Loose feces E. Abdominal cramping

Correct A, B, E Constipation is a condition in which the patient has difficulty in passing bowel movements. Constipation causes abdominal pressure, abdominal distention, and abdominal cramping. Accumulation of stool increases abdominal pressure, which causes stomach distention and abdominal cramping. Constipation does not cause stoma "budding"; "budding" in a stoma is normal. Loose feces are a sign of diarrhea; hard feces is a sign of constipation.

What are the reasons for the presence of ketones in a patient's urine? Select all that apply. A. Vomiting B. Prolonged fasting C. A diet high in sugars D. A diet adequate in proteins E. A diet low in carbohydrates

Correct A, B, E Ketonuria is the presence of ketones in the urine. It indicates the breakdown of fat for energy. Vomiting and prolonged fasting decreases glucose levels in the body and leads to the breakdown of fat to supply energy. A diet low in carbohydrates makes the body use other sources of energy, such as fats. A diet high in sugars does not cause ketonuria due to the presence of high glucose levels for energy; a diet low in sugars can lead to ketonuria. A diet adequate in proteins will not lead to ketonuria.

A nurse is teaching a group of people regarding colon cancer. Which factors should the nurse list as warning signs of colon cancer? Select all that apply. A. Rectal bleeding B. Obesity and inactivity C. Change in bowel habits D. Older than 50 years of age E. Having a family history of colon cancer

Correct A, C A change in bowel habits and rectal bleeding are both warning signs of colon cancer. Obesity, inactivity, older than 50 years, and a family history of colon cancer are all risk factors of developing colon cancer.

Which foods may alter the results of a patient's fecal occult blood test? Select all that apply. A. Carrots B. Cereals C. Red meat D. Grapefruit E. Milk products

Correct A, C, D A fecal occult blood test is done to determine the presence of microscopic or invisible blood in the stools. Carrots and red meat should be avoided. Grapefruit is rich in vitamin C and may lead to a false-negative result. Cereals and milk products do not alter the results of a fecal occult blood test.

A nurse is caring for a patient admitted with diarrhea. What could be the possible causes of diarrhea in the patient? Select all that apply. A. Use of opioid drugs B. Use of antibiotics C. Food allergies D. Psychological stress E. Hypothyroidism

Correct B, C, D Use of antibiotics may cause diarrhea by disrupting the normal flora of the intestine. Food allergies and psychological stress cause increased peristalsis resulting in diarrhea. Use of opioid drugs and hypothyroidism cause constipation by decreasing peristalsis.

A nurse is teaching a patient about healthy bowel habits. What information should be included in the teaching? Select all that apply. A. Laxatives should be used regularly. B. Dietary fibers should be an essential component of the diet. C. Fluid intake should be at least 6 to 8 glasses of water per day. D. Physical exercise should be avoided to prevent constipation. E. Stress management techniques should be practiced.

Correct B, C, E Consuming dietary fiber increases the bulk of stool and helps in better bowel elimination. Maintaining adequate fluid intake increases the water content of the stool and prevents it from hardening, and permits easy passage through the rectum and anus. Stress can cause constipation; therefore, the patient should be instructed to practice stress management techniques. Laxatives should not be used regularly, as the bowel becomes habituated to laxative use. Physical activity helps prevent constipation by facilitating bowel movements.

A nurse suspects a patient has a fecal impaction. Which findings would be consistent for a fecal impaction? Select all that apply. A. Fatigue B. Malaise C. Cramping D. Rectal pain E. Loss of appetite

Correct C, D, E An impaction refers to the presence of a hard fecal mass in the rectum or colon that cannot be expelled easily. Impactions may cause electrolyte disturbances, resulting in cramps. Rectal pain occurs because of the repeated attempts to defecate and pressure from the mass. Loss of appetite is a symptom of impaction due to the inability to defecate. Fatigue and malaise are symptoms of diarrhea.

A 70-year-old woman complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. What should the nurse teach the patient about her disorder? Select all that apply. A. It occurs due to local irritation. B. It occurs due to nervous system disorders. C. It occurs due to weakness of muscles around the urethra. D. It is called stress incontinence. E. It occurs when the intraabdominal pressure exceeds urethral resistance.

