Exam 3 - Nclex Practice Questions

What are manifestation that occur immediately before death.

- mottled skin - Semi comatose - Sunken and glazed eyes - decreased ability to move - dulled senses - abnormal breathing pattern - decreased cardiac output - difficulty clearing secretions - impaired heart and renal functioning.

Cultural competence is the process of: A. Acquiring specific knowledge, skills, and attitudes B. Influencing treatment and care of clients C. Learning about vast cultures D. Motivation and commitment to caring.

A. Acquiring specific knowledge, skills, and attitudes Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care.

The client's right to refuse treatment is an example of: A. Common law B. Statutory law C. Nurse practice acts D. Civil Law

A. Common law

What is agonal breathing?

Abnormal breathing pattern characterized by gasping, labored breathing, accompanied by strange vocalizations and twitching. Occurs every 3- 4 minutes with gasping sounds.

2. Rachel is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using? A. Undoing B. Compensation C. Denial D. Suppression

Answer: C. Denial. Option C: Individuals who have substance problems often use denial.

Which statement about loss is accurate? A. The more the individual has invested in what is lost, the less the feeling of loss. B. Loss may be maturational, situational, or both. C. The degree of stress experienced is unrelated to the type of loss. D. Loss is only experienced when there is an actual absence of something valued.

B. Loss may be maturational, situational, or both.

When going to the hospital, which forms should patients be encouraged to bring with them in case end-of-life care becomes an ethical or legal issue? A. Euthanasia B. Organ donor card C. Advance directives D. Do not resuscitate (DNR)

C. Advance directives

Ethnocentrism is the root of: A. Meanings by which people make sense of their experiences. B. Cultural beliefs C. Biases and prejudices D. Individualism and self-reliance in achieving and maintaining health.

C. Biases and prejudices

The most important factor in providing nursing care to clients in a specific ethnic group is: A. Time orientation B. Environmental control C. Communication D. Biological variation

C. Communication

The nurse is caring for a patient whose spouse died two weeks ago. The nurse observes that the patient does not engage in active conversation and avoids eye contact. Which stage of grief is the patient in? A. Denial B. Anger C. Depression D. Acceptance

C. Depression

A client diagnosed with terminal cancers says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who is dying." Which response by the nurse is therapeutic? A. Have you shared your feeling with your family? B. I think we should talk more about your anger with you family. C. You're feeling angry that your family continue to hope for you to be cured? D. You are probably very depressed, which is understandable with such a diagnosis.

C. You're feeling angry that your family continue to hope for you to be cured? Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Although it is appropriate for the nurse to attempt to asses the client's ability to discuss feeling openly with family members, it does not help the client discuss feelings causing the anger.

Which of the following assessment findings in a patient's health history supports a diagnosis of substance dependence? A. Numerous legal problems and interpersonal conflicts B. Withdrawal symptoms when not using the substance C. Impaired judgment and risk-taking behaviors D. Continued tardiness and absenteeism from work

Correct Answer B.

What are the appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply. A. Monitor vital signs. B. Provide stimulation in the environment. C. Maintain NPO status. D. Provide reality orientation as appropriate. E. Address hallucinations therapeutically.

Correct Answer: A, D, & E. When the client is experiencing the withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically

A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client? A. Arranging transportation to a safe house B. Advising the client about contacting the police C. Making an appointment to follow up on the injuries D. Making a referral to a counselor

Correct Answer: A. Arranging transportation to a safe house. Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.

Henry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. The patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest. He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Henry? A. Call for a staff meeting and take this up in the agenda. B. Seek help from her manager. C. Develop a strategic action on how to deal with these concerns. D. Ignore the issues since these will be resolved naturally.

Correct Answer: A. Call for a staff meeting and take this up on the agenda. This will allow for the participation of every staff in the unit. If they contribute to the solutions of the problem, they will own the solutions; hence the chance for compliance would be greater. It's one thing to articulate the change required and entirely another to conduct a critical review against organizational objectives and performance goals to ensure the change will carry the unit in the right direction strategically, financially, and ethically.

During a well-child checkup, a mother tells Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except: A. Conflictual relationships of parents B. Inconsistent communication patterns C. Rigid, authoritarian roles D. Use of violence to establish control

Correct Answer: A. Conflictual relationships of parents. There is no evidence in this situation that the parents are in conflict; in fact, the mother is describing that the child "needed to be disciplined." Often, in dysfunctional families, one child is singled out to be the victim and is the recipient of the blame for problems. In a family which is dysfunctional, there is no empathy or very little of it. Children will end up feeling bad about themselves. There is no unconditional love, and issues are always subjected to behavior corrections, even when it's not necessary or the child has made only a small mistake. There is no room for error, which creates a claustrophobic environment, which leads to a constant fear of failure in children.

On the other hand, Ms. Caputo notices that the Chief Nurse Executive has a charismatic leadership style. Which of the following behaviors best describes this style? A. Possesses inspirational quality that makes followers get attracted to him and regard him with reverence. B. Acts as he does because he expects that his behavior will yield positive results. C. Uses visioning as the core of his leadership. D. Matches his leadership style to the situation at hand.

Correct Answer: A. Possesses inspirational quality that makes followers gets attracted to him and regards him with reverence. Charismatic leaders make the followers feel at ease in their presence. They feel that they are in good hands whenever the leader is around. The charismatic leadership style relies on the charm and persuasiveness of the leader. Charismatic leaders are driven by their convictions and commitment to their cause.

Functional nursing has some advantages, which one is an exception? A. Psychological and sociological needs are emphasized. B. Great control of work activities. C. Most economical way of delivering nursing services. D. Workers feel secure in a dependent role.

Correct Answer: A. Psychological and sociological needs are emphasized. When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as 'tasks to be done '. Functional nursing was designed around an efficacy model that seeks to get many tasks accomplished in a short period of time.

Kendall, the sister of a client with a substance-related disorder, tells the nurse she calls out sick for her sister Kylie occasionally when the latter has too much to drink and cannot work. This behavior can be described as: A. Caretaking B. Codependent C. Helpful D. Supportive

Correct Answer: B. Codependent Enabling behaviors that inadvertently promote continued use of a substance by the person abusing substances is known as codependency. Codependency is a type of dysfunctional relationship that involves one person's self-esteem and emotional needs being dependent on the other person. The codependent person may also enable the other person's unhealthy behaviors.

As a manager, she focuses her energy on both the quality of services rendered to the patients as well as the welfare of the staff of her unit. Which of the following management styles does she adopt? A. Country club management B. Organization man management C. Team management D. Authority-obedience management

Correct Answer: C. Team management Team management has a high concern for services and high concern for staff. Team management is the ability of an individual or an organization to administer and coordinate a group of individuals to perform a task. Team management involves teamwork, communication, objective setting, and performance appraisals.

When a client abuses a CNS depressant, withdrawal symptoms will be caused by which of the following? A. Acetylcholine excess B. Dopamine depletion C. Serotonin inhibition D. Norepinephrine rebound

Correct Answer: D. Norepinephrine rebound CNS depressants, when abused, cause depletion of stimulating neurotransmitters. When the CNS depressant is stopped, the result is a rebound of excitatory or stimulating neurotransmitters, such as norepinephrine. Central Nervous System (CNS) depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders.

A blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." Involving the client's religious and spiritual leaders is a culturally responsive action at this point.

What are the specific legal responsibilities that a nurse is responsible for in post-mortem care.

Ensuring a death certificate is issued and signed Labeling the body Reviewing organ donation arrangements.

The nurse knows that the children of parents who abuse substances are at risk for: a. developing substance abuse problems b. developing criminal habits c. bullying d. SIDS

a. developing substance abuse problems

A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: a. "I just can't believe you have decided to go back to that horrible man." b. "I'm just afraid he will kill you or the children when you go back." c. "What makes you think things have changed with him?" d. "I hope you have made the right decision. Call this number if you need help."

d. "I hope you have made the right decision. Call this number if you need help."

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?: a.) Each staff member is assigned a specific task for a group of clients. b.) A staff member is assigned to determine the client's needs at home and begin discharge planning. c.) A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). d.) An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.

d.) An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients. In a nursing, nursing personnel are lead by a RN leader in providing care to a group of clients.

The scope of Nursing Practice, the established educational requirements for nurses, and the distinction between nursing and medical practice is defined by: A. Nurse practice acts B. Statutory law C. Civil law D. Common law

A. Nurse practice acts

How long may it take for a victim of rape to regain previous level of functioning.

Approx. 1 year.

A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the: A. Durable power of attorney B. Advance directives C. Informed consent D. Living will

B. Advance directives

Which concept related to professionalism should the nurse recognize as being most valued by clients and​ colleagues? A. Clinical decision making B. Electronic media use C. Communication D. Advocacy

C. Communication Rationale: Communication and application of culturally​ respectful, caring interventions through the nursing process are key elements valued by nursing students and nurses. Advocacy is an essential component of nursing practice that the new nurse may not yet have experience with. The use of electronic media and clinical decision making influence professional practice and further require professional guidelines to be adhered to.

A patient with bronchial carcinoma reports anorexia and nausea. What measures should the nurse implement to help this patient? A. Provide large meals twice a day. B. Offer bland food with spices. C. Provide small portions of favorite foods. D. Immediately put the patient on intravenous fluids.

C. Provide small portions of favorite foods.

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs.

C. The same religious beliefs can influence individuals differently Members of any particular religion should be assessed for individual feelings and ideas.

Which of the following is true about functional nursing? A. Concentrates on tasks and activities. B. Emphasizes the use of group collaboration. C. One-to-one nurse-patient ratio. D. Provides continuous, coordinated, and comprehensive nursing services.

Correct Answer: A. Concentrates on tasks and activities. Functional nursing is focused on tasks and activities and not on the holistic care of the patients. Functional nursing is task-oriented in scope. Instead of one nurse performing many functions, several nurses are given one or two assignments. Functional nursing was designed around an efficacy model that seeks to get many tasks accomplished in a short period of time.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? A. Ask the client why he started taking illegal drugs. B. Ask the client about the amount of drug use and it effects. C. Ask the client how long he thought that he could take drugs without someone finding out. D. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

Correct Answer: B. Ask the client about the amount of drug use and it's effects. Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct.

Her former manager demonstrated passion for serving her staff rather than being served. She takes time to listen, prefers to be a teacher first before being a leader, which is characteristic of: A. Transformational leader B. Transactional leader C. Servant leader D. Charismatic leader

Correct Answer: C. Servant leader Servant leaders are open-minded, listen deeply, try to fully understand others, and not being judgmental. Servant leadership is a leadership philosophy in which the goal of the leader is to serve. A servant leader shares power puts the needs of the employees first and helps people develop and perform as highly as possible. Servant leadership inverts the norm, which puts the customer service associates as the main priority.

A 70-year-old female patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? a. Patient b. Daughter c. Doctor d. Ethics consult team

a. Patient

Morphine, Codeine, and Methadone have a high potential for abuse or physiological/psychological dependency. Which class of drugs do they belong in? 1. designer drugs 2. stimulants 3. narcotics 4. inhalants

3. narcotics

A terminally ill patient has become confused, disoriented, and restless. The patient is incoherent and has clouding of consciousness. The nurse identifies that the patient has had constipation for 3 days. What action should the nurse take next? A. Obtain a prescription for a benzodiazepine. B. Administer laxatives to treat constipation. C. Do not take any measures as this is normal during the terminal stage. D. Inform the family members that the patient is breathing the last breaths.

B. Administer laxatives to treat constipation.

A client has recently been told he has terminal cancer. As the nurse enters the room, he yells, "My eggs are cold, and I'm tired of having my sleep interrupted by noisy nurses!" The nurse may interpret the client's behavior as: A. The result of maturational loss B. An expression of disenfranchised grief C. An expression of the anger stage of dying D. The result of previous losses

C. An expression of the anger stage of dying In the anger stage of Kubler-Ross's stages of dying, the individual resists the loss and may strike out at everyone and everything, in this case, the nurse.

