Module 5 and 6, EAQs

A male patient who has heard numerous horror stories about prostate diseases comes to the primary health care provider's office for a routine examination. What would be the best advice the nurse can offer the patient to address concerns? O "A blood test and examination can be used to diagnose prostate problems." O all men will have a prostate disease after the age of 75 O don't worry; if yo have a prostate problem, you'll know it O wait until there's problem and then seek medical treatment

"A blood test and examination can be used to diagnose prostate problems."

Which statement by the nurse about the effects of alcohol indicates effective learning?

"Alcohol affects the frontal cortex, which governs self-control."

Which statement by the nurse about the effects of alcohol indicateseffective learning? O Alcohol does not affect hunger, thirst, and sexual desire. O Alcohol heightens judgment and feelings of pleasure. O "Alcohol affects the frontal cortex, which governs self-control." O Rapid and large-quantity consumption of alcohol causes death."

"Alcohol affects the frontal cortex, which governs self-control." Rationale Alcohol is a central nervous system depressant affecting the higher centers of the brain, such as the frontal cortex. As a result, the patient loses self-control. Alcohol affects the nucleus accumbens in the limbic system, which regulates hunger, thirst, and sexual desire. The patient's judgment is blocked and the memory of pleasure is retained after consuming alcohol. Rapid and large quantity consumption of alcohol can lead to unconsciousness and affect respiration. Death can occur only due to acute alcohol. poisoning.

A nurse is talking with the mother of an 8-year-old child who expresses concern that her child is more focused on friends than anything else. Which is the most appropriate response? O "You need to be concerned" O "Monitor your child's behavior very closely" O "At this age, the child is developing his own personality." O "YOu need to give more praise to your child to stop this behavior"

"At this age, the child is developing his own personality."

The nurse is teaching various health promotion strategies to a group of elderly people in a community. What information does the nurse include in the teaching plan? Select all that apply. O "Drink 1500 mL of fluids per day." O "Get an influenza vaccination once a year." O Remove excess furniture from your home O social contact is beneficial O you only need to get out of the house once per week

"Drink 1500 mL of fluids per day." "Get an influenza vaccination once a year." Remove excess furniture from your home social contact is beneficial

The parents ask the nurse why their alcohol-addicted adolescent is prescribed disulfiram (Antabuse) during the rehabilitation phase. Which is the best response by the nurse?

"It will encourage abstinence from alcohol consumption."

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning?

"Nicotine gum will help decrease nicotine dependence."

Which question by the nurse is best to help identify a patient's addictive behavior pattern during an assessment?

"What do you do to relieve stress?"

The nurse is assessing a child's speaking abilities and understands the telegraphic speech of the child. What could be the age of the child that the nurse is assessing? O 5 years old O 1-year-old O 3 years old O 7 years old

1-year-old

Reducing Sudden Infant Death Syndrome

1. Back to sleep, 2. Avoid exposure to cigarette smoke 3. Avoid the use of soft bedding or pillows 4. Keep the room well ventilated 5.Breast-feed if possible 6. Maintain regular medical checkups for infants

A 59-year-old homeless man is admitted with diagnoses of hypothermia and pneumonia. The nurse notes that the patient is malnourished and has multiple ecchymotic areas on his arms and legs. The nurse also notes the odor of alcohol coming from the patient. In addition to being alert to the consequences of hypothermia and pneumonia, to which other signs and symptoms should the nurse be alert during her shift? 1 Rebound hyperthermia and burn injuries to skin 2 Decreasing level of consciousness and bradypnea 3 Tremors, diaphoresis, disorientation, and restlessness 4 Dyspnea, hypotension, bounding pulse, and urinary retention

3 Tremors, diaphoresis, disorientation, and restlessness

The nurse is caring for a patient injured in a car crash. The patient is manifesting signs of major alcohol withdrawal syndrome. Which symptoms will be seen in the patient? Select all that apply. 1 Sweating 2 Nausea 3 Visual hallucinations 4 Gross tremors 5 Seizures

3 Visual hallucinations 4 Gross tremors 5 Seizures

A patient has been admitted to the medical-surgical unit with a concussion and a fractured clavicle after a motor vehicle accident. When viewing the electronic medical record, the nurse notes that the patient had positive results for blood and urine alcohol, despite the patient reports of not having any problems with drugs or alcohol. Which explanation is the rationale for the patient's statements? 1 The patient is trying to avoid a ticket. 2 The patient is lying to avoid embarrassment. 3 A concussion can distort, alter, or eliminate parts of memory. 4 Denial is the predominant defense mechanism of substance abusers.