Correct C, D, E Involuntary voiding of urine on coughing occurs due to weakness of muscles around the urethra. It is also called stress incontinence. Stress incontinence occurs in older women when intraabdominal pressure exceeds urethral resistance. Involuntary voiding occurs only when abdominal pressure rises above the urethral pressure. Local irritating factors and nervous system disorders usually lead to urge incontinence.

The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to: A.Attempt to extinguish the fire B.Pull the fire alarm C.Call the physician to obtain orders to take the client off the ventilator D.Use an Ambu bag and remove the client from the area

D) Use an Ambu bag and remove the client from the area

A patient is scheduled for a plain film x-ray of the kidney, ureter, and bladder. What preliminary preparations should this patient take 1. No preparation is required in plain film. 2. Bowel preparation is done with magnesium citrate. 3. Light sedatives are provided the previous night. 4. Fasting is required before examination.

Correct 1. No preparation is required in plain film. For getting a plain film of kidney, ureter, and bladder there is no specific preliminary preparation that needs to be done. Bowel preparation with magnesium citrate is required for barium enema, colonoscopy, and flexible sigmoidoscopy. Light sedation is required for upper endoscopy, colonoscopy, sigmoidoscopy, and for computed tomography scan. The patient needs to fast before the examination for certain procedures. Such procedures include barium swallow, upper endoscopy, barium enema, ultrasound, computed tomography, and magnetic resonance imaging.

A patient is scheduled for a plain film x-ray of the kidney, ureter, and bladder. What preliminary preparations should this patient take? 1. No preparation is required in plain film. 2. Bowel preparation is done with magnesium citrate. 3. Light sedatives are provided the previous night. 4. Fasting is required before examination.

Correct 1. No preparation is required in plain film. For getting a plain film of kidney, ureter, and bladder there is no specific preliminary preparation that needs to be done. Bowel preparation with magnesium citrate is required for barium enema, colonoscopy, and flexible sigmoidoscopy. Light sedation is required for upper endoscopy, colonoscopy, sigmoidoscopy, and for computed tomography scan. The patient needs to fast before the examination for certain procedures. Such procedures include barium swallow, upper endoscopy, barium enema, ultrasound, computed tomography, and magnetic resonance imaging.

A nurse is caring for a patient who has a colostomy. When assessing the color of the stoma, which color indicates the stoma is healthy? 1. Reddish pink 2. Purple 3. Blue 4. Brown 5. Black

Correct 1. Reddish pink A normal stoma should be moist, reddish pink, and "budding" slightly above skin level. A stoma that is purple, blue, brown, or black in color may have a compromised circulation.

Which diagnostic examination is the safest way to assess the urinary system in pregnant women? 1. Cystoscopy 2. An ultrasound examination 3. An intravenous pyelogram 4. A computed tomographic scan

Correct 2. An ultrasound examination An ultrasound examination helps to assess the kidneys. It is safe to perform in pregnant women because no radiation or contrast dyes are used. Anesthesia must be administered to a patient before performing cystoscopy; therefore, the patient notifies the primary healthcare provider before undergoing the procedure. An intravenous pyelogram may expose the patient to low amounts of radiation that can affect the fetus during the pregnancy. A computed tomographic scan may cause a teratogenic effect in the fetus due to the radiation used in the process.

The nurse is reviewing the lab report of a patient. The presence of what substance in the urine hints at the possibility of an abnormality? 1. Protein - 6 2. Glucose ++ 3. Red blood cells - 2 4. White blood cells - 4

Correct 2. Glucose ++ A normal urinalysis should not be positive for glucose, as glucose undergoes complete reabsorption. The presence of protein in the urine is acceptable under 8 mg/100 mL. The presence of 2 red cells is acceptable, but there should not be any more than this. A white cell of count 4 is acceptable and does not indicate abnormality.

A patient has stress incontinence. What is a characteristic of stress incontinence? 1. A sudden urge to void 2. Loss of urine when coughing 3. Constant dribbling of urine 4. Inability to reach the toilet

Correct 2. Loss of urine when coughing Loss of urine control during activities such as coughing that increase intra-abdominal pressure indicates stress incontinence. A sudden urge to void indicates urge incontinence. A constant dribbling of urine indicates overflow incontinence. The inability to reach the toilet in time indicates functional incontinence.

The nurse is teaching a group of staff members about abnormal urination patterns. Which statement made by a staff member indicates effective learning? 1. "Anuria is painful urination." 2. "Anuria is reduced volume of urine." 3. "Anuria is the failure to excrete urine." 4. "Anuria is excessive urination at night."