Cultural awareness is an in-depth self-examination of one's: A. Engagement in cross-cultural interactions B. Motivation and commitment to caring. C. Background, recognizing biases and prejudices. D. Social, cultural, and biophysical factors

C. Background, recognizing biases and prejudices. Cultural awareness is an in-depth examination of one's own background, recognizing biases and prejudices and assumptions about other people.

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of: A. Neglect B. Assault C. Battery D. Invasion of privacy

C. Battery

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call Security B. Call the police. C. Call the nursing supervisor. D. Lock the coworker in the medication room until help is obtained.

C. Call the nursing supervisor Nurse practice act require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question support his need and so this is not an appropriate action.

3. A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services. B. Ask what is making the client cry. C. Ensure no visitors or staff enter the room for a short time period. D. Turn on the television for a distraction

C. Ensure no visitors or staff enter the room for a short time period. Providing privacy and time for the reading of religious materials supports the client's spiritual health.

When the nurse described the client as "that nasty old man in 354," the nurse is exhibiting which ethical dilemma? A. Beneficence B. Code of ethic violation C. Gender bias and ageism D. HIPPA violation.

C. Gender bias and ageism Stereotyping and "old man" as "nasty" is a gender bias and an ageism issue. The nurse is verbalizing a negative descriptor about the client.

The nurse provides care on an oncology unit and is discussing the difference between hospice care and palliative care with the patient's family. What is an appropriate explanation by the nurse? A. Hospice care involves only chemotherapy that is given in a hospital. B. Hospice care involves radiation therapy and chemotherapy that are given in a hospital. C. Hospice care is provided after a person decides to forgo curative treatment. D. Hospice care allows a person to undergo both curative and palliative treatment together.

C. Hospice care is provided after a person decides to forgo curative treatment.

A patient is admitted to the medical unit after experiencing chest pain. Which of these additional findings would support a diagnosis of cocaine abuse? A. Jaundice B. Hypotension C. Perforated nasal septum D. Profuse diarrhea

Correct Answer C. Perforated nasal septum Long-term intranasal use of cocaine is associated with a perforated nasal septum.

When planning the therapeutic milieu, it is most important to select group activities which: A. Match the clients' preferences. B. Are consistent with clients' skills. C. Achieve clients' therapeutic goals. D. Build skills of group participation.

Correct Answer: C. Achieve clients' therapeutic goals. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self-care skills, etc. In group therapy settings, it includes the social community consisting of others who are part of the group. Using the combined elements of positive peer influence, trust, safety, and repetition, the therapeutic milieu provides an ideal setting for people to work toward their therapeutic goals.

He likewise stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to? A. Scalar chain B. Discipline C. Unity of command D. Order

Correct Answer: C. Unity of command Henry Fayol, a famous industrialist of France, has described fourteen principles of management in his book General and Industrial Management. According to the principle of unity of command, an individual employee should receive orders from only one superior at a time and that employee should be answerable only to that superior. If there are many superiors giving orders to the same employee, he will not be able to decide as to which order is to be given priority. He thus finds himself in a confusing situation.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plant to care for first? A. A client who is ambulatory demonstrating steady gait. B. a postoperative client who has just received an opioid pain medication. C. A client scheduled for physical therapy for the first crutch-walking session. D. A client with a WBC count of 14,000 and a temperature of 38.4C

D. A client with a WBC count of 14,000 and a temperature of 38.4C The nurse should plan to care for the client who has an elevated WBC count and a fever first.

Trying questionable and experimental forms of therapy is a behavior that is characterized of which stage of dying? A. Acceptance B. Depression C. Anger D. Bargaining

D. Bargaining

The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to: A. Receive free medical benefits as needed within the county of residence B. Have basic care with a sliding scale payment plan from all health care facilities C. Pick any physician and insurance company despite one's income D. Have equal access to all health care regardless of race and religion

D. Have equal access to all health care regardless of race and religion

Which statement about an institutional ethics committee is correct? A. The ethics committee relieves health care professionals from dealing with ethical issues. B. The ethics committee replaces decision making by the client and health care providers. C. The ethics committee would be the first option in addressing an ethical dilemma. D. The ethics committee is an additional resource for clients and health care professionals.

D. The ethics committee is an additional resource for clients and health care professionals.

How may therapy be beneficial to a victim of rape?

Focuses on restoring the victims sense of control; relieving feelings of helplessness, dependency, and obsession with the assault that frequently follow rape; regaining trust; improving daily function; finding adequate social support; and dealing with feelings of guilt, shame, and anger.

If the family has refused, when may a coroner request an autopsy?

When death is unanticipated, sudden/unexpected, suspicious, or due to injury.

Which of the following individual is at highest for committing suicide? a. 71 year old male, alcohol user, independent-minded b. 16 year old female, diabetic, with 2 best friends c. 47 year old male, schizophrenic, unemployed d. 57 year old female, depression, active in church

a. 71 year old male, alcohol user, independent-minded

The nurse initiating a therapeutic relationship with a client should explain the purpose, which is to a. Alleviate stressors in life b. Become stabilized on medications c. Establish relationships d. Facilitate a positive change

d. Facilitate a positive change

A chronic alcoholic is admitted to the medical unit for pneumonia. Which medication would the nurse expect the health-care provider to prescribe to prevent delirium tremors? 1. chlordiazepoxide (Librium) 2. Thiamine (vitamin B1) 3. disulfiram (antabuse) 4. fluoxetine (Prozac)

1. chlordiazepoxide (Librium) Chlorpromazine (antipsychotic) can control hallucination, decreases BP, and relieves nausea.

Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal? 1. Agitation 2. Delirium tremens 3. Tachycardia 4. Bradycardia

2. Delirium tremens Delirium tremens (DT) is a rapid onset of confusion seen during alcohol withdrawal. The symptoms of DT include altered mental status, autonomic instability, and even seizures. DT is also characterized by hallucinations such as the sensation of something "crawling" on the patient. DT is the most severe consequence of withdrawal and can be fatal if untreated.

A client's wife asks the nurse to pray for her. What would be the best initial response for a nurse who believes in prayer? 1. "May I call the chaplain to come and pray with you?" 2. "I know your faith is important to you. It is to me, too. Let's pray." 3. "I'm happy to do that. For what would you like me to pray?" 4. "Isn't it wonderful that we have a God with whom we canshare our concerns?"

3. "I'm happy to do that. For what would you like me to pray?" The best initial response is to assess.

A dying client states, "Part of what makes dying hard is that I don't know for sure where I'm going. Nurse, what do you believe happens in the hereafter?" Which ethical guideline should guide your response? 1. Never share personal spiritual beliefs. 2. Share all spiritual beliefs, favoring none. 3. Share only your beliefs. 4. First assess for what prompts the client's question.

4. First assess for what prompts the client's question. Assessment is always the first step of the process of spiritual caregiving or any nursing activity.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment. Select all that apply? A. The acuity level of the clients. B. Specific request from the staff C. The clustering of the rooms on the unit. D. The number of anticipated client discharged. E. Client needs and worker's needs and abilities.

A, E There are guidelines that the nurse should use when delegating and planning assignments. These include the following: - ensuring client safety - be aware of individual s variations in work abilities. - determine which tasks can be delegated and to whom. - match the task to the delegate on the basis of the nurse practice act and appropriate position descriptions - provide directions that are clear, concise, accurate, and complete - validate the delegatee's understanding of the directions. - communicate a feeling of confidence to the delegatee and provide feedback promptly after task is performed. -maintain continuity of care as much as possible when assigning client care.

The nurse is preparing to obtain a referral to a pain clinic for a client. Which question should the nurse ask the client that is related to healthcare​ systems? A. "Do you currently have health​ insurance?" B. ​"Can you rate your pain for me on a scale of 1 to​ 10?" C. ​"Do you have any religious or spiritual​ preferences?" D. ​"Do you have a living will or a durable power of​ attorney?"

A. "Do you currently have health​ insurance?" Rationale: The question that most reflects professionalism related to healthcare systems​ is, "Do you currently have health​ insurance?" By assessing the​ client's insurance​ status, the nurse can assist the client in finding affordable and practical ways of meeting healthcare needs. Inquiring about a religious or spiritual​ practice, rating pain on a​ scale, and inquiring about a living will or durable power of attorney are not questions specifically related to healthcare systems.

The nurse manager is preparing an annual review for a nurse. Which measure will the manager use to assess the​ nurse's competency? A. Accountability B. Integrity C. Ethics D. Formation

A. Accountability Rationale: A​ nurse's competence, or ability to perform the job​ correctly, is the practical measure of accountability. Formation is a process that facilitates the transformation of an individual from a layperson to a professional nurse. Ethics are moral principles that govern behavior. Integrity can be defined as an adherence to a moral code.

The caregiver of a patient with chronic illness experiences grief after the death of the patient. The caregiver recalls positive memories of the deceased patient, and the nurse notices that the caregiver is accepting the reality of the death of the patient. What type of grief does the nurse identify in the caregiver? A. Adaptive grief B. Anticipatory grief C. Complicated grief D. Prolonged grief disorder

A. Adaptive grief

When action is taken on one's prejudices: A. Discrimination occurs B. Delivery of culturally congruent care is ensured. C. Sufficient comparative knowledge of diverse groups is obtained. D. People think/know you are a dumb for being prejudiced.

A. Discrimination occurs

An 80-year-old patient is receiving palliative care for heart failure. What are the primary purposes of her receiving palliative care (select all that apply)? A. Improve her quality of life. B. Assess her coping ability with disease. C. Have time to teach patient and family about disease. D. Focus on reducing the severity of disease symptoms. E. Provide care that the family is unwilling or unable to give.

A. Improve her quality of life. D. Focus on reducing the severity of disease symptoms. The focus of palliative care is to reduce the severity of disease symptoms. The goals of palliative care are to prevent and relieve suffering and to improve quality of life for patients with serious, life-limiting illnesses.

Disparities in health outcomes between the rich and the poor illustrates: a (an) A. Influence of socioeconomic factors in morbidity and mortality. B. Combination of naturalistic, religious, ad supernatural modalities. C. Illness attributed to natural, impersonal, and biological forces. D. Creation of own interpretation and descriptions of biological and psychological malfunctions.

A. Influence of socioeconomic factors in morbidity and mortality. Disparities in health outcomes between the rich and the poor illustrate the influence of socioeconomic factors in morbidity and mortality. Social factors such as poverty and lack of universal medical insurance compromise the health status of the poor and unemployed.

Which characteristic should the nurse understand is associated with a strong work​ ethic? A. Integrity B. Advocacy C. Compassion D. Collaboration

A. Integrity Rationale: The characteristic that is associated with a strong work ethic is integrity. Nurses demonstrate integrity by accepting feedback​ (positive or​ negative) as a tool for improving their delivery of client care by maintaining accountability for their actions and freely admitting when they make mistakes and by following their​ state's nurse practice act and never working outside their scope of practice. Compassion is a demonstration of attitude. Advocacy is the practice of expressing and defending​ clients' needs and is an essential component of professional nursing. Collaboration is a skill defined as the ability to work as a team member.

Even though the nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the: A. Physician B. Student nurse C. Client D. Supervising nurse.

A. Physician

The nurse practice acts are an example of: A. Statutory Law B. Common Law C. Civil Law D. Criminal Law

A. Statutory Law

The nurse cares for a patient in the terminal stage of leukemia who has opted for hospice care. When is the patient considered to be eligible for hospice care? A. When two primary health care providers certify that the patient has less than 6 months to live. B. When a primary health care provider certifies that the patient has less than 6 months to live. C. When it is certain that the patient is going to die within 9 months. D. When one primary health care provider guarantees that the patient cannot recover further.

A. When two primary health care providers certify that the patient has less than 6 months to live.

The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation

ANS: A A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.

The nurse is caring for a patient who is being evaluated clinically for brain death by a physician. Which assessment findings by the nurse support brain death? a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8 F

ANS: A Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.

