exam 4

19. A nurse is reviewing a patient's history. Which priority finding will alert the nurse to assess the patient for possible sexual dysfunction? a. Takes vacations out of the country b. Takes antianxiety medication c. Takes exercise classes d. Takes afternoon naps

ANS: B Medications that can affect sexual functioning include antihypertensive, antipsychotics, antidepressants, and antianxiety. Taking vacations out of the country, exercise classes, and afternoon naps are not as priority for sexual functioning as medications.

4. During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

ANS: A A BMI of 25 to 29.9 is in the overweight range. A BMI of <18.5 is in the underweight range. A BMI of 30 to 34.9 is obesity class I, a BMI of 35 to 39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19 to 24 is in the normal range.

34. A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. Maintaining a closed urinary drainage system b. Inserting the catheter using strict clean technique c. Disconnecting and replacing the catheter drainage bag once per shift d. Fully inflating the catheter's balloon according to the manufacturer's recommendation

ANS: A A key intervention to prevent infection is maintaining a closed urinary drainage system. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgment and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.

10. A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected? a. Perceptual b. Cognitive c. Affective d. Social

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

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." b. "Some people have a slower bowel than others, and this is nothing to be concerned about." c. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." d. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day."

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

6. A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, "I feel happier, but my sex driveis gone." Which nursing diagnosis has the highest priority? a. Sexual dysfunction b. Ineffective coping c. Risk for self-directed violence d. Deficient knowledge about contraception

ANS: A Antidepressants have adverse effects on sexual desire and response. The nurse should be sure to educate the patient on the potential for these side effects and how to correct for them, for example, using lubricant to ease discomfort. The patient has taken steps toward effective coping by seeking therapy. The patient has not expressed a reason for the nurse to be concerned about contraceptives. The nurse should always assess for concerns about violence in a patient's life. Although some antidepressants have been related to self-directed violence, this patient focus is on becoming pregnant (fertility treatments) but sex drive is gone.

17. A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask? a. Have you noticed any changes in the way you feel about yourself? b. What is your favorite sex position with men and with women? c. Do you think your partner is attractive? d. Why do you like men over women?

ANS: A Asking about any changes in the way you feel about yourself is an appropriate question to ask during a sexual assessment. Asking about favorite sex position with men and/or women is inappropriate and invasive. The assessment needs to focus on the patient, not the partner. Asking "why" questions is nontherapeutic and is judgmental in this scenario.

35. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a. Drapes the urinary drainage tubing with no dependent loops b. Washes the drainage tube toward the meatus with soap and water c. Places the urinary drainage bag gently on the floor below the patient d. Allows the spigot to touch the receptacle when emptying the drainage bag

ANS: A Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. Using a clean washcloth, soap, and water, with your dominant hand wipe in a circular motion along the length of the catheter for about 10 cm (4 inches), starting at the meatus and moving away.

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care? a. Teach the patient about special assistive devices. b. Make the patient talk as much as possible. c. Obtain an order for antidepressant medications. d. Place a consult for a home health nurse.

ANS: A Because a stroke often causes partial or complete paralysis of one side of a patient's body, the patient needs special assistive devices. The nurse should include interventions that help the patient adapt to this deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for him- or herself. Making the patient talk can be inappropriate and demeaning. A home health nurse is not necessary as long as the patient is able to care for him- or herself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.

20. A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect? a. Physical aggression and sleep disturbances b. Many peers and no drug usage c. Panic attacks and anorexia d. Anxiety and depression

ANS: A Behavioral signs of sexual abuse in a child include physical aggression, sleep disturbance, poor peer relationships, and substance abuse. Panic attacks, anorexia, anxiety, and depression are behavioral signs for adults.

23. A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take? a. Offer the patient a back rub. b. Hang a "Do not disturb" sign on patient's door. c. Ask the patient "Would you like a newspaper to read?" d. Place the patient in the room farthest from the nurses' station.

ANS: A Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-nurse interaction and promote further social isolation.

8. A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend? a. Condom b. Diaphragm c. Spermicide d. Oral contraceptive

ANS: A Condoms are both a contraceptive and a barrier against STIs and HIV; proper use will greatly reduce the risk. Spermicides, diaphragms, and oral contraceptives all protect against pregnancy; however, they are not a barrier and do not prevent bodily fluids from coming in contact with the patient during sexual intercourse.

29. A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Dressing the left side first b. Dressing the right side first c. Dressing the lower extremities first d. Dressing the upper extremities first

ANS: A Dressing the left side first will be praised by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the body. The right side or upper and lower extremities are not as effective.