Correct 3. "Anuria is the failure to excrete urine." Anuria is the failure of the kidneys to excrete urine. Dysuria is the term for painful urination. A reduced volume of urine is called oliguria. Excessive urination at night is called nocturia.

Which complication does the nurse monitor for in a pregnant patient who is taking prenatal vitamin tablets with iron? 1. Diarrhea 2. Flatulence 3. Constipation 4. Incontinence

Correct 3. Constipation Prenatal vitamins are rich in iron and interfere with bowel function. Iron slows down intestinal peristalsis and increases absorption of water in the colon, resulting in constipation. Diarrhea occurs due to an increase in intestinal peristalsis. Vitamins high in iron do not increase the production of gases leading to flatulence or cause fecal incontinence.

A patient with abdominal discomfort has presence of bowel sounds that are loud, high-pitched, and rushing. What pattern of the bowel sounds should the nurse record? 1. Normal 2. Hypoactive 3. Hyperactive 4. Tympanic note

Correct 3. Hyperactive Hyperactive bowel sounds tend to be loud, high-pitched, and rushing; they are commonly heard with diarrhea or inflammatory disorders. Normal bowel sounds occur every 5-15 seconds and last for one to a few seconds. Hypoactive sounds will be fewer than 5 sounds per minute. Tympanic note is not an auscultation finding; instead it is a percussion finding.

The nurse is preparing to administer erythropoietin to a patient who presents with a deficiency. The nurse knows that the patient needs this medication because of dysfunction in which organ? 1. Liver 2. Bone 3. Kidney 4. Spleen

Correct 3. Kidney Kidneys produce erythropoietin. Patients with chronic renal failure require exogenous erythropoietin supplementation for red blood cell production. The liver, bones, and spleen are not involved in the synthesis of erythropoietin.

Chinese

Death is regarded as a negative life events and there's no concept of afterlife

A patient with a bladder disorder is advised to get a urinary diversion. The patient wishes to have the type of urinary diversion that allows normal voiding. Which type of urinary diversion suits the patient's requirement? 1. Ileal conduit 2. Indiana pouch 3. Orthotopic neobladder 4. Mainz pouch

Correct 3. Orthotopic neobladder Orthotopic neobladder is the diversion procedure that allows the patient to have normal voiding. In the case of an ileal conduit, urine drains through a stoma into a collection bag. Incontinent urinary diversion is associated with continuous urinary drainage without the patient's voluntary control. For cutaneous continent diversions (Kock pouch, Mainz pouch, Indiana pouch), a collection reservoir is surgically created using a segment of the intestine; the patient then needs to catheterize the reservoir through a cutaneous stoma every 4 to 6 hours to drain stored urine.

To minimize the patient's episodes of nocturia, the nurse would teach him or her to: 1. Perform perineal hygiene after urinating. 2. Set up a toileting schedule. 3. Double void. 4. Limit fluids before bedtime.

Correct 4. Limit fluids before bedtime. The patient with nocturia has to get up during the night to urinate. Limiting fluids 2 hours before bedtime minimizes nocturia.

A nurse is preparing to administer a continuous bladder irrigation. Which type of catheter is useful for this type of bladder irrigation? 1. Foley catheter 2. Coudé catheter 3. Straight catheter 4. Triple-lumen catheter

Correct 4 Triple-lumen catheter Triple-lumen catheters have one lumen to introduce sterile irrigation fluid, one to drain the urine, and the third lumen to fill the retention balloon at the tip of the catheter. A Foley catheter has two lumens; one for draining urine and the other for filling a balloon. Coudé catheters are a special type of double-lumen catheter with a curved tip for use in patients with enlarged prostate glands. Straight catheters have only one lumen to drain the urine.

A 76-year-old client lives alone at home. Which of the following is the highest priority question for his home health nurse to ask regarding his safety? A."Do you use softglow light bulbs in your front room lamps?" B."At what temperature is your thermostat set?" C."Why don't you consider selling your two-story home and buying a house without stairs?" D."Do any of your medications cause you to be physically unsteady?"

D) "Do any of your medications cause you to be physically unsteady?"