The nurse is working for a hospital that holds an agreement with a local organ procurement organization (OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a. I need to notify TransLife (OPO) of my patients impending death. b. I will contact the physician to obtain informed consent for organ donation. c. The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead. d. I need the physician to evaluate my patients suitability for organ donation.

ANS: A Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the physician, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur prior to death, not after the patient has been pronounced dead.

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patients organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8 F d. Central venous pressure of 8 mm Hg

ANS: B Donor management, focuses on maintaining hemodynamic stability and normallaboratory parameters.

The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8 F. Which physician order should the nurse implement first? a. Apply forced air warming device to keep temperature > 96.8 b. Obtain basic metabolic panel every 4 hours until surgery c. Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg d. Draw arterial blood gas every 4 hours until surgery

ANS: C Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP > 90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.

A family member approaches the nurse caring for their gravely ill son and states, We want to donate our sons organs. What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospitals ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.

ANS: C It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospitals ethics committee are not appropriate actions in this scenario. Informed consent to withdraw life support is provided by the physician.

The nurse manager is discussing the facility protocol in the even of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply? A. Open doors to client rooms. B. Move beds away from windows. C. Close window shades and curtain. D. Place blankets over client who are confined to bed. E. Relocate ambulatory clients from hallways back into their rooms.

B, C, D In this weather event, the appropriate nursing action focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from the window, and close window shades and curtains to protect client's visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. A Libel B Battery C Assault D Slander E False Imprisonment

B, C, E False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention.

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client."

B. "I will ask the client if they want to schedule some times to pray during the day." Islamic practices include praying five times per day. Work with the client to establish a schedule for the day, noting which times the client prefers to pray, and scheduling treatments around those times when possible.

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A. Standards of care from experts in the practice field B. American Nurses Association's (ANA's) Code of Ethics C. Good Samaritan laws for civil guidelines D. Nurse Practice Act (NPA) written by state legislation

B. American Nurses Association's (ANA's) Code. This set of ethical principles provides the professional guidelines established by the ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to establish rules and then incorporate guidelines for accountability and responsibility of each nurse within the practice setting.

Besides the Joint Commission on Accreditation of Healthcare Organizations (JACHO), which governing agency regulates hospitals to allow continued safe services to be provided, funding to be received from the government and penalties if guidelines are not followed? A. Board of Nursing Examiners (BNE) B. Americans With Disabilities Act (ADA) C. Nurse Practice Act (NPA) D. American Nurses Association (ANA)

B. Americans With Disabilities Act (ADA). If the hospital fails to follow ADA guidelines for meeting special needs, the facility loses funding and status for receiving low-income loans or reimbursement of expenses. ADA protects the civil rights of disabled people. It applies to both the hospital clients and hospital staff. Privacy issues for persons who are positive for human immunodeficiency virus (HIV) have been one issue in relationship to getting information when hospital staff have been exposed to unclean sticks. The ADA allows the infected client the right to choose whether or not to disclose that information.

The nurse arrive at work and is told to report (float) to the intensive care unit ICU for the day because the ICU is understaffed and needs additional nurse to care for the clients. The nurse has never worked in ICU. The nurse should take which best actions? A. Refuse to float to the ICU based on lack of unit orientation. B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. C. Ask the nursing supervisor to review the hospital policy on floating. D. Submit a written protest to nursing administration, and then call the hospital lawyer.

B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specific area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leaders to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

1. A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk.

B. Determine client understanding several times during the conversation. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk.

Most litigation in the hospital comes from the: A. Nurse documenting blame on the physician when a mistake is made B. Nurse following an order that is incomplete or incorrect C. Nurse abandoning the clients when going to lunch D. Supervisor watching a new employee check his or her skills level

B. Nurse following an order that is incomplete or incorrect The nurse is responsible for clarifying all orders that are illegible, unreasonable, unsafe, or incorrect. The failure of the nurse to question the physician about an order creates an area of liability on the nurse's part because this is perceived as a medical action and not the role of the nurse to write orders. Some RNs do have prescriptive privileges based upon advanced degrees and certification. Therefore the nurse who cannot correct the order must document that the physician was called and clarification or a new order was given to correct the unclear or illegible one that was currently on the chart. Phone calls, follow-up, and lack of follow-up by the physician should also be documented if there is a problem with getting the information in a timely manner. The nurse must show the sequence of events of a situation in a clear manner if there is any conflict or question about any orders or procedures that were not appropriate. Assessments and documentation of the client's status should also be included if there is a potential risk for harm present. Contact of the staff's chain of command should also be specifically stated for the proof of the responsibilities being followed according to hospital policy.

Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to: A. Blend the values of the nurse that are for the good of the client and minimize the client's individual values and beliefs during care B. Provide care while aware of one's own bias, focusing on the client's individual needs rather than the staff's practices C. Include care that is culturally congruent with the staff from predetermined criteria D. Focus only on the needs of the client, ignoring the nurse's beliefs and practices

B. Provide care while aware of one's own bias, focusing on the client's individual needs rather than the staff's practices. Without understanding one's own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific for this client.

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? A. Libel B. Slander C. Assault D. Negligence

B. Slander Defamation is a false communication or a careless disregard for the truth that cause damage to someone's reputation, either in writing (Libel) or verbally (slander).

The code of ethics for nurses is composed and published by: A. The national league for Nursing B. The American Nurses Association C. The Medical American Association D. The National Institutes of Health, Nursing division.

B. The American Nurses Association the ANA has established widely accepted codes that professional nurses attempt to follow.

A nurse finds that a terminally ill patient has cold, clammy, and wax-like skin. What should the nurse infer from this assessment? A. The patient is improving. B. The patient is likely to die soon. C. The patient has edema and needs diuretics. D. The intravenous fluids have extravasated.

B. The patient is likely to die soon.

The nurse is discussing leadership styles that will help eliminate the lateral violence that is occurring in the workplace. Which leadership style should the nurse associate with the most positive​ change? A. Facilitative B. Transformational C. ​Laissez-faire D. Autocratic

B. Transformational Rationale: The leadership style to bring about the most positive change is transformational leadership. Transformational leadership is recommended as the leadership style for facilitating progress and innovation in nursing. The autocratic leader holds all authority and responsibility. Facilitative leadership is dependent on measurements and outcomes.​ Laissez-faire leaders give the authority to the employees.

A patient has experienced brain death after a head injury and the family has consented to organ donation. In this situation, who does the nurse now recognize as managing the care of that donor? A) Attending physician B) Intensive care physician team C) Registered nurse from organ procurement organization D) Pathophysiologist from the medical examiners office

C) Registered nurse from organ procurement organization

The RN is planning the client assignments for the day. Which is the post appropriate assignment for an AP? A. A client requiring a colostomy irrigation. B. A client receiving continuous tube feedings. C. A client who requires urine specimen collections. D. A client with difficult swallowing food and fluids.

C. A client who requires urine specimen collections. The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urines specimen collections. The AP is skilled in the procedure.

A bioethical issue should be described as: A. After the client gives permission, the physician's disclosing all information to the family for their support in the management of the client. B. The withholding of food and treatment at the request of the client in a written advance directive given before a client acquired permanent brain damage from an accident. C. A research project that included treating all the white men and not treating all the black men to compare the outcomes of a specific drug therapy. D. The physician's making all decisions of client management without getting input from the client

C. A research project that included treating all the white men and not treating all the black men to compare the outcomes of a specific drug therapy. The ethical issue was the inequality of treatment based strictly upon racial differences. Secondly, the drug was deliberately withheld even after results showed that the drug was working to cure the disease process in the white men for many years. So after many years, the black men were still not treated despite the outcome of the research process that showed the drug to be effective in controlling the disease early in the beginning of the research project. Therefore harm was done. Nonmaleficence, veracity, and justice were not followed.

The nurse is discussing ethical practices. Which information should the nurse​ include? A. Joining a professional organization B. Integrating caring interventions C. Adhering to the nurse practice act D. Working toward cultural competency

C. Adhering to the nurse practice act Rationale: The information the nurse will include when discussing ethical practice is the importance of adhering to the nurse practice act. Consistent adherence to the practice act is a demonstration of ethical behavior. Joining a professional organization is a reflection of accountability. Integrating caring interventions and working toward cultural competency are concepts related to professionalism.

A patient is admitted to a hospital with Cheyne-Stokes respirations. What would the nurse expect the assessments findings to reveal? A. A respiratory rate of less than 5 breaths per minute B. A respiratory rate of more than 30 breaths per minute C. Alternating periods of apnea and deep, rapid breathing D. Noisy and congested breathing

C. Alternating periods of apnea and deep, rapid breathing

A student nurse who is employed as a nursing assistant may perform any functions that: A. Are expected of a nurse at that level B. Have been learned about in school C. Are identified in the positions job description D. Require technical rather than professional skill.

C. Are identified in the positions job description

The nurse is preparing for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating the family? A. Discourage reminiscing. B. Make the decisions for the family. C. Encourage expression of feelings, concerns, and fears. D. Explain everything that is happening to all family members. E. Touch and hold the client's or family members hand if appropriate. F. Be honest and let the client and family know they will not be abandoned by the nurse.

C. Encourage expression of feelings, concerns, and fears. E. Touch and hold the client's or family members hand if appropriate. F. Be honest and let the client and family know they will not be abandoned by the nurse. The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

A client is hospitalized in the end stage of terminal cancer. His family members are sitting at his bedside. What can the nurse do to best aid the family at this time? A. Limit the time visitors may stay so they do not become overwhelmed by the situation. B. Discourage spiritual practices because this will have little connection to the client at this time. C. Find simple and appropriate care activities for the family to perform. D. Avoid telling family members about the client's actual condition so they will not lose hope.

C. Find simple and appropriate care activities for the family to perform. It is helpful for the nurse to find simple care activities for the family to perform, such as feeding the client, washing the client's face, combing hair, and filling out the client's menu. This helps the family demonstrate their caring for the client and enables the client to feel their closeness and concern. a. Older adults often become particularly lonely at night and may feel more secure if a family member stays at the bedside during the night. The nurse should allow visitors to remain with dying clients at any time if the client wants them. It is up to the family to determine if they are feeling overwhelmed, not the nurse.

After receiving feedback from​ clients, the nurse​ states, "I understand how I can improve my​ care." Which best describes the​ nurse's behavior? A. Caring B. Decision making C. Integrity D. Commitment

C. Integrity Rationale: Nurses demonstrate integrity by accepting feedback​ (positive or​negative) as a tool for improving the delivery of client care by maintaining accountability for their actions and freely admitting when they make mistakes.​Caring, commitment, and decision making are concepts related to professionalism.

The nurse is demonstrating professionalism when following safety guidelines and principles of​ evidence-based practice. Which is reflective of the​ nurse's ability to provide safe​ care? A. Assessing the​ client's insurance status and ability to access healthcare B. Establishing trust and rapport with the client and team members C. Maintaining a sense of physical limitations and boundaries D. Using​ evidence-based standards when practicing primary prevention

C. Maintaining a sense of physical limitations and boundaries ​Rationale: Maintaining a sense of​ one's own physical limitations and boundaries promotes the safety of the nurse and the healthcare team. Communication is used to establish trust and rapport with the client and team members. Assessing the​client's insurance status and ability to access healthcare reflects the concept of the use of the healthcare system. Using​ evidence-based standards when practicing primary prevention assists the nurse in the promotion of health in the individual and the community.

When a client is confused, left alone with the side rails down, and the bed in a high position, the client falls and breaks a hip. What law has been broken? A. Assault B. Battery C. Negligence D. Civil tort

C. Negligence Knowing what to do to prevent injury is a part of the standards of care for nurses to follow. Safety guidelines dictate raising the side rails, staying with the client, lowering the bed, and observing the client until the environment is safe. As a nurse, these activities are known as basic safety measures that prevent injuries, and to not perform them is not acting in a safe manner. Negligence is conduct that falls below the standard of care that protects others against unreasonable risk of harm.