4 Denial is the predominant defense mechanism of substance abusers.

A nurse has been assigned a patient who abuses alcohol. The patient is at risk for delirium tremens (DTs). In monitoring the patient, which signs would alert the nurse to the development of DTs? 1 Stupor, severe agitation, muscle rigidity 2 Hypotension, ataxia, persistent vomiting 3 Hypotension, coarse hand tremors, agitation 4 Elevated temperature, hallucinations, and agitation

4 Elevated temperature, hallucinations, and agitation

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? O A client incontinent of urine and feces O A client with chronic nutritional deficiencies O A client with a lowered mental awareness status O A client who is unable to move about and is confined to bed

A client with a lowered mental awareness status

Which processes does the nurse teach a patient with anxiety due to depression to encourage positive emotional growth? Select all that apply.

Adaptive mechanisms to deal with stress Using coping mechanisms to deal with anxiety

Which concept do the four elements of excessive use or abuse—display of psychological disturbance, decline of social and economic function, and uncontrollable consumption indicating dependence—define?

Addiction

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

Administer an opioid analgesic last taken 6 hours ago.

Which term best describes the external manifestation of inner feelings or emotions that is often reflected by one's facial expressions?

Affect

After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

Ambulation three times daily

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?

Apply cold compresses to the affected area.

After assessing a patient with alcohol abuse, the nurse observes severe withdrawal symptoms and cravings. Which drugs would the nurse anticipate being prescribed by the healthcare provider? Select all that apply. O Naltrexone (ReVia) O Atenolol (Tenormin) O Conidine (Catapres) O Acamprosate (Campral) O Carbamazepine (Carbatrol)

Atenolol (Tenormin) Conidine (Catapres) Rationale Beta blockers such as atenolol (Tenormin) and alpha agonists such as clonidine (Catapres) may reduce cravings and decrease the severity of withdrawal symptoms in a patient suffering from severe alcohol abuse Naltrexone (ReVia) and acamprosate (Campral) are mainly prescribed to prevent relapse in patients with alcohol abuse. Carbamazepine (Carbatrol) is used to decrease seizure frequency and some of the psychiatric symptoms associated with alcohol withdrawal

A frustrated father asks the nurse what can be done for a child who is independent, wants to do things his own way, and is constantly using the word "no." According to Erikson's stages of psychosocial development, which stage should the nurse explain the child experiencing? O Basic trust versus mistrust O Autonomy versus shame and doubt O initiative versus guilt O Identity versus role confusion

Autonomy versus shame and doubt

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition?

Blistering skin

"Self" is a complex concept comprising four distinct parts that influence behavior. Which part includes feeling about the way one's body functions?

Body image

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash

CAGE screening

C: Have you ever felt you ought to CUT down on drinking? A: Have people ANNOYED you by criticizing your drinking? G: Have you ever felt bad or GUILTY about your drinking? E: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (As an EYE OPENER)

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair

A nurse is caring for an 88-year-old patient with extremely fragile skin. What interventions would the nurse place on the nursing care plan to provide the best protection for the skin? O Wash with mild soap O Change positions frequently O Apply lotion once daily O Provide adequate clothing for protection

Change positions frequently

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk

Physical Activity Guidelines & Recommendations

Children • 60 minutes or more daily Adults •150 minutes/week •Moderate intensity •Brisk walking •75 minutes vigorous intensity •Running or jogging •Include muscle strengthening 2x/week •Weight bearing exercise

Which drug would be administered to decrease tremors and agitation in patients with opioid toxicity? O Naloxone (Narcan) O Clonidine (Catapres) O Atenolol (Tenormin) O Buprenorphine (Subutex)

Clonidine (Catapres) Rationale Opioid agonists such as clonidine (Catapres) are administered to decrease tremors and agitation in patients with opioid toxicity. Naloxone (Narcan) is used to prevent buprenorphine (Subutex) abuse. Atenolol (Tenormin) is used to reduce alcohol cravings and withdrawal symptoms. Buprenorphine (Subutex) is prescribed for opioid maintenance therapy.