Medical errors... A) Only happen to new nurses B) Are the reason malpractice insurance is needed C) Are primarily data entry errors D) Account for 60% of all errors

D) Account for 60% of all errors

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A) Home accidents B) Physiological changes of aging C) Poisoning and child abduction D) Automobile accidents, suicide and substance abuse

D) Automobile accidents, suicide and substance abuse

A frantic grandmother calls the emergency room to report that her grandson took some of her medicine and that she is unable to arouse him. The nurse should instruct her to: A.Induce vomiting with syrup of ipecac B.Provide fluids to dilute the toxin C.Hyperextend his head D.Bring the medicine bottle to the hospital

D) Bring the medicine bottle to the hospital

In regards to safety, which of the following statements in most accurate? A.Bacterial contamination of foods is uncontrollable. B.Fire is the greatest cause of unintentional death. C.Temperature extremes seldom affect the safety of clients in acute care facilities. D.Carbon dioxide levels should be monitored in home settings.

D) Carbon dioxide levels should be monitored in home settings

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A) Begin cardiopulmonary respiration. B) Restrain the child to prevent injury. C) Place a tongue blade over the tongue to prevent aspiration. D) Clear the area around the child to protect the child from injury.

D) Clear the area around the child to protect the child from injury.

Which of the following is not an example of bioterrorism? A) Anthrax B) Smallpox C) Pneumonic Plague D) Hepatitis E) Botulism

D) Hepatitis

The developmental stage that carries the highest risk of an injury from a fall is: A) Preschool B) Adulthood C) School age D) Older adulthood

D) Older adulthood

QSEN, developed to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes necessary to continuously improve quality and safety stands for what? A) Quality & Security for Every Nurse B) Qualtiy & Standards Evaluating Nurses C) Quality & Satisfactory Education Nursing D) Quality and Safety Education for Nurses: developed

D) Quality and Safety Education for Nurses: developed

he nurse assesses that the client may need a restraint and recognizes that: A.An order for a restraint may be implemented indefinitely until it is no longer required by the client. B.Restraints may be ordered on a prn basis. C.No order or consent is necessary for restraints in long term care facilities. D.Restraints are to be periodically removed to have the client re-evaluated.

D) Restraints are to be periodically removed to have the client re-evaluated.

Definition of Hypersomnolence

Excessive daytime sleepiness or prolonged nighttime sleep that is not restorative. -- sleeping for long periods

TRUE/FALSE Excercise *just before* bed will make a patient tired, therefore promoting a good nights sleep.

FALSE RATIONALE: Exercise just before bedtime is a stimulant that prevents sleep. (Nursing Care Plan p.1004) Exercising *2 hours or more* before bedtime allows the body to cool down and maintain a state of fatigue that promotes relaxation. (p.999)

TRUE/FALSE Long term use of antianxiety, sedative, or hypnotic agents improves sleep

FALSE RATIONALE: Long-term use of antianxiety, sedative, or hypnotic agents disrupts sleep and leads to more serious problems. (p.1010)

TRUE/FALSE Newborns spend more time in light sleep.

FALSE Newborns and children spend more time in deep sleep. Sleep becomes more fragmented with aging, and a person spends more time in lighter stages.

TRUE/FALSE Older adults and infants sleep best in dark rooms

FALSE RATIONALE: Infants and older adults sleep best in softly lit rooms. (p.1006)

TRUE/FALSE Insomnia is most common in men

FALSE Insomnia occurs more frequently in and is the most common sleep problem for women. (p. 996)

Jewish

Family member stays with body until burial usually the burial occurs within 24 hours but not on the sabbath

The nurse is reviewing the laboratory reports of a patient. The urine report shows the presence of large proteins in the urine. What is the most probable cause of proteinuria? Glomerular injury 2 Infection of the urinary tract 3 Excessive aspirin ingestion 4 Starvation

Glomerular injury The glomerular capillaries filter water, glucose, amino acids, urea, creatinine, and major electrolytes from the blood. Large proteins do not normally get filtered because of the size of protein molecules. However, if the glomeruli are injured, the large proteins may pass into the urine. The presence of white blood cells in the urine indicates infection of the urinary tract. The presence of ketones in urine may be due to excess ingestion of aspirin and starvation. Test-Taking Tip: The longest answer is not always the correct one! You must read and evaluate each choice without regard to length or pattern of previous answers.