The nurse frequently volunteers to participate in​ hospital-wide committees. Which type of commitment describes the​ nurse's behavior? A. Organizational B. Collaborative C. Professional D. Ethical

C. Professional Rationale: The nurse participating in many​ hospital-wide committees demonstrates professionalism by upholding the ethics of the profession of nursing. Organizational commitment is the relative strength of an​ individual's relationship to and sense of belonging to an organization. Ethical and collaborative behaviors are characteristics of a professional nurse.

A client who had a "Do Not Resuscitate" order passed away. After verifying there is no pulse or respirations, the nurse should next: A. Call the transplant team to retrieve vital organs. B. Call the funeral director to come and get the body. C. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position appropriately. D. Have family members say goodbye to the deceased.

C. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position appropriately. The body of the deceased should be prepared before the family comes in to view and say their goodbyes. This includes removing all equipment, tubes, supplies, and dirty linens according to protocol, bathing the client, applying clean sheets, and removing trash from the room.

A health care issue often becomes an ethical dilemma because: A. Decisions must be made quickly, often under stressful conditions. B. A clients legal rights coexist with a health professionals obligation. C. The choices involved do not appear to be clearly right or wrong. D. Decisions must be made based on value systems.

C. The choices involved do not appear to be clearly right or wrong.

When helping a person through grief work, the nurse knows: A. Most clients want to be left alone. B. Coping mechanisms that were effective in the past are often disregarded in response to the pain of a loss. C. The sequencing of stages of grief may occur in order, they may be skipped, or they may recur. D. A person's perception of a loss has little do with the grieving process.

C. The sequencing of stages of grief may occur in order, they may be skipped, or they may recur.

Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values it may be possible to identify a philosophy of utilitarianism, with proposes that: A. The decision to perform a lover transplant depends on a measure of the moral life that the client has led so far. B. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician. C. The value of something is determined by its usefulness to society. D. The value of people is determined solely by leaders in the Unitarian church.

C. The value of something is determined by its usefulness to society. A utilitarian system of ethics proposes that the value of something is determined by its usefulness.

A client is brought to ED via EMS after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fracture and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure. B. Ask the EMS team to sign the informed consent . C. Transport the victim to the operating room for surgery. D. Call the police to identify the client and locate the family.

C. Transport the victim to the operating room for surgery. In general, there are two situation in which informed consent of an adult is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent.

A patient in the terminal stage of acute myeloid leukemia has become unconscious. On examination, a nurse finds that the patient's mouth is very dry. How would the nurse help the patient to restore the moisture? Select all that apply. A. Give ice chips. B. Give sips of fluids. C. Use moist cloths for the oral mucosa. D. Apply lubricant to the lips and oral mucus membrane as needed. E. Provide complete and regular oral care.

C. Use moist cloths for the oral mucosa. D. Apply lubricant to the lips and oral mucus membrane as needed. E. Provide complete and regular oral care.

Joey stresses the importance of promoting 'esprit d corps' among the members of the unit. Which of the following remarks of the staff indicates that they understand what he pointed out? A. "Let's work together in harmony; we need to be supportive of one another" B. "In order that we achieve the same results; we must all follow the directives of Julius and not from other managers." C. "We will ensure that all the resources we need are available when needed." D. "We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients."

Correct Answer: A. "Let's work together in harmony; we need to be supportive of one another" Esprit de corps means managers should create and foster among their employees the morale, common spirit, sense of identification, feeling of pride, loyalty, devotion, honor, solidarity, unity, and cohesiveness with respect to their organization or organizational department.

An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse? A. Administer IV fluid incorporated with Vitamin B1 as ordered B. Administer Naloxone (Narcan) 4 mg as ordered C. Contact the family to get information about the client D. Obtain an order for the determination of blood alcohol level

Correct Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered. The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke's encephalopathy is underdiagnosed and undertreated.

He raised the issue of giving priority to patient needs. Which of the following offers the best way for setting priority? A. Assessing nursing needs and problems. B. Giving instructions on how nursing care needs are to be met. C. Controlling and evaluating the delivery of nursing care. D. Assigning a safe nurse: patient ratio.

Correct Answer: A. Assessing nursing needs and problems. This option follows the framework of the nursing process and at the same time applies the management process of planning, organizing, directing, and controlling. At the basic level, management is a regimen that comprises five standard functions, namely, planning, organizing, staffing, leading, and controlling. These functions are part of a body of practices and theories that educate on becoming an efficient manager.

She finds out that some managers have a benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? A. Have condescending trust and confidence in their subordinates. B. Gives economic or ego awards. C. Communicates downward to the staff. D. Allows decision-making among subordinates.

Correct Answer: A. Have condescending trust and confidence in their subordinates. Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. In Benevolent-Autocratic Leadership Style, the manager has condescending confidence and trust in subordinates, motivates with rewards and some punishments, permits some upward communication, solicits some ideas and opinions from subordinates, and allows some delegation of decision making but with close policy control.

Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident, and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take? A. Identify the source of the conflict and understand the points of friction. B. Disregard what she feels and continues to work independently. C. Seek help from the Director of Nursing. D. Quit her job and look for another employment.

Correct Answer: A. Identify the source of the conflict and understand the points of friction This involves a problem-solving approach, which addresses the root cause of the problem. Seek to understand the underlying emotions of the employees in conflict. Employers can manage workplace conflict by creating an organizational culture designed to preclude conflict as much as possible and by dealing promptly and equitably with conflicts that employees cannot resolve among themselves.

In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? A. Provide emotional support and supportive communication B. Assess immediate emotional state and physical injuries C. Ensure that the "chain of custody" is maintained D. Collect hair samples, saliva swabs, and scrapings beneath fingernails

Correct Answer: A. Provide emotional support and supportive communication The LPN/LVN is able to listen and provide emotional support for her patients. The client is the center of care. The needs of the client must be competently met with the knowledge, skills, and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Stephanie considers shifting to transformational leadership. Which of the following statements best describes this type of leadership? A. Uses visioning as the essence of leadership. B. Serves the followers rather than being served. C. Maintains full trust and confidence in the subordinates. D. Possesses innate charisma that makes others feel good in his presence.

Correct Answer: A. Uses visioning as the essence of leadership. Transformational leadership relies heavily on visioning as the core of leadership. Transformational leadership is a leadership style that can inspire positive changes in those who follow. Transformational leaders are generally energetic, enthusiastic, and passionate. Not only are these leaders concerned and involved in the process; they are also focused on helping every member of the group succeed as well.

After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this? A. Collaboration B. Majority rule C. Dominance D. Compromise

Correct Answer: B. Majority rule The majority rule involves dividing the house and the highest vote wins. 1/2 + 1 is a majority. The majority rule is a decision rule that selects alternatives that have a majority, that is, more than half the votes. It is the binary decision rule used most often in influential decision-making bodies, including all the legislatures of democratic nations.

Which of the following is the best guarantee that the patient's priority needs are met? A. Checking with the relative of the patient. B. Preparing a nursing care plan in collaboration with the patient. C. Consulting with the physician. D. Coordinating with other members of the team.

Correct Answer: B. Preparing a nursing care plan in collaboration with the patient. The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively. It is about understanding each patient's health outcome goals and health care preferences and ensuring that the care provided is in line with those goals.

Which of the following conclusions of Ms. Caputo about leadership characteristics is true? A. There is a high correlation between the communication skills of a leader and the ability to get the job done. B. A manager is effective when he has the ability to plan well. C. Assessment of personality traits is a reliable tool for predicting a manager's potential. D. There is good evidence that certain personal qualities favor success in a managerial role.

Correct Answer: C. Assessment of personality traits is a reliable tool for predicting a manager's potential. It is not conclusive that certain qualities of a person would make him become a good manager. It can only predict a manager's potential of becoming a good one. Successful leaders tend to have certain traits. Two keys areas of personal growth and development are fundamental to leadership success: self-confidence and a positive attitude.

Katherine tells one of the staff, "I don't have time to discuss the matter with you now. See me in my office later" when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use? A. Smoothing B. Compromise C. Avoidance D. Restriction

Correct Answer: C. Avoidance This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect, the problem remains unsolved and both parties are in a lose-lose situation. Someone who uses a strategy of "avoiding" mostly tries to ignore or sidestep the conflict, hoping it will resolve itself or dissipate.

In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? A. Being aware of the signs and symptoms of potential agents of bioterrorism B. Making ethical decisions regarding exposing self to potentially lethal substances C. Being aware of the agency's emergency response plan D. Being aware of what and how to report to the Centers for Disease Control and Prevention

Correct Answer: C. Being aware of the agency's emergency response plan. In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings. Planning membership groups should address key aspects across these fields including but not limited to: public safety, facilities, logistics, pharmacy, transportation, clinical patient care, non-clinical patient care, media/public relations, communications, radiation, infection control, and administration.

He is hopeful that his unit will make a big turnaround in the succeeding months. Which of the following actions of Henry demonstrates that he has reached the third stage of change? A. Wonders why things are not what they used to be. B. Finds solutions to the problems. C. Integrate the solutions to his day-to-day activities. D. Selects the best change strategy.

Correct Answer: C. Integrate the solutions to his day-to-day activities. Integrate the solutions to his day-to-day activities is expected to happen during the third stage of change when the change agent incorporates the selected solutions into his system and begins to create a change. In the third and final stage, freezing, the new mindset of the change begins to become the standard, and people's comfort levels return to normal.

She came across a theory which states that the leadership style is effective depends on the situation. Which of the following styles best fits a situation when the followers are self-directed, experts, and are matured A. Democraticindividuals? A. Democratic B. Authoritarian C. Laissez-faire D. Bureaucratic

Correct Answer: C. Laissez faire Laissez-faire leadership is preferred when the followers know what to do and are experts in the field. This leadership style is relationship-oriented rather than task-centered. This kind of leadership is very hands-off—managers trust their employees and are confident in their abilities. They give guidance and take responsibility where needed, but this leadership style means that subordinates and team members have the real lead.

The nurse administers bromocriptine (Parlodel) to Bryan who is undergoing detoxification for amphetamine abuse. The rationale for this medication is to: A. Aid in GABA inhibition B. Prevent norepinephrine excess C. Restore depleted dopamine levels D. Treat psychotic symptoms

Correct Answer: C. Restore depleted dopamine levels Amphetamine abuse depletes the neurotransmitter dopamine. When withdrawing from amphetamines, dopamine depletion causes depression, insomnia, and intense craving for the drug. Bromocriptine (Parlodel) is a dopamine agonist that will help restore this neurotransmitter. GABA inhibition, prevention of norepinephrine excess, and treatment of psychotic symptoms are incorrect rationales for the use of this medication.

Cole is an emergency nurse who encountered a patient who is a suspected carrier of a biologic agent. Which of these if found in the patient is not classified as a Category A biologic agent? A. Bacillus anthracis (anthrax) B. Francisella tularensis (tularemia) C. Clostridium botulinum toxin (botulism) D. Burkholderia pseudomallei (Melioidosis) E. Yersinia petis (plague)

Correct Answer: D. Burkholderia pseudomallei (Melioidosis) Burkholderia pseudomallei (Melioidosis) belongs to the category B priority pathogen. These agents are moderately easy to be transmitted and can result in moderate morbidity rates. Melioidosis is endemic to southeast Asia and northern Australia but has also occurred in South America, Central America, Africa, and the Middle East. Melioidosis may present in an acute form with an incubation period of one day to three weeks. However, latent melioidosis may not present for decades. Melioidosis often infects those with underlying risk factors such as diabetes, kidney disease, alcohol abuse, and thalassemia, although healthy patients may also contract the disease.

A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? A. Examine the client's visual acuity B. Patch the eye C. Use Restasis (Allergan) drops in the eye D. Flush the eye repeatedly using sterile normal saline

Correct Answer: D. Flush the eye repeatedly using sterile normal saline. Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries.

Ms. Caputo learns that some leaders are transactional leaders. Which of the following does not characterize a transactional leader? A. Focuses on management tasks. B. Is a caretaker. C. Uses trade-offs to meet goals. D. Inspires others with vision.