1. A 55-year-old male patient post-myocardial infarction (MI) asks the nurse whether he will be healthy enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and beta-blockers. During health teaching, the nurse understands that the three phases of the four-stage model of the human sexual response cycle that are of concern for this patient include which phases? a. Excitement, plateau, and orgasmic b. Plateau, orgasmic, and resolution c. Excitement, orgasmic, and resolution d. Arousal, excitement, and plateau

ANS: A During these three phases, heart rate, blood pressure, and respirations increase steadily, increasing stress to the heart muscle. This would be the period of greatest concern for a patient who has recently experienced an MI. The plateau and orgasmic phases may be of physiologic concern to this patient, but during the resolution phase, vital signs return to normal, and muscles relax. Arousal is not a phase in the four-stage model of the human sexual response cycle, although some researchers feel this should be added.

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

ANS: A Good oral hygiene keeps the taste buds well hydrated. Having an unpleasant taste in the mouth discourages the patient from eating. Well-seasoned, differently textured food eaten separately heightens taste perception. Avoid blending foods together because this makes it difficult to identify tastes. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable. Flavored vinegar or lemon juice adds tartness to food.

7. During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth

ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

37. To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do? a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of the irrigation solution at least 12 inches above the bladder.

ANS: A To reduce discomfort use room temperature solution. Using cold solutions and instilling solutions too quickly can cause discomfort. During an irrigation, the solution does not sit in the bladder; it is allowed to drain. A container is not raised about the bladder 12 inches when performing a closed intermittent catheter irrigation.

32. A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse take? a. Teach the patient how to self-cath the pouch. b. Teach the patient how to perform Kegel exercises. c. Teach the patient how to change the collection pouch. d. Teach the patient how to void using the Valsalva technique.

ANS: A In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir.

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion? a. Keep a day-by-day calendar at the patient's bedside. b. Place a patient observer in the patient's room for safety. c. Assess the patient's level of consciousness and document every 4 hours. d. Prepare to discharge once the patient is awake, alert, and oriented.

ANS: A Keeping a calendar in the patient's room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.`

5. A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment? a. Impaired night vision b. Difficulty hearing low pitch c. Heightened sense of smell d. Increased taste discrimination

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

6. When assessing high-risk behaviors, which question specifically identifies a blood-related risk for a sexually transmitted infection? a. "Have you ever received donor semen, eggs, or transplanted tissue?" b. "Have you ever exchanged sex for drugs, money, or shelter?" c. "How do you protect yourself from HIV and sexually transmitted infections?" d. "Have you ever injected drugs using shared equipment?"

ANS: A Receipt of any donated organ, tissue, semen, or eggs is considered a blood-related risk. Other blood-related risks include blood transfusion, sex with a person with hemophilia, or sharing equipment for tattoos and body piercing. The exchange of sex for money, drugs, or shelter is considered a drug use-related risk. Other drug use-related risks include having sex with a person who uses or shares, and having sex while stoned, high, or drunk so that you cannot remember the details. By using male condoms, female condoms, or other barriers, patient can protect themselves against sexual risk. Other high-risk behaviors in this category include: having sex against one's will, failing to use protection, having sex with a partner who is bisexual or gay, having anal intercourse, and sexual activity with an increased number of partners. Sharing equipment to inject street drugs or steroids is a drug use-related risk.

1. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. Which response by the nurse will be most effective? a. "Sexually transmitted infections and unwanted pregnancy are a real risk. Let's discuss what you think is t method for protecting yourself." b. "Having sexual interaction with both males and females places you at higher risk for STIs. To protect you you need to decide which orientation you are." c. "Your current friends are leading you to make poor choices. You should find new friends to hang out wit d. "I think it's best to notify your parents. They know what's best for you and can help make sure you practi sex."

ANS: A Some adolescents participate in risky behaviors. The nurse should acknowledge this feeling to the patient and offer education and alternatives, while giving the patient the autonomy to make his or her own decisions. Adolescents who engage in sexual risk behaviors experience negative health outcomes such as STIs and unintended pregnancy. In addition, the pattern of risk-taking behavior tends to be established and continue throughout life. The nurse should not force the patient to make a choice of orientation and should not pass judgment on a patient's sexual orientation or social network; this would make the patient feel defensive and would eliminate the trust in the relationship. Involving parents is not the first line of action; parents should be notified only if the child is in a life or death situation.

27. The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority? a. Hearing b. Vision c. Smell d. Taste

ANS: A Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

12. A nurse is assessing cognitive functioning of a patient. Which action will the nurse take? a. Administer a Mini-Mental State Examination (MMSE). b. Ask the patient to state name, location, and what month it is. c. Ask the patient's family if the patient is behaving normally. d. Administer the hearing handicap inventory for the elderly (HHIE-S).

ANS: A The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitivefunctioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.

13. The nurse is using the Snellen chart. Which patient is the nurse assessing? a. A patient who frequently reports the incorrect time from the clock across the room. b. A patient who is having difficulty remembering how to perform familiar tasks. c. A patient who turns the television up as loud as possible. d. A patient who has trouble saying words.