Physical changes hours or days before death

Increased periods of sleeping/unresponsiveness Coolness or color changes in extremity, nose, fingers (cyanosis, Poler, molting) Bowel or bladder incontinence Restlessness, confusion or disorientation Decreased urine output it, dark colored urine Decreased intake of food or fluids, inability to swallow Congestion/increased pulmonary secretions; noisy respiration Altered breathing (apnea, labored or irregular breathing, Cheyene strokes pattern) Decreased muscle tone, relaxed jaw muscles, saggy mouth Fatigue and weakness

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

It is most important to maintain strict aseptic technique while inserting an indwelling catheter to try to prevent a urinary tract infection. It is not necessary to medicate patients before urinary catheterization. Although comfortable positioning and deep breathing may help to relax the patient, this is not the primary concern.

Hispanic or Latino

People in Hispanic and Mexican chimeric and cultures often special objects such as amulets or rosary beads, alternative healing practices, and prayer that is often believe to be the will of God

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to:

Promote venous return to the heart.

Which stage of NREM does sleep-walking and enuresis (bed wetting) occur?

Stage 4 Box 43-1 p. 994

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? A. Using silence B. Asking "Why are you crying today?" C. Use therapeutic touch D. Stating "I see that you're crying"

Stating "I see that you're crying"

TRUE/FALSE REM sleep is necessary for brain tissue restoration and appears to be important for cognitive restoration and memory.

TRUE p. 994

TRUE/FALSE Benzodiazepines in older adults is potentially dangerous

TRUE p.1010

TRUE/FALSE Chamomile has a mild sedative effect that may be beneficial in promoting sleep

TRUE p.1008

TRUE/FALSE Central sleep apnea involves dysfunction in the respiratory control center of the brain.

TRUE (P.996)

Hindu

The body is placed on the floor with the head facing north. People of the same gender handle the body after death

Native American

Traditional Navajo do not touch the body after death

What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.

The peristomal area can be washed by the patient using warm water and mild soap as needed and routinely at bath time. The collection device typically has a face plate to ensure a good fit and prevent leakage of urine. These appliances are changed less frequently than before bed each night, and neither a widely cut wafer or firm pressure is needed for their application.

What are some management methods for sleepiness that a nurse can inform her patient about? Select all that apply a. Exercise b. Eating light meals high in protein c. Eating a full plate of food right before bed d. chewing gum e. Long distance driving.

a, b, d (p.997)

Restless leg syndrome is most common in who? Select all that apply a. Women b. Older people c. Men d. Those with iron deficiency anemia

a, b, d Many people experience restless leg syndrome, which occurs before sleep onset. More common in women, older people, and those with iron deficiency anemia.... (p.995)

Which of these are factors that promote sleep for older adults? Select all that apply a. Limit naps to 20 minutes or less twice a day b. Avoid exercise or watching TV just before bedtime c. Keep the head of the bed flat to 180 degrees d. Elevate the head of the bead and use extra pillows e. Consume carbs or milk as a light snack before bedtime f. If unable to sleep in 15-30 mins, get out of bed

a, b, d, e,f BOX 43-8 p.1006

Which questions are appropriate for the nurse to ask when assessing the patient for Insomnia? Select all that apply a. How easily do you fall asleep? b. What do you think about as you try to fall asleep? c. Do you snore loudly? d. Do you have vivid life-like dreams when going to sleep? e. What do you do to prepare for sleep?

a, b, e Box 43-6 p.1001

After 3 months, and infant sleeps an average of how many hours a night? a. 8 - 10 hours b. 16 hours c. 12 hours d. 7 hours

a. 8 - 10 hours The infant normally takes several naps during the day but usually sleeps an average of 8 -10 hours during the night. (p.997)

What type of laboratory study would the nurse expect her patient with a sleep disorder to receive? a. A polysomnogram b. Ultrasound c. Vision test d. CBC

a. A polysomnogram A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep.