Correct Answer: D. Inspires others with vision. Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit. Transactional leadership depends on self-motivated people who work well in a structured, directed environment. By contrast, transformational leadership seeks to motivate and inspire workers, choosing to influence rather than direct others.

She surfs the internet for more information about leadership styles. She reads about shared leadership as a practice in some magnet hospitals. Which of the following describes this style of leadership? A. Leadership behavior is generally determined by the relationship between the leader's personality and the specific situation. B. Leaders believe that people are basically good and need not be closely controlled. C. Leaders rely heavily on visioning and inspire members to achieve results. D. Leadership is shared at the point of care.

Correct Answer: D. Leadership is shared at the point of care. Shared governance allows the staff nurses to have the authority, responsibility, and accountability for their own practice. Shared leadership is the practice of governing a school by expanding the number of people involved in making important decisions related to the school's organization, operation, and academics. In practice, shared leadership may be defined differently from school to school, and it may take a wide variety of forms.

Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do? A. Advise her staff to go on vacation. B. Ignore her observations; it will be resolved even without intervention. C. Remind her to show loyalty to the institution. D. Let the staff ventilate her feelings and ask how she can be of help.

Correct Answer: D. Let the staff ventilate her feelings and ask how she can be of help. Reaching out and helping the staff is the most effective strategy in dealing with burnout. Knowing that someone is ready to help makes the staff feel important; hence her self-worth is enhanced. Even though the entire team may be experiencing burnout, have conversations on an individual basis. Addressing the entire group can be intimidating and make it difficult for members to open up.

When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority? A. Each patient is listed on the worksheet. B. Patients who need the least care. C. Medications and treatments required for all patients. D. Patients who need the most care.

Correct Answer: D. Patients who need the most care. In setting priorities for a group of patients, those who need the most care should be the number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care can be attended to later or even delegated to assistive personnel according to rules on delegation. The ability to prioritize and manage time is vital for any successful nurse, whether a novice or expert.

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Instruct personnel to don personal protective equipment B. Direct the clients to the cold or clean zone for immediate treatment C. Immediately remove other clients and visitors from the area D. Measure vital signs and auscultate lung sounds E. Direct the clients to the decontamination area

Correct Answer: E. Direct the clients to the decontamination area. Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.

An older woman is brought to the emergency department for treatment of a fracture arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nurse response? A. "Oh, really? I will discuss this situation with you son". B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until your resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and hep find a safe place for you to stay."

D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and hep find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discuss with non medical personnel or the client's family or friends without the client's permission. Client's should be assure that information is kept confidential, unless it places the nurse under legal obligation.

A client's family member says to the nurse, "The doctor said he will provide palliative care. What does that mean?" The nurse's best response is: A. "The goal of palliative care is to affect a cure of a serious illness or disease." B. "Palliative care means the client and family take a more passive role and the doctor focuses on the physiological needs of the client. The location of death will most likely occur in the hospital setting." C. "Palliative care is given to those who have less than 6 months to live." D. "Palliative care aims to relieve or reduce the symptoms of a disease."

D. "Palliative care aims to relieve or reduce the symptoms of a disease." The goal of palliative care is the prevention, relief, reduction, or soothing of symptoms of disease or disorders without effecting a cure.

A family is considering hospice for their loved one who is terminally ill, but they are concerned that they cannot afford hospice care. Which response by the nurse is accurate? A. "The hospice program usually has a small co-pay." B. "The hospice provides better quality of care than the family can." C. "The hospice assists with curative treatments for dying patients and their families." D. "The hospice Medicare program pays for all equipment and medications that are related to the patient's primary hospice diagnosis."

D. "The hospice Medicare program pays for all equipment and medications that are related to the patient's primary hospice diagnosis."

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a LPN and 3 AP on a nursing team. Which client would the nurse most appropriately assign to the LPN? A. A client who requires a bed bath. B. An older client requiring frequent ambulation. C. A client who requires hourly vital sign measurements. D. A client requiring abdominal wound irrigations and dressing changes every 3 hours.

D. A client requiring abdominal wound irrigations and dressing changes every 3 hours. When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The LPN is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A post-operative client prepared for discharge with a new medications. B. A client requiring daily dressing changes of a recent surgical incision. C. A client scheduled for a chest x-ray after insertion of a NG tube. D. A client with asthma who requested a breathing treatment during previous shift.

D. A client with asthma who requested a breathing treatment during previous shift. Airway is always the highest priority.

The nurse employed in an ED is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. a client complaining of muscle aches, headaches, and history of seizures. B. A client who twisted her ankle when roller blading and is requesting medication for pain. C. A client with minor laceration on the index finger sustained while cutting an eggplant. D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce. In an emergency department, triage involves brief client assessment to classify clients according to their needs for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Client's with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are highest priority.

The nurse finds that a terminally ill patient is experiencing nausea and vomiting. Which would be an appropriate nursing action? A. Encourage or provide three big meals rather than small frequent meals. B. No action is required, as this issue is common during the last days of life. C. Prevent family members from bringing home-cooked food, which might overwhelm the patient. D. Administer antiemetic drugs before meals, as ordered.

D. Administer antiemetic drugs before meals, as ordered.

The nurse manager has implemented a change in the method of the nursing delivery system from function to team nursing. An AP is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? A. Ignore the resistance. B. Exert coercion on the AP. C. Provide a positive reward system for the AP. D. Confront the AP to encourage verbalization of feeling regarding the change.

D. Confront the AP to encourage verbalization of feeling regarding the change. Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem.

The nurse is giving a bed bat to an assigned client when an AP enters the client's room and tells the nurse that another assigned client is in pain and needs pain medications. Which is the most appropriate nursing action? A. Finish the bed bath and then administer the pain medication to the other client. B. Ask the AP to find out when the last pain medication was given to the client. C. Ask the AP to tells the client in pain that medication will be administered as the bed bath is complete. D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication.

The nurse is frequently interrupted by personal calls while working. Which area of professionalism is​ compromised? A. Ethics B. Competence C. Communication D. Demeanor

D. Demeanor

Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: A. Consult a professional ethicist to ensure that the steps of the process occur in full. B. Ensure that the attending physician has written an order for an ethics consultation to support the ethics process. C. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion. D. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.

D. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. Each step in the processing of an ethical dilemma resembles steps in critical thinking. The nurse begins by gathering information and moves through assessment, identification of the problem, planning, implementation, and evaluation.

In most ethical dilemmas, the solution to the dilemma requires negotiation among members of the health care team. The nurse's point of view is valuable because: A. The principle of autonomy guides all participants to respect their own self-worth. B. Nurses have a legal license that encourages their presence during ethical discussions. C. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care. D. Nurses develop a relationship to the client that is unique among all professional health care providers.

D. Nurses develop a relationship to the client that is unique among all professional health care providers. When ethical dilemmas arise, the nurses point of view unique and critical. The nurse usually interacts with clients over longer time intervals than do other disciples.

A nursing instructor delivers a lecture to nursing students regarding the issues of clients' rights and ask a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Performing a procedure without consent. B. Threatening to give a client a medication. C. Telling the client that he or she cannot leave the hospital. D. Observing care provided to the client without the client's permission.

D. Observing care provided to the client without the client's permission. Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs.

The scope of nursing practice is legally defined by: A. Physicians in the employing situations. B. Hospital policy and procedure manuals C. Professional nursing organizations D. State nurses practice acts.

D. State nurses practice acts.

The nurse is providing physical care to the end-of-life patient who remains in a state of confusion, incoherence, and anxiety and often hallucinates. The nurse anticipates that the patient's condition is caused by the administration of opioids and corticosteroids. What nursing management does the nurse implement for this patient? Select all that apply. A. Assess for spiritual distress. B. Encourage consumption of ice chips. C. Assess the patient's tolerance for activities. D. Stay physically close to the frightened patient. E. Provide a room that is quiet, well-lit, and familiar.

D. Stay physically close to the frightened patient. E. Provide a room that is quiet, well-lit, and familiar.

A family member of a patient who is nearing death expresses that the patient is having audible and irregular breath sounds. Which explanation to the family member is appropriate? A. The irregular sounds will improve with regular suctioning of secretions. B. The issue could be due to an incorrect position. C. The irregular breathing will likely correct itself in a short time. D. The issue is caused by accumulation of mucus or fluid in the airways.

D. The issue is caused by accumulation of mucus or fluid in the airways.

There has been improvement in the health of an elderly patient who has been in hospice care for 6 months. What should the nurse suggest to this patient? A. The patient can leave hospice care only when the primary health care provider allows doing so. B. The patient must continue for another 6 months in hospice care before leaving. C. The patient is in hospice care and is not eligible for curative treatment. D. The patient can withdraw from hospice care and can receive other health services.

D. The patient can withdraw from hospice care and can receive other health services.

Transcultural nursing implies: A. Combining all cultural beliefs into a practice that is a nonthreatening approach to minimize cultural barriers for all clients' equality of care B. Ignoring all cultural differences to provide the best generalized care to all clients. C. Working in another culture to practice nursing within their limitations D. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate

D. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate. Transcultural care means that by understanding and learning about specific cultural practices the nurse can integrate these practices into the plan of care for a specific individual client who has the same beliefs or practices to meet the client's needs in a holistic manner of care.

Nurse James has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse James would best ensure client safety and obtain necessary assistance for the co-worker? A. Warn the co-worker that this practice is unsafe B. Report the coworker's behavior to the appropriate supervisor C. Make general statements about safety issues at the next staff meeting D. Ignore the co worker's behavior, and frequently assess the clients assigned to the co-worker

Option B: The nurse is obligated by ethical considerations of client safety, as well as by nurse practice acts in many states, to report substance abuse in health care workers. Most healthcare facilities have an employee assistance program to help workers with substance abuse problems.

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

a. A 35-year-old female with severe chest pain: red tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? a. Acceptance b. Anger c. Bargaining d. Denial

a. Acceptance

A patient is admitted for major depression. The nurse should expect to find which of the following in the assessment? a. Anhedonia, feelings of worthlessness, and difficulty focusing b. depressed mood, guilt, pressured speech c. changes in sleep pattern, tired, grandiose mood d. difficulty focusing, feelings of helplessness, flight of ideas

a. Anhedonia, feelings of worthlessness, and difficulty focusing

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse caring for the patient that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse and husband both agree that this seems to be all that therapy is now doing for her. The nurse would suggest that the husband speak to his wife's physician about which type of order? a. Comfort-measures-only b. Do-not-hospitalize c. Do-not-resuscitate d. Slow-code-only

a. Comfort-measures-only

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (SATA) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

a. Partial-thickness burns covering both legs c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes f. Bruising and pain in the right lower abdomen

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

a. The Medical Reserve Corps The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

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

a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. f. The patient's daughter writes a poem expressing her sorrow.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? a. The nurse places the patient in a sitting position while the family visits. b. The nurse places identification tags on both the shroud and the ankle. c. The nurse removes soiled dressings and tubes. d. The nurse makes sure a death certificate is issued and signed.

a. The nurse places the patient in a sitting position while the family visits.

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death.

A battered woman presents to the ED with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. The priority nursing intervention is: a. tending to the immediate care of her wounds. b. providing her with information about a safe place to stay. c. administering the prn tranquilizer ordered by the physician. d. explaining how she may go about bringing charges against her husband.

a. tending to the immediate care of her wounds.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (SATA) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care

During the working phase of a therapeutic relationship, which of the following actions by the nurse would best help the client to explore problems? a. Comparing past and present coping strategies b. Encouraging the client to clarify feelings and behavior c. identifying possible solutions for the client's problems d. Referring the client to a self-help group

b. Encouraging the client to clarify feelings and behavior

Jana, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that Jana has numerous bruises on her arms and torso, in various stages of healing. She also notices some small scars. Jana's abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse suspects that: a. Jana is experiencing physical and sexual abuse. b. Jana is experiencing physical abuse and neglect. c. Jana is experiencing emotional neglect. d. Jana is experiencing sexual and emotional abuse.

b. Jana is experiencing physical abuse and neglect.