ANS: A The Snellen chart is used to assess vision. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental and cognitive status. Turning the television up louder indicates the need for a hearing assessment. For a patient having trouble saying words a picture board/chart may be used.

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.

ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

26. A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take? a. Place a raised Braille sticker on the call button. b. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. c. Instruct the patient to tell a family member to get the attention of the staff. d. Color code the call light system.

ANS: A The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Using family members is not the best option. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch at any time. Color coding the call light will not help a severely visually impaired patient.

18. A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic? a. Ask the patient what concerns she may have about the vaccination. b. Inquire about how many sexual partners she has had in the past year. c. Remind her that her mother knows best and that she should respect her parents' wishes. d. Promote the importance of the vaccine, and recommend that the patient get the vaccine as soon as possible.

ANS: A The nurse should encourage health promotion behaviors but first must consider the autonomy of the patient and assess the patient for more data. The nurse should value the input of the patient in making a decision and assess what the patient is thinking to address any concerns the patient may have. The HPV vaccine is a preventative treatment; whether or not the patient is sexually active (asking about how many sexual partners) does not matter in this case. The nurse should not make assumptions about a patient's home life (mother knows best); instead, the nurse should ask questions while establishing a therapeutic relationship. Recommending the patient get the vaccine as soon as possible is in violation of the patient's rights.

16. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up? a. "I have lost 12 pounds on this diet." b. "I use the diaphragm to prevent pregnancy." c. "I use a contraceptive cream with my diaphragm." d. "I know this provides a barrier over the cervical opening."

ANS: A The woman needs to be refitted after a significant change in weight (10-pound gain or loss) or pregnancy. The diaphragm is a round, rubber dome that has a flexible spring around the edge. It is used with a contraceptive cream or jelly and is inserted in the vagina so it provides a contraceptive barrier over the cervical opening.

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

ANS: A Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.

33. The nurse is preparing to apply an external catheter. Which action will the nurse take? a. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter. b. Spiral wrap the penile shaft using adhesive tape to secure the catheter. c. Twist the catheter before applying drainage tubing to the end of the catheter. d. Shave the pubic area before applying the catheter.

ANS: A When applying an external catheter, allow 2.5 to 5 cm (1 to 2 inches) of space between the tip of the penis and the end of the catheter. Spiral wrap the penile shaft with supplied elastic adhesive. The strip should not overlap. The elastic strip should be snug but not tight. NOTE: Never use adhesive tape. Connect drainage tubing to the end of the condom catheter. Be sure the condom is not twisted. Connect the catheter to a large-volume drainage bag or leg. Clip hair at the base of the penile shaft, as necessary. Do not shave the pubic area.

4. The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Dysequilibrium c. Diabetic retinopathy . Peripheral neuropathy

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Disequilibrium is balance. Diabetic retinopathy affects vision. Peripheral neuropathy includes numbness and tingling of the affected areas and stumbling gait.

1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

5. The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply.) a. Habit training uses a bladder diary. b. Timed voiding is based upon the patient's urge to void. c. Prompted voiding includes asking patients if they are wet or dry. d. Elevation of feet in patients with edema can decrease nighttime voiding. d. Bladder retraining teaches patients to follow the urge to void as quickly as possible.

ANS: A, C Habit training is a toileting schedule based upon the patient's usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. Prompted voiding is a program of toileting designed for patients with mild or moderately cognitive impairment. Patients are toileted based upon their usual voiding pattern. Caregivers ask the patient if they are wet or dry, give positive feedback for dryness, prompt the patient to toilet, and reward the patient for desired behavior. Timed voiding or scheduled toileting is toileting based upon a fixed schedule, not the patient's urge to void. The schedule maybe set by a time interval, every 2 to 3 hours or at times of day such as before and after meals. In bladder retraining, patients are taught to inhibit the urge to void by taking slow and deep breaths to relax, perform 5 to 6 quick strong pelvic muscle exercises (flicks) in quick succession followed by distracting attention from bladder sensations. When the urge to void becomes less severe or subsides, only then should the patient start the trip to the bathroom. Encourage patients with edema to elevate the feet for a minimum of a few hours in the afternoon to help diminish nighttime voiding frequency; while this is helpful, it is not a toileting schedule.

1. A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.) a. Stairway faintly lit b. Bathtub with grab bars c. Scatter rugs in the kitchen d. Absence of smoke alarms e. Low-pile carpeting in the living room f. Level thresholds between bathroom and bedroom

ANS: A, C, D Assess the patient's home for common hazards, including the following: (1) loose area rugs and runner placed over carpeting, (2) poor lighting in stairways, and (3) absence of smoke alarms. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. A bathtub with grab bars is safe and does not need to be addressed. Teach patients and family members to keep all flooring in good repair, and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor.