Which disorder is characterized by sleep disturbances that result in daytime sleepiness and are not caused by disturbed sleep or alterations in circadian rhythm? a. Hypersomnias b. Insomnia c. Parasomnias d. Sleep-related movement disorders.

a. Hypersomnias (p. 995)

What effect does sleep have on heart rate? a. heart rate decreases b. heart rate increases

a. heart rate decreases (P. 993)

A patient reports to her nurse that the reason she is having difficulty falling asleep is that she is stressed out. Which of these implementations is appropriate? Select all that apply a. Tell the patient to try her best to think about sleep because this will make her sleepier b. Encourage her to get up and read a bod. c. Teach her relaxation exercises d. Suggest drinking a cup of tea before bed.

b, c (p.1007)

How many hrs a night do toddlers and preschoolers get? a. 8 - 10 hours b. 16 hours c. 12 hours d. 7 hours

c. 12 hours

A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll add plenty of carbohydrates to my meals." b. "I'll take a short nap whenever I feel a little sleepy." c. "I'll make sure I stay warm when I am at my desk at work." d. "It's okay to drink alcohol as long as I limit it to one drink per day."

b. "I'll take a short nap whenever I feel a little sleepy." RATIONALE: Patients who have narcolepsy should take short naps to reduce feelings of drowsiness.

How long does stage 3 & 4 last? a. 10-20 min b. 15-30 min c. a few min d. 90 min

b. 15-30 min Box 43-1 p. 994

Neonates up to 3 months averages about how many hours of sleep? a. 8 - 10 hours b. 16 hours c. 12 hours d. 7 hours

b. 16 The neonate up to the age of 3 months averages about 16 hours of sleep a day. (p.997)

Medications that induce sleep are called a. Sedatives b. Hypnotics

b. Hypnotics p.1010

Which disorder is related to short periods of sleep or difficulty falling asleep? a. Hypersomnias b. Insomnia c. Parasomnias d. Sleep-related movement disorders.

b. Insomnia RATIONALE: *Insomnia disorders* are related to difficulty falling asleep, frequently awakening from sleep, short periods of sleep, or sleep that is nonrestorative. (p.995)

Which herbal product helps promote sleep in patients with *anxiety*? a. Valerian b. Kava c. Chamomile

b. Kava p.1008

In which stage of sleep does vivid full-color sleep occur? a. NREM b. REM

b. REM Box 43-1 p. 994

Which part of the brain controls the sleep wake cycle? a. The cortex b. The Hypothalamus c. The Thalamus d. The Cerebellum

b. The Hypothalamus The suprachasmatic nucleus nerve cells in the hypothalamus control the rhythm of the sleep wake cycle and coordinate this cycle with other circadian rhythm. (992) The major sleep center in the body is the hypothalamus. (993)

Which drug is the treatment of choice for insomnia? a. Nicotine b. Zolpidem c. Propanolol d. Furosemide

b. Zolpidem RATIONALE: The Benzodiazepine like drugs have become the treatment of choice for insomnia because of improved efficacy and safety of use. Experts recommend a low dose of a short-acting medication such as zolpidem. (p.1010)

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply) a. REM sleep provides cognitive restoration b. REM sleep lasts about 90 min c. It is difficult to awaken a person in REM sleep d. Sleepwalking occurs during REM sleep. e. Vivid dreams are common during REM sleep.

c, e

A female patient is ready for discharge after giving birth 3 days ago. Her nurse is doing her discharge teaching on Sudden Infant Death Syndrome (SIDS), which statement made by mom indicates an understanding of how to prevent SIDS. a. I will place my child on her tummy while she sleeps b. I will make sure to completely feed my child before putting her to bed c. I will place my child on her back to sleep d. I will surround my child's crib with stuffed animals for cushion

c. I will place my child on her back to sleep RATIONALE: Because of an association between the prone position and the occurrence of SIDS, the American Academy of Pediatrics recommends that parents place apparently healthy infants in the supine position during sleep. (p.997)

Sleep apnea is characterized by: a. Increased blood flow to the brain for periods of 10 seconds or longer during sleep. b. Decreased ability to awaken c. Lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep

c. Lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep (p.996)

A woman brings her husband to the ER. She tells the triage nurse that her husband has been falling asleep suddenly; during dinner time, and even during intimate moments. He says he cannot control it, and often experiences loss of muscle control and falls to the floor. The nurse suspects that this patient has a. Sleep apnea b. Parasomnia c. Narcolepsy d. Hypersomnia

c. Narcolepsy RATIONALE: A person with narcolepsy falls asleep uncontrollably at inappropriate times. (p996)

_____________ are undesirable behaviors that usually occur during sleep. a. Hypersomnias b. Insomnia c. Parasomnias d. Sleep-related movement disorders.

c. Parasomnias