A nurse is caring for terminally ill patients in a hospital setting. Which example describes appropriate end-of-life care? a. To eliminate confusion, taking care not to speak too much when caring for a comatose patient b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient c. Referring to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father d. Telling a dying patient to sit back and relax and performing patient hygiene for the patient because it is easier than having the patient help

b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

c. Arrange for critical incident stress debriefing. The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? a. Abbreviated b. Anticipatory c. Dysfunctional d. Inhibited

c. Dysfunctional

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

d. Multiple fractured ribs and shortness of breath Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? a Inform the family that there is no need for them to wash the body since the mortician typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. c. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

A nurse is monitoring an 18 year old who is experiencing heroin withdrawal. What symptoms might the nurse observe? 1. Coma and convulsions 2. Yawning, cramps, and diarrhea 3. Seizures, tremors, and tachycardia 4. Nausea and fainting

2. Yawning, cramps, and diarrhea Yawning, cramps, and diarrhea are common signs of heroin withdrawal.

Alcohol abuse-induced thiamine deficiency can cause which of the following? 1. Wolf-Hirschhorn syndrome 2. Lewy body dementia 3. Agnosia 4. Wernicke-Korsakoff syndrome

4. Wernicke-Korsakoff syndrome Wernicke-Korsakoff syndrome is caused by a severe deficiency in thiamine, often seen in severe alcohol dependency. It is characterized by visual disturbances, ataxia, and altered consciousness.

A patient is experiencing withdrawal from benzodiazepine dependence. The healthcare provider will monitor the patient for which of the following symptoms? (select all that apply.) A. Hypersomnia B. Tremors C. Anxiety D. Yawning E. Seizures

B. Tremors C. Anxiety E. Seizures

Which of the following goals would the healthcare provider identify as realistic for a patient with a substance abuse problem? A. Explore genetic anomalies associated with substance abuse B. Use the substance only in moderation and in certain situations C. Identify situations that trigger a desire to use the substance D. Focus on how cravings can be eliminated by enhancing willpower

C. Identify situations that trigger a desire to use the substance

A patient is brought to the emergency department (ED) by a friend. The patient is unresponsive and respirations are slow and shallow. Which of the following is the priority intervention? A. Check the patient's blood glucose level B. Administer naloxone, per protocol C. Administer 100% oxygen per nasal cannula D. Ask the friend if they were using illicit drug

Correct Answer C.

Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply. A. Enuresis (involuntary urination) B. Red and swollen labia and rectum C. Vaginal tears D. Injuries in different stages of healing E. Cigarette burns F. Lice infestation

Correct Answer: A, B, C These are all indications that a female child has been the victim of sexual abuse. Children often do not talk about sexual abuse because they think it is their fault or they have been convinced by their abuser that it is normal or a "special secret". Options D, E, and F are signs of physical abuse of a child, not sexual abuse. In the short term, children may suffer health issues, such as sexually transmitted infections, physical injuries and unwanted pregnancies. In the long term, people who have been sexually abused are more likely to suffer from depression, anxiety, eating disorders and post-traumatic stress disorder (PTSD). They're also more likely to self-harm, become involved in criminal behavior,

During an initial assessment of a client admitted to a substance abuse unit for detoxification and treatment, the nurse asks questions to determine patterns of use of substances. Which of the following questions are most appropriate at this time? Select all that apply. A. How long have you used substances? B. How often do you use substances? C. How do you get substances into your body? D. Do you feel bad or guilty about your use of substances? E. How much of each substance do you use? F. Have you ever felt you should cut down substance use? G. What substances do you use?

Correct Answer: A, B, C, E, G These questions will elicit information about the client's pattern of use of substances.

Sheila tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. A. Help Sheila to develop a plan to ensure safety, including phone numbers for emergency help. B. Help Sheila to get her boyfriend into an appropriate treatment program. C. Communicate acceptance, avoiding any implication that Sheila is at fault for not leaving. D. Help Sheila to explore available options, including shelters and legal protection. E. Tell Sheila that she should leave because things will not improve. F. Reinforce concern for Sheila's safety and her right to be free of abuse.

Correct Answer: A, C, D, F These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client's feeling responsible for the abuse. Advising the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.

During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"

Correct Answer: A. "Are you being threatened or hurt by your partner?" The use of simple, direct questions, asked in an emphatic manner, is best to validate the presence of an abusive situation. The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence, and refer to females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up. Answer D is indirect and may no lead to the discussion of an abusive situation.

The community nurse practicing primary prevention of alcohol abuse would target which groups for educational efforts? A. Adolescents in their late teens and young adults in their early twenties. B. Elderly men who live in retirement communities. C. Women working in careers outside the home. D. Women working in the home.

Correct Answer: A. Adolescents in their late teens and young adults in their early twenties High-risk groups for alcohol abuse include individuals between ages 18 and 25 and the unemployed. According to the 2015 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Administration, an estimated 20.8 million Americans age 12 and older had a substance use disorder, of which 15.7 million were alcohol use disorders. Of the people with alcohol use disorder and illicit drug disorder, 623,000 of these were adolescents ages 12 to 17 (2.5% of all adolescents).

Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse? A. Antonia, an adult child, quits her job to move in and care for a parent with severe dementia. B. Mr. Wright, an elderly man with severe heart disease, resides in a personal care home and is frequently visited by his adult child. C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives help from several adult children. D. Antoinette cares for her husband who is in early stages of Alzheimer's disease and has a network of available support persons.

Correct Answer: A. Antonia quits her job to move in and care for a parent with severe dementia. In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parents. Caring for someone with severe dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse. A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of elder abuse. They are contributing factors and may or may not be direct causes.

A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client's: A. Disturbed thought processes B. Imbalanced nutrition C. Self-care deficit D. Deficient knowledge

Correct Answer: A. Disturbed thought processes Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person's capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option A is correct.

A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned? A. Family violence affects every socioeconomic level. B. Family violence is caused by drugs and alcohol abuse. C. Family violence predominantly occurs in lower socioeconomic levels. D. Family violence rarely occurs during pregnancy.

Correct Answer: A. Family violence affects every socioeconomic level. Family violence occurs in all socioeconomic levels, races, religions, and cultural groups. Family and domestic violence (including child abuse, intimate partner abuse, and elder abuse) is a common problem in the United States. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremens? A. Hypertension, changes in LOC, hallucinations B. Hypotension, ataxia, hunger C. Stupor, agitation, muscular rigidity D. Hypotension, coarse hand tremors, agitation

Correct Answer: A. Hypertension, changes in LOC, hallucinations Some of the symptoms associated with delirium tremens typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions. Delirium tremens was first recognized as a disorder attributed to excessive alcohol abuse in 1813. It is now commonly known to occur as early as 48 hours after abrupt cessation of alcohol in those with chronic abuse and can last up to 5 days. It has anticipated mortality of up to 37% without appropriate treatment. It is crucial to identify early signs of withdrawal because it can become fatal.

The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say: A. "My attendance at the meetings has helped me to see that I provoke my husband's violence." B. "I no longer feel that I deserve the beatings my husband inflicts on me." C. "I can tolerate my husband's destructive behavior now that I know they are common with alcoholics." D. "I enjoy attending the meetings because they get me out of the house and away from my husband."

Correct Answer: B. "I no longer feel that I deserve the beatings my husband inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control

A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states: A. "I'll never let this happen to me again. I won't let my boss or my job or my family get to me!" B. "It's important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I've got to get in to see my doctor." C. "I've learned that I'm a good person and that I am worthy of giving and receiving love. I don't need anyone; I have myself to rely on!" D. "I don't know what happened to me. I've always been able to make decisions for myself and for my business. I don't ever want to feel so weak or vulnerable again!"

Correct Answer: B. "It's important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I've got to get in to see my doctor." The exact cause of depression is not known but is believed to be related to the biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatments for the disease process. Nursing care plan goals for patients with major depression include determining a degree of impairment, assessing the client's coping abilities, assisting the client to deal with the current situation, providing for meeting psychological needs, and promoting health and wellness.

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse "I should get out of this bad situation." The most helpful response by the nurse would be: A. "I agree with you. You should get out of this situation." B. "What do you find difficult about this situation?" C. "Why don't you tell your husband about this?" D. "This is not the best time to make that decision."

Correct Answer: B. "What do you find difficult about this situation?" The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. Develop a trusting relationship through frequent contact being honest and nonjudgmental. Project an accepting attitude about alcoholism. Provides the patient with a sense of humanness, helping to decrease paranoia and distrust. The patient will be able to detect biased or condescending attitudes of caregivers.

The newly hired nurse at Nurseslabs Medical Center is assessing a client who abuses barbiturates and benzodiazepine. The nurse would observe for evidence of which withdrawal symptoms? A. Respiratory depression, stupor, and bradycardia B. Anxiety, tremors, and tachycardia C. Muscle aches, cramps, and lacrimation D. Paranoia, depression, and agitation

Correct Answer: B. Anxiety, tremors, and tachycardia Barbiturates and benzodiazepine are CNS depressants; therefore, withdrawal symptoms are related to CNS stimulation caused by the rebounding of neurotransmitters (norepinephrine). Symptoms include increased anxiety, tremors, and vital sign changes (such as tachycardia and hypertension). Chronic abusers can develop severe withdrawal symptoms within 8 to 15 hours of cessation. Symptoms include restlessness, tremors, hyperthermia, sweating, insomnia, anxiety, seizures, circulatory failure, and potentially death.

Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was "bad luck"? A. Encourage the client to verbalize the experience. B. Assist the client in defining the experience. C. Work with the client to take steps to move on with his life. D. Help the client accept positive and negative feelings.

Correct Answer: B. Assist the client in defining the experience. The client must define the experience as traumatic to realize the situation wasn't under his personal control. Encourage the client to talk about traumatic experiences under non-threatening conditions. Help the client work through feelings of guilt related to the traumatic event. Help the client understand that this was an event to which most people would have responded in like manner. Support the client during flashbacks of the experience. Verbalization of feelings in a non-threatening environment may help the client come to terms with unresolved issues.

Ryan who is a chronic alcohol abuser is being assessed by Nurse Gina. Which problems are related to thiamine deficiency? A. Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels. B. CNS symptoms, such as ataxia and peripheral neuropathy. C. Gastrointestinal symptoms, such as nausea and vomiting. D. Respiratory symptoms, such as cough and sore throat.

Correct Answer: B. CNS symptoms, such as ataxia and peripheral neuropathy Wernicke's encephalopathy is a CNS disorder caused by acute thiamine deficiency in people who abuse alcohol. Other symptoms, besides ataxia and peripheral neuropathy, are acute confusion or delirium. Deficiency of thiamine can affect the cardiovascular, nervous, and immune system, as is commonly seen in wet beriberi, dry beriberi, or as Wernicke-Korsakoff syndrome. Wet and dry beriberi often have overlapping features, and in either condition, paresthesias may be a presenting feature.

Nurse Angela is working in the emergency department of Nurseslabs Medical Center. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? A. Contact the appropriate legal services. B. Ensure privacy for interviewing the victim away from the abuser. C. Establish a rapport with the victim and the abuser. D. Request the presence of a security guard.

Correct Answer: B. Ensure privacy for interviewing the victim away from the abuser. Privacy, away from the abuser, is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser (especially if she decides to return to the abusive situation). If there is no immediate danger, the assessment should focus on the mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention. Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.

Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? A. Flexible role functioning between parents. B. History of the parent having been abused as a child. C. Single-parent home situation. D. Presence of parental mental illness.

Correct Answer: B. History of the parent having been abused as a child. One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Risk factors are those characteristics linked with child abuse and neglect, but they may or may not be direct causes. A combination of individual, relational, community and societal factors contribute to the risk of child abuse and neglect. Although children are not responsible for the harm inflicted upon them, certain factors have been found to increase their risk of being abused and or neglected.