1. An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

2. The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) a. Keeping the urine collection container on ice when indicated b. Withholding all patient medications for the day c. Irrigating the sample as needed with sterile solution d. Testing the urine sample with a reagent strip by dipping it in the urine e. Asking the patient to void and discarding that urine to start the collection

ANS: A, E When obtaining a 24-hour urine specimen, it is important to keep the urine in cool conditions, depending upon the test. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution. A 24-hour urine specimen is not tested with a reagent strip.

1. An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.) a. Plan sexual activity around a time when the couple feels rested. b. Encourage intimate touching, such as hugging and kissing. c. Use extra lubrication to decrease discomfort. d. Take pain medication before intercourse. e. Avoid alcohol and tobacco. f. Eat well-balanced meals.

ANS: A, E, F Alcohol, tobacco, and certain medications (such as narcotics for pain) may cause drowsiness and fatigue and negatively affect sexual stamina. Eating well-balanced meals can help to increase energy levels. Planning sexual activity when the couple is well rested will help them not get fatigued as quickly. Encouraging intimate touching may help increase libido but not energy levels. Extra lubrication and taking pain medications may ease the discomfort of sexual intercourse but are not appropriate interventions for fatigue.

1. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

ANS: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.

22. The nurse is caring for a group of patients and is monitoring for sensory deprivation.Which patient will the nurse monitor most closely? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage lung cancer

ANS: B A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (airborne precautions) is at risk for sensory deprivation because of limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke may have difficulty with tactile sensation but is not at as high a risk for sensory deprivation as is one in isolation. A patient with lung cancer may have deficits, but hospice is present so the patient is at home with others.

3. The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet

ANS: B A low sodium diet will prevent water retention which could increase blood pressure. Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.

39. The nurse anticipates a suprapubic catheter for which patient? a. A patient with recent prostatectomy b. A patient with a urethral stricture c. A patient with an appendectomy d. A patient with menopause

ANS: B A patient with a urethral stricture is most likely to have a suprapubic catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery). A patient with a recent prostatectomy indicates the enlarged prostate was removed and would not need a suprapubic catheter; however, continuous bladder irrigation may be needed. Appendectomies and menopause do not require a suprapubic catheter.

10. A nurse is preparing a community class about sexually transmitted infections. Which primary group will the nurse focus on for this class? a. Bisexual women b. Men who have sex with men c. Youths between the ages of 24 and 27 d. Pregnant women and their partners

ANS: B About 20 million people in the United States are diagnosed with an STI each year, with the highest incidence occurring in men who have sex with men, bisexual men, and youths between the ages of 15 and 24. While bisexual women, youths between the ages of 24 and 27, and pregnant women and their partners are important, they are not the primary groups affected by STIs.

25. The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? a. Measure bladder before the patient voids. b. Measure bladder within 10 minutes after the patient voids. c. Measure bladder with head of bed raised to 60 degrees. d. Measure bladder with head of bed raised to 90 degrees.

ANS: B Measurement should be within 10 minutes of voiding. It is a postvoid so the measurement is after the patient voids and the urine volume is recorded. Patient is supine with head slightly elevated.

19. A nurse is working to prevent blindness. Which preventive action is a priority? a. Screen young adults early for visual impairments. b. Include rubella and syphilis screening in the preconception care plan. c. Instruct parents to report reduced eye contact from their child immediately. d. Administer eye prophylactic antibiotics to newborns within 24 hours after birth.

ANS: B Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases such as rubella, syphilis, chlamydia, and gonorrhea that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible; waiting until children are young adults is too late. Another technique is administering eye prophylaxis in the form of erythromycin ointment approximately 1 hour after an infant's birth. Reporting reduced eye contact is recommended but is not a preventative measure.

3. Which patient is most in need of a nurse's referral to adoption services? a. A woman considering abortion for an unwanted pregnancy b. An infertile couple religiously opposed to artificial insemination c. A woman who suffered miscarriage during her first pregnancy d. An infertile couple who has been attempting conception for 3 months

ANS: B Adoption is an option for someone with infertility, especially if infertility treatments are unavailable owing to religious or financial constraints. A patient who wishes to have an elective abortion may be educated about all the possibilities, but the nurse should approach the patient in a nonjudgmental manner and should accept the patient's decision. When a patient has recently miscarried, the nurse should assess the patient's feelings about the loss and should address any concerns the patient may have about fertility. Infertility is the inability to conceive after 1 year of unprotected intercourse; therefore, talking about adoption after one miscarriage or after only 3 months of attempting conception would be too soon.

1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. "The patient is angry about the dementia diagnosis." b. "The patient is losing sphincter control due to the dementia." c. "The patient forgets where the bathroom is located due to the dementia." d. "The patient wants to leave the hospital."

ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

11. The nurse is leading a seminar about menopause and age-related changes. Which response from a group member indicates the nurse needs to follow up? a. "Hormones of sexual regulation decrease with aging." b. "Orgasms are no longer achievable after menopause." c. "The excitement phase is prolonged as we age." d. "As men age, their erection may be less firm."

ANS: B Believing that orgasms are no long achievable requires follow-up to correct this misconception. Orgasms are achievable at any age; however, it may take longer with aging. All other statements indicate that the patient does have an understanding of age-related changes and needs no follow-up. Both genders experience a reduced availability of sex hormones. The excitement phase prolongs in both men and women. Men often have erections that are less firm and shorter acting.

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." b. "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." c. "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" d. "I see now why when my child has a cold, he complains about everything tasting blah!"

ANS: B Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

2. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? a. Speak with the patient's family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.

ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

18. The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates success full earning? a. Asks the nurse to test the temperature of the water before entering the bath. b. Places colored stickers on faucet handles to indicate temperature. c. Replaces all lace-up shoes with Velcro straps for ease. d. Uses a heating pad on a low setting to keep warm

ANS: B If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold," or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population. Asking the nurse to test the water does not promote independence, although it does promote safety. Velcro is easier for a patient with a tactile deficit to manipulate and promotes self-care but not safety.

9. A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes on her labia. The patient is distraught because her partner must have cheated on her.Which response by the nurse is most effective in establishing an open rapport with a patient? a. Share a story. b. Inform the patient that all encounters are confidential. c. Encourage the patient to break up with her partner for cheating. d. Tell the patient that she must be honest about every sexual experience she has had.

ANS: B If open communication is to be established with the patient, the patient must know that she can trust health care team members. By telling the patient that all encounters are confidential, the nurse establishes trust. Sharing a story brings the focus to the nurse, inhibiting open rapport. The nurse does not tell the patient what to do, because that should be the patient's decision. Forcing the patient to confide by sharing every sexual encounter may hinder a trusting relationship.

3. A 37-year-old heterosexual African-American man has come for his annual health screening. Which test must the nurse ensure is ordered for this patient? a. Human papilloma virus (HPV) b. Prostate-specific antigen (PSA) c. HIV d. Venereal disease research laboratory (VDRL)

ANS: B PSA testing is recommended annually for men at increased risk for prostate cancer. This includes men with a family history or those of African-American descent. HPV testing would likely be ordered for patients with genital warts. This might not be necessary for this patient. Tests for HIV should be ordered for patients that belong to high-risk populations, including men who have sex with men, and all pregnant women. All sexually active men and women should have a VDRL and rapid plasma reagin performed.

16. The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift? a. Expressive b. Receptive c. Global d. Motor

ANS: B Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. Global aphasia is the inability to understand language or communicate orally.

13. A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV vaccine? a. Protects against human immunodeficiency virus (HIV) b. Protects against cervical cancer c. Protects against chlamydia d. Protects against pregnancy

ANS: B The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is not effective against HIV, chlamydia, or pregnancy. DIF:Understand (comprehension)REF:719-720 | 728 OBJ: Discuss the nurse's role in maintaining or enhancing a patient's sexual health.

2. A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse's religious and ethical values are strongly opposed. How should the nurse best handle the situation? a. Attempt to educate the patient about the consequences of abortion. b. Refer the patient to a family planning center or another health professional. c. Continue to care for the patient, and limit conversation as much as possible. d. Inform the patient that, because of immoral issues, another nurse will have to care for her.

ANS: B The nurse must be aware of personal beliefs and values and is not required to participate in counseling or procedures that compromise those values. However, the patient is entitled to nonjudgmental care and should be referred to someone who can create a trusting environment. The nurse should not care for a patient if the quality of care could be jeopardized. The nurse should not attempt to push personal values onto a patient. The nurse also should not create tension by informing the patient that he or she does not have the same morals; this could cause the patient to feel guilty or defensive when receiving care from any health care professional.

36. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge inconti b. A patient with reflex incontinence with elevated blood pressure and pulse rate c. A patient with an indwelling catheter that has stool on the catheter tubing d. A patient who has just voided and needs a postvoid residual test

ANS: B The nurse should see the patient with reflex incontinence first. Patients with reflex incontinence are at risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis. This is a medical emergency requiring immediate n intervention; notify the health care provider immediately. A patient with urge incontinence will dribble, and this is expected. While a patient with a catheter and stool on the tubing does need to be cleaned, it is not life threatening. The nurse has 10 minutes before checking on the patient who has a postvoid residual test.

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist

ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

14. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session? a. It is recommended for girls 6 to 9 years old. b. It is recommended for females ages 11 to 26. c. It is recommended that booster injections be given. d. It is recommended to receive four required injections.

ANS: B The vaccine is safe for girls as young as 9 years old and is recommended for females ages 11 to 26 if they have not already completed the three required injections. Booster doses currently are not recommended. The vaccine is most effective if administered before sexual activity or exposure.

27. A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient progress. b. Utilizing the power of suggestion by turning on the faucet and letting the water run. c. Obtaining an order for a Foley catheter. d. Administering diuretic medication.

ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

3. Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.) a. Increasing fluid intake b. Dribbling of urine c. Voiding in small amounts d. Voiding within 6 hours of catheter removal e. Burning with the first couple of times voiding

ANS: B, C Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention. All the rest are normal and do not require follow-up. The patient should increase intake. The first few times a patient voids after catheter removal may be accompanied by some discomfort, but continued complaints of painful urination indicate possible infection. Patient should void 6 to 8 hours after catheter removal.

4. A nurse administers an antimuscarinic to a patient. Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.) a. Decrease in dysuria b. Decrease in urgency c. Decrease in frequency d. Decrease in prostate size e. Decrease in bladder infection

ANS: B, C When newly started on an antimuscarinic, you should monitor the patient for effectiveness, watching for a decrease in symptoms such as urgency, frequency, and urgency urinary incontinence episodes. Patients with painful urination are sometimes prescribed urinary analgesics that act on the urethral and bladder mucosa (e.g., phenazopyridine). Antibiotics are used to treat bladder infections. Agents that shrink the prostate include finasteride and dutasteride.

1. Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Allowing the patient adequate time and privacy to void d. Wearing gown, gloves, and mask for all specimen handling e. Transporting specimens to the laboratory in a timely manner f. Collecting the specimen from the drainage bag of an indwelling catheter

ANS: B, C, E All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Urine cultures can take up to 48 to 72 hours to develop. Only gloves are necessary to handle a urine specimen. Gown and mask are not needed unless otherwise indicated. Never collect the specimen from the drainage bag of a catheter; obtain the sample from the special sampling port.

30. The nurse will anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection

ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear

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

5. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. Which response by the nurse will help establish a trusting relationship? a. "Don't worry. It's just a phase you will grow out of." b. "Those are abnormal impulses. You should seek therapy." c. "At your age, it is normal to be curious about both genders." d. "Having questions about sexuality is normal but if these sexual activities make you feel bad you shoul

ANS: C Adolescents have questions about sexuality. The patient will feel most comfortable discussing his sexual concerns further if the nurse establishes that it is normal to ask questions about sexuality. The nurse can then discuss in greater detail. Although it is normal for young adults to be curious about sexuality, the nurse should use caution in giving advice on taking sexual action. The nurse should promote safe sex practices. Telling the patient not to worry dismisses his concern. Telling the patient that he is abnormal might offend the patient and prevent him from establishing an open relationsh

5. The nurse is caring for a 44-year-old married woman who is complaining of painful intercourse and incontinence due to prolapse of reproductive organs. Clinical evaluation reveals that the patient has a cystocele. Which treatment option is most appropriate for this patient? a. Pelvic floor training b. Vaginal pessaries c. Surgical correction d. Lifestyle changes

ANS: C Depending on the cause, a cystocele can be readily corrected by surgery. Pelvic muscle floor training (Kegel exercises) will most definitely help with symptoms of urinary incontinence. This alone is not adequate treatment for this patient. Vaginal pessaries are an excellent treatment modality for uterine prolapse. Lifestyle changes such as weight loss, avoiding constipation, and reducing high-impact exercise, such as running, will all help the patient with pelvic organ prolapse. Although these modalities will provide relief, they will not correct the cystocele without surgical intervention.

4. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? a. "I will make sure that Dad always wears warm socks." b. "Dad needs to wear his glasses so he can delay the onset of macular degeneration." c. "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." d. "We will give him only warm foods, so that he doesn't burn his mouth."

ANS: C Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one's own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

4. The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV . Which response by the nurse is best? a. "You should have your blood drawn today to see if you were infected." b. "If you have the virus, you will have flu-like symptoms in 6 months." c. "Highly active antiretroviral therapy has been shown effective in slowing the disease process." d. "I will set you up with a support group to help you cope with dying within the next 10 years."

ANS: C Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after the virus is contracted; during that time, the patient may experience flu-like symptoms. A support group may be beneficial for a patient who contracts HIV; however, it is unknown whether the patient has contracted HIV, and antiretroviral therapy has helped people live beyond the 10 years expected if HIV goes untreated.

38. Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? a. Output that is smaller than the amount instilled b. Blood clots or sediment in the drainage bag c. Bright red urine turns pink in the tubing d. Bladder distention with tenderness

ANS: C If urine is bright red or has clots, increase irrigation rate until drainage appears pink, indicating successful irrigation. Expect more output than fluid instilled because of urine production. If output is smaller than the amount instilled, suspect that the tube may be clogged. The presence of blood clots indicates the patient is still bleeding, while sediment could mean an infection or bleeding. The bladder should not be distended or tender; the irrigant may not be flowing freely if these occur, or the tube may be kinked or blocked.

8. A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan? a. Risk for falls b. Self-care deficit c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall risk are physiological risks for the patient.

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas

ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Set your alarm clock to wake you every 2 hours, so you can get up to void." b. "Line your bedding with plastic sheets to protect your mattress." c. "Drink your nightly glass of milk earlier in the evening." d. "Empty your bladder completely before going to bed."