The client has been hospitalized and is participating in a substance abuse therapy group sessions. On discharge, the client has consented to participate in AA community groups. The nurse is monitoring the client's response to the substance abuse sessions. Which statement by the client best indicates that the client has developed effective coping response styles and has processed information effectively for self use? A. "I know I'm ready to be discharged. I feel I can say 'no' and leave a group of friends if they are drinking... 'No Problem.'" B. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me like the people in this group have... They'll all help me... I know they will... They won't let me go back to my old ways." C. "I'm looking forward to leaving here. I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." D. "I'll keep all my appointments; go to all my AA groups; I'll do everything I'm supposed to... Nothing will go wrong that way."

Correct Answer: C. "I'm looking forward to leaving here. I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." The client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement. In support groups, there's a collective strength — a collaboration of like-minded individuals all pursuing recovery and willing to help others who desire a sober life as well. Here you'll share experiences as well as provide encouragement and support to fellow group members.

An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn't know where he was. He was sedated and the next morning he was fine. At dinnertime, the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client's son asks the nurse what causes sundown syndrome. The nurse's best response is that it is attributed to A. An underlying depression B. Inadequate cerebral flow C. Changes in the sensory environment D. Fluctuating levels of oxygen exchange

Correct Answer: C. Changes in the sensory environment Because the confusion occurs at sundown, the cause probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion. The evaluation and management of altered mental status are broad and require careful history and physical examination to eliminate life-threatening situations. Changes in consciousness can be categorized into changes of arousal, the content of consciousness, or a combination of both. Arousal includes wakefulness and/or alertness and can be described as hypoactivity or hyperactivity, while changes in the content of consciousness can lead to changes in self-awareness, expression, language, and emotions

A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the young children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation? A. Delayed growth and development, related to performance expectations of the child. B. Anxiety (moderate), related to difficulty managing the home situation. C. Impaired parenting, related to the role reversal of mother and child. D. Social isolation, related to lack of extended family assistance

Correct Answer: C. Impaired parenting, related to role reversal of mother and child. The role of a 12-year-old child in a family should not be that of a parent. In this situation, the child and mother have reversed roles. Assess parents for the achievement of developmental tasks of self and understanding of child's growth and development; how they are bonded and attached to the child; how they interpret and respond to the child; how they accept and support the child; how they meet the child's social, psychological and physical needs. Provides information about parent-child relationship and parenting styles that may lead to child abuse; identifies parents at risk for violence or other abusive behavior.

Mariefer is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is: A. Assess the scope of the abuse problem. B. Analyze family dynamics. C. Implement measures to ensure the victim's safety. D. Teach appropriate coping skills.

Correct Answer: C. Implement measures to ensure the victim's safety. The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety. One of the first nursing intervention priorities for action after someone has been found to be a victim of abuse is to provide a safe environment. When a report of abuse is made by the nurse to CPS, a caseworker will decide whether or not the report warrants an investigation. If a child is in immediate danger, he/she will be removed from the home and placed in either the home of a relative or in the foster care system. There are also organizations like Stop Abuse of Elders, or SAFE, which is based in Maryland, that can be used for crisis intervention when an elderly person is in danger. They can refer the victim to a shelter or safe house until more long-term measures can be taken.

During a home visit to a family of three: a mother, father, and their child, The mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse? A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening. B. The nurse commends the mother's efforts and agrees to let her handle things. C. The nurse commends the mother's efforts and also contacts protective services. D. The nurse confronts the mother's failure to protect the child.

Correct Answer: C. The nurse commends the mother's efforts and also contacts protective services. The nurse would validate and reinforce the mother's efforts to seek help; however, the nurse must also report the abuse to the appropriate protective services. The priority is to maintain the child's safety. Communicate information and needs of the child to those on the abuse team (or to new caretakers if the child is being placed with a foster parent or someone other than parents); provide written instruction for care and child's needs. Provides a care plan for the child based on the court decision to caretakers working with the family based on the court decision for child's care.

A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client's mother begins to cry and states "My son's brain will be destroyed. How can the doctor do this to him?" The nurse's best response is: A. "It sounds as though you need to speak with the psychiatrist" B. "Your son has decided to have this treatment. You should be supportive of him." C. "Perhaps you'd like to see the ECT room and speak to the staff." D. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have."

Correct Answer: D. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have." The nurse encourages the client and the family to verbalize fears and concerns. Today ECT is now frequently used to treat a variety of mental health disorders besides depression. The procedure is relatively safe and does work. However, the delivery of ECT requires an interprofessional team that includes a nurse, anesthesiologist, psychiatrist, and neurologist. The benefits of ECT are seen after several sessions and the results are durable. The key is to educate the patient and family about ECT because the procedure has been associated with many false and illogical beliefs.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to: A. Restrain the client until the physician can be reached. B. Call security to block all areas. C. Tell the client that the client cannot return to this hospital again if the client leaves now. D. Call the nursing supervisor.

Correct Answer: D. Call the nursing supervisor. A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. A patient must be deemed incompetent and a danger to himself or someone else before his rights may be taken away and the patient placed in restraints and kept in the hospital against his wishes. If a patient does not wish to stay but has not been deemed incapable of making this decision, the hospital and its staff can be held accountable for false imprisonment.

A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is: A. Explain to the client the importance of a good nutritional intake. B. Weight the client 3 times per week before breakfast. C. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible. D. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times.

Correct Answer: D. Consult with the nutritionist, offer the client several small meals per day and schedule brief nursing interactions with the client during these times. Change in appetite is one of the major symptoms of depression. Weight the client weekly and observe the eating patterns of the client. Give the information needed for revising the intervention. Encourage eating with others. This increases socialization, decreases focus on the food.

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience? A. Diaphoresis and tremors B. Increased blood pressure and heart rate C. Illusions D. Delusions of grandeur

Correct Answer: D. Delusions of grandeur. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal. Mania also commonly presents with psychotic features, which include delusions or hallucinations. Many patients endorse grandiose delusions, believing they are high-level operatives such as spies, government officials, members of secret agencies, or that they are knowledgeable professionals (even when they have no such background)

Johnette is reviewing her lessons in Pharmacology. She is aware that the general classification of drugs belonging to the opioid category is analgesic and: A. Tranquilizing B. Hallucinogenic C. Stimulant D. Depressant

Correct Answer: D. Depressant Opiates are both analgesics and CNS depressants because they decrease the effect of neurotransmitters that are excitatory or stimulating. Opioids act both presynaptically and postsynaptically to produce an analgesic effect. Presynaptically, opioids block calcium channels on nociceptive afferent nerves to inhibit the release of neurotransmitters such as substance P and glutamate, which contribute to nociception. Postsynaptically, opioids open potassium channels, which hyperpolarize cell membranes, increasing the required action potential to generate nociceptive transmission. The mu, kappa, and delta-opioid receptors mediate analgesia spinal and supraspinal.

Mrs. Smith was admitted to the emergency department of Nurseslabs Medical Center with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband, Mr. Smith, who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? A. Mrs. Smith's explanation is appropriate acceptance of her responsibility. B. Mrs. Smith's explanation is an atypical reaction of an abused woman. C. Mrs. Smith's explanation is evidence that the woman may be an abuser as well as a victim. D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.

Correct Answer: D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser. Self-blame is a common psychological response to a woman who is a victim of abuse. In this situation, the message that violence occurred because the woman provoked the abuser is accepted and owned by the victim; however, the victim is not responsible for the violence. Social reactions are associated with whether and how survivors blame themselves for the assault (Ullman & Najdowski, 2011). For example, fewer positive responses are associated with more self-blame of survivors (Wyatt, Newcomb & Notgrass, 1991). Survivors may also already blame themselves for the assault, and negative reactions from others could strengthen that self-blame.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best? A. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book. B. Plan nothing until the client asks to participate in milieu. C. Offer the client a menu of daily activities and insist the client participate in all of them D. Provide a structured daily program of activities and encourage the client to participate.

Correct Answer: D. Provide a structured daily program of activities and encourage the client to participate. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness, and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood

Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? A. Contact the child's parents and ask about the child's injury. B. Encourage the child to be truthful with her. C. Question the teacher about the parent's behavior. D. Report suspicion of abuse to the proper authorities.

Correct Answer: D. Report suspicion of abuse to the proper authorities. The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse. Maintain factual and objective documentation of all observations, including child's physical condition, child's behavioral response to parents, health care workers, other visitors, parent's response to child, and interviews with family members.

Nurse Christine is teaching an adolescent health class about the dangers of inhalant abuse; the nurse warns about the possibility of: A. Contracting an infectious disease, such as hepatitis or AIDS. B. Recurrent flashback events. C. Psychological dependence after initial use. D. Sudden death from cardiac or respiratory depression

Correct Answer: D. Sudden death from cardiac or respiratory depression. Inhalants are CNS depressants; if taken in an excess amount, they can cause cardiac and respiratory depressions. It is impossible to control the inhalant dosage; therefore, death can occur. Prognosis depends upon follow up and motivational and cognitive behavior therapy. Support like Alcoholics-Anonymous groups play an important role in prognosis. Substance use leads to a number of problems among youth, including accidents, death, health effects, crime, unplanned pregnancy, and lower achievement.

Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? A. The child is fearful of the caregiver and other adults. B. The child has a lack of peer relationships. C. The child has self-injurious behavior. D. The child has an interest in things of a sexual nature.

Correct Answer: D. The child has an interest in things of a sexual nature. An 8-year-old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is the priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show an unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.

The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure... I can't do anything right!" The best nursing response would be: A. To tell the client this is not true; that we all have a purpose in life. B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings. C. To reassure the client that you know how the client is feeling and that things will get better. D. To identify recent behaviors or accomplishments that demonstrate skill ability.

Correct Answer: D. To identify recent behaviors or accomplishments that demonstrate skill ability. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distort the cognitive view of self. Silence may be interpreted as agreement.

The interventions common to treatment plans for survivors include which of the following? Select all that apply. A. Establish trust and rapport. B. Identify areas of control. C. Remove the client from home. D. Support the client in the decisions he/she makes. E. Encourage the client to pursue legal action.

Correct Answers: A, B, & D Identifying areas of control empowers the client. Supporting the client in the decisions he/she makes empowers the client and enhances the client's current problem-solving ability. Establishing trust and rapport provides the client with an ally.

A patient being discharged appears angry with the nurse when she attempts to review discharge instructions with the patient. The nurse can best assist the patient in this stage of the relationship with which of the following responses? a. "You should be able to regulate your feelings better by now. Why are you angry?" b. "I can sense you are angry this morning. Tell me how you feel about being discharged today." c. "Would you rather not be discharged today?" d. "We have to go over these instructions before you can go. Please try to listen."

b. "I can sense you are angry this morning. Tell me how you feel about being discharged today."

Kate is an 18-year-old freshman at the state university. She was extremely flattered when Don, a senior star football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Kate to the emergency department. Kate says to the nurse, "It's all my fault. I shouldn't have allowed him to stop at the lake." The nurse's best response is: a. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to stop at the lake." b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d. "You'll just have to see that he is arrested so he won't do this to anyone else."

b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."

The nurse fails to assess personal values surrounding homosexuality before caring for a patient that is openly gay. The nurse is most at risk for which of the following when working with this patient? a. Neglecting to include the patient's desires in the plan of care. b. Holding a prejudice toward this patient. c. Being manipulated by this patient. d. Expressing shock when assessing the patient's history.

b. Holding a prejudice toward this patient.

The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which of the following is the most therapeutic response by the nurse? a. Move to another chair closer to the client and say, "The staff is here to help you." b. Move to a chair a little further away and say, "We can just sit together quietly." c. Remain in place and say, "How are you feeling today?" d. Say, "I'll visit with you a little later," and leave the client alone for a while.

b. Move to a chair a little further away and say, "We can just sit together quietly."