ANS: C Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination but will not affect urine produced throughout the night from late-night fluid intake.

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

ANS: C Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

31. A nurse is evaluating a nursing assistive personnel's (NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene? a. Emptying the drainage bag when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Securing the catheter tubing to the patient's thigh

ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the rest are correct procedures and do not require follow-up. The drainage bag should be emptied when half full; an overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra and/or urinary meatus and increasing risk for urinary tract infections. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.

3. A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit? a. The patient frequently cleans out eyes with saline washes. b. The patient applies different spices during mealtime to food. c. The patient turns one ear toward the nurse during conversation. d. The patient isolates self from social situations with groups of people.

ANS: C Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive.

15. A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene? a. "Avoiding alcohol use will enhance your sexual functioning." b. "You need to tell your partner how you feel about sex and any fears you may have." c. "You do not need to worry about getting a sexually transmitted infection at this point in your life." d. "Using pillows and taking pain medication if needed before having sexual intercourse often help alleviate improve sexual functioning."

ANS: C Research indicates many older adults are more sexuality active than previously thought and engage in high-risk sexual encounters, resulting in a steady increase HIV and STI rates over the past 12 years. Therefore, the nurse needs to intervene when the student tells the older adults that they are not at risk for developing an STI. Avoiding the use of alcohol; using pillows; taking pain medications before having intercourse if needed; and communicating thoughts, fears, and feelings about sex all enhance sexual functioning.

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient's visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.

ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a "Do not disturb" sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate? a. Call for security to remove the surgeon. b. Allow the surgeon to enter. c. Firmly explain that the patient does not wish to have visitors at this time. d. Scold the surgeon for not obeying the sign and respecting the patient's wishes.

ANS: C The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the surgeon to leave regardless of position in the hospital. A creative solution to decrease excessive environmental stimuli that prevents restful, healing sleep is to institute "quiet time" in ICUs. Data collected from one hospital that implemented 1 hour of quiet time daily found decreased staff and unit noise and improved patient satisfaction. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle the situation with professionalism when addressing the surgeon; scolding the visitor is not appropriate.

7. A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal secretions. The nurse suggests using water-soluble lubricants. Which component of PLISSIT is the nurse using? a. P b. LI c. SS d. IT

ANS: C The nurse is using the specific suggestions (SS). The PLISSIT model is as follows: Permission to discuss sexuality issuesLimited Information related to sexual health problems being experienced Specific Suggestions—only when the nurse is clear about the problem Intensive Therapy—referral to professional with advanced training if necessary

4. The school nurse is developing a curriculum for a junior human sexuality class. In order to provide the most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy for preventing sexually transmitted infections (STIs)? a. A vaccine to prevent HPV infection b. HIV screening c. Abstinence d. The male condom

ANS: C The single most effective (100%) way to prevent sexually transmitted infections is abstinence. When used correctly, the male condom is an effective method for preventing sexually transmitted infections as well as being a very highly effective contraceptive agent. A significant primary prevention strategy is the recent introduction of a vaccine used to prevent cervical cancer and genital warts caused by HPV. One of two FDA-approved vaccines should be routinely administered to 11- and 12-year-old girls and can be given up to the age of 26. HIV screening is recommended for all sexually active teens by the Centers for Disease Control and Prevention. Screening for existing infection is a secondary prevention strategy. By educating teens towards behavior change related to high-risk behaviors, nurses may be able to reduce the risk for contracting sexually transmitted infections.

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient? a. Administer an opioid medication to help the patient sleep. b. Keep the door open during the night. c. Open the shades at night. d. Provide the patient with earplugs.

ANS: D Control of excessive stimuli becomes an important part of a patient's care; earplugs provide relief. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors. Allow patients to shut their room door to decrease noise. Opioid medications (for pain relief) should not be the first option; however, antianxiety medications and sleep aids may be considered.

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

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

1. A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp? a. The child's sensation is intact. b. The child's reception is intact. c. The child's perception is intact. d. The child's reaction is intact.

ANS: C When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. Reaction is how a person responds to a perceived stimulus.

1. Which statements related to sexual dysfunction are correct? (Select all that apply.) a. Biological factors play a more significant role than psychologic factors. b. Sexual dysfunction is more prevalent among men than women. c. The best predictor of sexual health is emotional well-being. d. The patient with sexual dysfunction is at risk for anxiety and depression. e. Sexual dysfunction remains uncommon.

ANS: C, D The best predictor of sexual health is emotional well-being rather than the impairment of the physical aspects of sexual arousal and function. Nurses must remain cognizant that sexual dysfunction, regardless of the cause, is likely to result in a number of negative consequences including anxiety, stress, and depression. Although sexual arousal may be diminished by biological factors such as illness and hormone levels, psychologic factors such as anxiety, mood disorders, or stress play a more significant role in sexual health. Sexual dysfunction is more common in women, with 40 to 45% of women reporting symptoms as opposed to 20 to 30% of men. It appears that sexual dysfunction is very common among the general population, with rates varying from 20 to 50%.

5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall

ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time consuming to acquire and requires a trained/skilled dietary interviewer.

2. In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse? a. A recently divorced 50-year-old woman b. A Hispanic teenage girl c. A 30-year-old African-American male d. An individual with intellectual or developmental disabilities

ANS: D As more of these individuals move into mainstream society, it is important that sexual health is promoted, including teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual abuse. In today's society, the newly unpartnered are likely to begin dating and acquire one or more new sexual partners. This group is at significant risk for exposure to sexually transmitted infections and requires health teaching related to safer sexual practices. The Hispanic teenage girl is at increased risk for unintended teen pregnancy. Adolescent pregnancy puts an undue burden on the young woman during a crucial period of growth and development. Hispanic teens experience double the rate of pregnancy of Caucasian adolescents. Major health disparities continue to exist between African-Americans and their Caucasian counterparts—in particular a significantly increased risk for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases.

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

ANS: D Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. Goals and outcomes need to be realistic and measurable; recovery in 1 day is not realistic. A patient who has expressive aphasia may not be able to speak or write words with a pen and paper. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

3. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response? a. "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." b. "Notify your doctor immediately, because this is a concerning reaction to the medication." c. "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." d. "You should see an improvement in the next week or so. Call if this continues."

ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

2. The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. "This will help us to identify your baby's risk for ear infections the first year of life." b. "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." c. "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." d. "Imitation of sounds is the first step in language development, and it is important to identify alterations early."

ANS: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby's response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

5. What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing

ANS: D Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

21. The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide? a. Store in a warm lit space. b. Use massage oils for lubrication. c. Rinse and reuse the condom if needed. d. Hold onto the condom when pulling out.

ANS: D Teach patients to pull out right after ejaculating and to hold onto the condom when pulling out. Store condoms in a cool, dry place away from sunlight. Instruct patient to never reuse a condom or use a damaged condom. Instruct patient to only use water-based lubricants (e.g., K-Y jelly) to prevent the condom from breaking; do not use petroleum jelly, massage oils, body lotions, or cooking oil.

12. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the ostomy is physically unattractive. Which initial nursing intervention will be most effective in helping this patient resume sexual activity? a. Inform the patient about a support group for people with colostomies. b. Reassure the patient that lots of people resume sex the same week the colostomy is placed. c. Teach the patient about intimate activities that can be done to incorporate the ostomy. d. Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy.

ANS: D The nurse should first address the patient's need to be comfortable with his or her own body image; once the patient's issues related to body image are resolved, intimacy may follow. Reassuring the patient that others manage to have sexual intercourse with an ostomy may help to decrease anxiety but may have the unintended effect of making the patient feel abnormal because he or she has not yet resumed sexual activity. Support groups may be helpful for the patient, but this is not the most effective initial intervention a nurse can provide; this may be helpful later. The patient is worried about the ostomy; incorporating it into intimate activities is insensitive and can even be damaging to the stoma.

26. A nurse is watching a nursing assistive personnel (NAP) perform a post void bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up? a. Palpates the patient's symphysis pubis b. Wipes scanner head with alcohol pad c. Applies a generous amount of gel d. Sets the scanner to female

ANS: D The nurse will follow up if the NAP sets the scanner to female. Women who have had a hysterectomy should be designated as male. All the rest are correct and require no follow-up. The NAP should palpate the symphysis pubis, the scanner head should be cleaned with an alcohol pad, and a generous amount of gel should be applied.

1. A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a. Normal in the older adult b. A need for the patient to be evaluated for cognitive impairment c. A side effect of anti-hypertensive medication d. Pathologic impairment of sensory responses

ANS: D This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

2. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. "Your weight is within normal limits. Continue maintaining with current lifestyle choices." b. "You are a little overweight. Cut down on calories and increase your activity, and you should be fine." c. "You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery." d. "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

ANS: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.

29. A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a. Hold the shaft of the penis at a 60-degree angle. b. Hold the shaft of the penis with the dominant hand. c. Cleanse the meatus 3 times with the same cotton ball from clean to dirty. d. Cleanse the meatus with circular strokes beginning at the meatus and working outward.

ANS: D Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the nondominant hand (now contaminated), retract the foreskin (if uncircumcised) and gently grasp the penis at the shaft just below the glans. Hold the shaft of the penis at a right angle to the body.

9. During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit

ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. Neurological deficits include peripheral neuropathy and stroke. Visual deficits include presbyopia, cataracts, glaucoma, and macular degeneration. Hearing deficits include presbycusis and cerumen accumulation.

2. When conducting a health history assessment, the nurse would want to know what most important information about the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting

NS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

6. During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein

NS: C Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.