A client is supposed to be ambulating ad lib. Instead, he refuses to get out of bed, asks for a bed bath, and makes many demands of the nurses. He also yells that they are lazy and incompetent. The client's behavior is an example of which of the following defense mechanisms? a. Introjection b. Projection c. Rationalization d. Reaction formation

b. Projection

A young woman who has just undergone a sexual assault is brought into the ED by a friend. The priority nursing intervention would be to: a. help her to bathe and clean herself up. b. provide physical and emotional support during evidence collection. c. provide her with a written list of community resources for survivors of rape. d. discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

b. provide physical and emotional support during evidence collection.

The nurse is teaching a 70-year-old man about his depression. Which of the following statements by the client would indicate that teaching has been effective? a. "All old people get depressed at times." b. "I'm glad I'll feel better in 2 or 3 days." c. "I never knew depression could just happen for no specific reason." d. "When I reduce the stress in my life, the depression will go away."

c. "I never knew depression could just happen for no specific reason."

A patient asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. The best explanation by the nurse would be which of the following? a. "You have reservations about going to therapy?" b. "Both are recommended. Since your insurance covers both that is the best plan for you." c. "Medications help your brain function better, but the therapy helps you achieve lasting behavior change." d. "The effects of medications will not last forever. You will need to eventually

c. "Medications help your brain function better, but the therapy helps you achieve lasting behavior change."

The nurse is assessing a client who is talking about her son's recent death but who shows no emotion of any kind. The nurse recognizes this behavior as which of the following defense mechanisms? a. Dissociation b. Displacement c. Intellectualization d. Suppression

c. Intellectualization Dissociation = withdrawn from sense of self and the world Displacement = redirects negative emotion Intellectualization = thinking is used to avoid feeling. Suppression = voluntarily making efforts to put them out of conscious awareness.

Emergency medical personnel bring an unconscious patient to the emergency department. The patient's pupils are pinpoint and respirations are depressed. Intoxication of which of the following substances could contribute to these clinical signs? A. Methamphetamine B. Methadone C. Cocaine D. Ecstasy

correct Answer B. Methadone

A patient has a history of suicidal ideation. The nurse understands that the patient is at highest risk for self-harm at which of the following times? a. Immediately after a family visit b. On the anniversary of significant life events in the patient's life c. During the first few days after admission d. Approximately 2 weeks after starting antidepressant medication

d. Approximately 2 weeks after starting antidepressant medication

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect? a. Blunt affect b. Restricted affect c. Broad affect d. Flat affect

d. Flat affect

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority? a. Hopelessness related to recent divorce b. Ineffective coping related to inadequate stress management c. Spiritual distress related to conflicting thoughts about suicide and sin d. Risk for suicide related to highly lethal plan

d. Risk for suicide related to highly lethal plan

Which of the following statements is true about a nurse's self-disclosure? a. It is the basis for effective communication. b. Self-disclosure should be used with all clients to some degree. c. The more the nurse discloses, the more the client will disclose. d. Self-disclosure on the nurse's part should benefit the client.

d. Self-disclosure on the nurse's part should benefit the client.

A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which of the following actions by the nurse is most likely to help the client be successful in this group? a. Allowing the client to direct her participation at her own pace b. Giving the client several choices of projects so she can choose her favorite c. Staying away from the client during the session to encourage free expression d. Structuring the activity to facilitate completion of one specific task

d. Structuring the activity to facilitate completion of one specific task

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? 1. "only oral ingestion of alcohol will cause a reaction when taking this drug" 2. "it is safe to drink beverages that have only 12% alcohol content" 3. "this medication will decrease your cravings for alcohol" 4. "reactions to combining antabuse with alcohol can occur 2 weeks after stopping the drug."

4. "reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

The nurse should recommend which of the following self-help groups for a 14 year old recovering heroin addict that was sold into prostitution? 1. Calix society 2. Al-Anon 3. Drugs Anonymous 4. Alateen

4. Alateen

Prolonged alcohol abuse can result in a severe deficiency in what vitamin? 1. Vitamin C 2. Niacin (B3) 3. Folate 4. Thiamine (B1)

4. Thiamine (B1) Prolonged alcohol abuse can result in a severe deficiency in thiamine, or vitamin B1 by reducing dietary thiamine intake, impairing gastrointestinal absorption of thiamine, and causing impaired thiamine utilization in cells. Note that individuals who partake in prolonged alcohol abuse may have various other dietary deficiencies.

A patient is brought to the emergency department by a family member. The patient has been agitated for the past several hours and has alternated between grandiosity and expressing a desire to commit suicide. Upon examination, the patient is diaphoretic, hypertensive, and tachycardic. Intoxication with which of the following substances would contribute to these symptoms? A. Methamphetamine B. Benzodiazepine C. Marijuana D. Alcohol

A. Methamphetamine

Nurse Michael recommends that the family of a client with substance-related disorder attend a support group, such as Al-Anon and Alateen. The purpose of these groups is to help family members understand the problem and to: A. Maintain focus on changing their own behaviors B. Learn how to assist the abuser in getting help C. Prevent substance problems in vulnerable family members D. Change the problem behaviors of the abuser

Answer: A. Maintain focus on changing their own behaviors. Option A: Family support groups, such as Al-Anon and Alateen, emphasize the importance of changing one's own behavior rather than trying to change the behavior of the individual with a substance abuse problem.

3. Nurse Chelsey is teaching a community group about substance abuse. She explains that a genetic component has been implicated in which of the following commonly abused substances? A. Heroin B. Alcohol C. Marijuana D. Barbiturates

Answer: B. Alcohol. Option B: Several chromosomes (1, 3, and 7) have been implicated in increased vulnerability to alcohol abuse. Statistics have shown that risk for alcohol abuse in first-degree relatives of alcohol abusers is as high as 40% to 60%. Most of the genetic research has been done related to alcohol.

Nurse Christine is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in: A. Increased pulse and blood pressure B. Abdominal cramps and diarrhea C. Drowsiness and decreased respiration D. Flushing, vomiting, and dizziness

Answer: D. Flushing, vomiting, and dizziness. Option D: Disulfiram (Antabuse) prevents complete alcohol metabolism in the body. Therefore when alcohol is consumed, the client has a hypersensitivity reaction. Flushing, vomiting, and dizziness are associated with the incomplete breakdown of alcohol metabolites.

A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? A. Bradycardia and hypothermia B. Irritability and nausea C. Hyperthermia and euphoria D. Depressed respirations and somnolence

B. Irritability and nausea The healthcare provider would expect to observe irritability and nausea. Heart rate and blood pressure will be baseline or elevated, and temperature will be unchanged.

The nurse is providing palliative care to a patient who is in the last stage of cancer. What does the nurse monitor in the patient as part of neurologic assessment? Select all that apply. A. Urine output B. Pupil response C. Nutritional intake D. Presence of reflexes E. Level of consciousness

B. Pupil Response D. Presence of reflexes E. Level of Consciousness

A patient presents to the clinic with a report of fatigue and difficulty concentrating. Which additional statement made by the patient would alert the healthcare provider to possible marijuana use? A. I feel nauseous and don't feel like eating." B. I feel anxious and have trouble sleeping." C. "I've noticed that my eyes are red lately." D. "I keep having really vivid and scary nightmares."

Correct Answer C. "I've noticed that my eyes are red lately." Marijuana use can cause corneal vasodilation and conjunctivitis. It's more likely that marijuana would increase appetite, decrease anxiety, and promote sleep.

When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse will identify this crisis as which type? A. Psychiatric emergency crisis B. Developmental crisis C. Anticipated life transition D. Dispositional crisis

Correct Answer D. Dispositional crisis A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse. These crises can ensue from a lack of information, such as not knowing which job to take, what type of medical referral to seek for a particular symptom, what one's options are about living arrangements, whom to ask for what.

A patient who has a history of chronic back pain requires a higher dose of an opioid medication in order to achieve adequate pain relief. The healthcare provider suspects that these findings are a result of which of the following? A. Dependence B. Pseudoaddiction C. Addiction D. Tolerance

Correct Answer D. Tolerance Tolerance is a decrease in sensitivity to a medication. It is a common occurrence when opioids are taken for an extended period time, and requires a progressively larger dose to achieve the same degree of pain management.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A. Monitor Vital sings B. Provide a safe environment. C. Address hallucinations therapeutically. D. Provide stimulation in environment., E. Provide reality orientation as appropriate. F. Maintain NPO status.

Correct Answer: A, B, C, E When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

Which statement by the client during the initial assessment in the emergency department is most indicative of suspected domestic violence? A. "I am determined to leave my house in a week." B. "No one else in the family has been treated like this." C. "I have only been married for two (2) months." D. "I have tried leaving, but have always gone back."

Correct Answer: D. "I have tried leaving, but have always gone back." Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members of the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.

In conferring with the treatment team, the nurse should make which of the following recommendations for a client who tells the nurse that everyday thoughts of suicide are present? A. A no-suicide contract B. Weekly outpatient therapy C. A second psychiatric opinion D. Intensive inpatient treatment

Correct Answer: D. Intensive inpatient treatment For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Put on either suicide precaution (one-on-one monitoring at one arm's length away) or suicide observation (15-minute visual check of mood, behavior, and verbatim statements), depending on the level of suicide potential. Protection and preservation of the client's life at all costs during a crisis is part of medical and nursing staff's responsibility. Follow unit protocol.

Which medication is commonly used in treatment programs for heroin abusers to produce a non-euphoric state and to replace heroin use? A. Diazepam B. Carbamazepine C. Clonidine D. Methadone

Correct Answer: D. Methadone Methadone maintenance programs are used to provide a heroin-depleted individual with a medically controlled dose of methadone to produce a non euphoric state that will prevent withdrawal symptoms. This method of treatment is advocated to help heroin abusers avoid criminal activities associated with obtaining heroin; it also prevents diseases associated with I.V. use of heroin. Methadone is an alternative in treating patients with opioid-tolerance as they may not respond to traditional analgesic regimens. In such patients, methadone dosages are adjusted, or combined with other opioids as adjuvant treatments to enhance response to analgesic interventions.

A school nurse notices bruises and scars on a child's body. The nurse suspects that the child is being physically abused. How should the nurse proceed with this information? a. As a health-care worker, report the suspicion to the Department of Health and Human Services. b. Check Jana again in a week and see if there are any new bruises. c. Meet with Jana's parents and ask them how Jana got the bruises. d. Initiate paperwork to have Jana placed in foster care.

a. As a health-care worker, report the suspicion to the Department of Health and Human Services.

A client who had been in a substance abuse treatment program asks the nurse for a date after the client is discharged. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. The nurse is using which of the following techniques? a. Defining boundaries b. Reprimanding the client c. Letting the client down gently d. Defining therapy

a. Defining boundaries

During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, "I'm old, and my life has no purpose anymore. But promise me you won't tell anyone." How should the nurse respond? a. "Don't worry, I won't tell anyone else." b. "I'm sorry, but I can't keep that kind of secret." c. "Let's talk about something to cheer you up." d. "What can we do to help you feel better?"

b. "I'm sorry, but I can't keep that kind of secret."

Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department (ED) with her three small children. She tells the nurse her husband inflicted these wounds on her. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: a. "How often does he drink too much?" b. "It is not your fault. You did the right thing by coming here." c. "How many times has he done this to you?" d. "He is not a good husband. You have to leave him before he kills you."

b. "It is not your fault. You did the right thing by coming here."

A woman who was sexually assaulted six months ago by a man with whom she was acquainted has since been attending a support group for survivors of rape. From this group, she has learned that the most likely reason the man raped her was that: a. because he had been drinking, he was not in control of his actions. b. he had not had sexual relations with a girl in many months. c. he was predisposed to become a rapist by virtue of the poverty conditions under which he was reared. d. he was expressing power and dominance by means of sexual aggression and violence.

d. he was expressing power and dominance by means of sexual aggression and violence.

A school nurse notices bruises and scars on a child's body, but the child refuses to say how she received them. Another way in which the nurse can get information from the child is to: a. have her evaluated by the school psychologist. b. tell her she may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse's questions. c. explain to her that if she answers the questions, she may stay in the nurse's office and not have to go back to class. d. use a "family" of dolls to role-play the child's family with her.

d. use a "family" of dolls to role-play the child's family with her.