Which drugs can be prescribed to a patient with an alcohol-related disorder who is seeking treatment for withdrawal symptoms? O Naltrexone O Disulfiram O Clorazepate O Acamprosate

Clorazepate Rationale Clorazepate is a benzodiazepine that is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Naltrexone is an opioid antagonist that is prescribed to block pharmacologic effects associated with opioids and alcohol. Disulfiram reduces the desire for alcohol by inducing nausea and vomiting. Acamprosate helps patients maintain abstinence from alcohol.

The nurse is assigned to care for a client with herpes zoster. Which characteristics should the nurse expect to note when checking the lesions of this infection?

Clustered skin vesicles

While examining the medical record of a patient diagnosed with a diabetic foot ulcer, the nurse notes that the patient has a diagnosed history of both alcohol and opiate abuse. The patient summons the nurse and complains that the pain medication administered 2 hours ago is "wearing off" and another dose, or perhaps a stronger medication, is needed. The nurse recognizes that pain management may be complicated by prior substance abuse. The patient's medication has been prescribed to be given every 4 hours as needed (prn). Which action by the nurse would be most appropriate? O Collecting thorough data regarding the patient's pain O Telling the patient that 2 hours is not that long and will pass quickly O Searching the prn medication prescriptions for an anxiolytic agent to help calm the patient O Notifying the health care provider to request an additional or stronger dose of pain medication

Collecting thorough data regarding the patient's pain Rationale Before contacting the provider, the nurse should collect thorough and complete data regarding the patients complaints of pain. Careful assessment of pain and observation of drug-seeking behavior are necessary for persons with a history of addiction: Dismissing the patient's complaint or telling the patient to wait are not acceptable approaches for pain management. Notifying the health care provider is indicated, but not until more information has been obtained. Administering an anxiolytic for a nonprescribed use is unacceptable.

Which symptoms are likely to be observed in a patient with severe cocaine intoxication? Select all that apply. O Coma O Hallucination O Hyperpyrexia O Tonic-clonic seizures O Depression with suicidal ideation

Coma Hyperpyrexia Tonic-clonic seizures Rationale Severe intoxication with cocaine may lead to coma and death. The patient may also experience hyperpyrexia, tonic-clonic seizures, and respiratory depression Hallucinations are observed in patients with alcohol intoxication. Depression with suicidal ideation is associated with cocaine withdrawal, not intoxication.

Which subjective data does the nurse collect while assessing a patient with substance abuse? Select all that apply.

Complaints of nausea or pain The patient's drinking pattern The date and time of last drink

Which subjective data does the nurse collect while assessing a patient with substance abuse? Select all that apply. O Presence of tachycardia O Complaints of nausea or pain) O The patient's drinking pattern: O The date and time of last drink O Presence of small scabs on the forearms

Complaints of nausea or pain) The patient's drinking pattern: The date and time of last drink Rationale The nurse should assess subjective data, such as complaints of nausea or pain, because it will help to understand if there are any coexisting diseases. The patient's drinking pattern, as well as the date and time of the last drink, helps the nurse understand the severity of the addiction. The presence of tachycardia is objective data; it can be quantified and easily understood by the nurse without the patient's explanation. The presence of small scabs on the forearms indicate intravenous drug use, which is an objective datum.

A patient tells a nurse that he must walk around the table four times before he eats any meal; otherwise he will get sick. Which clinical symptom would the nurse document in the patient record?

Compulsion

The nurse is caring for a patient who reports, "I am not feeling well, but I do not want to consult my health care provider because I don't want to hear bad news." Which issue does the nurse suspect in the patient?

Conflict

The licensed practical/vocational nurse (LPN/LVN) notices that the new nurse is the only nurse who administers pain medications to several of the patients during the night shift. During the medication pass, the LPN/LVN asks one of the patients about pain experienced during the night. The patient states that she has not had any pain at night for a long time. Which action by the LPN/LVN would be appropriate?

Contacting the nursing supervisor and relating any suspicions

The licensed practical/vocational nurse (LPN/LVN) notices that the new nurse is the only, nurse who administers pain medications to several of the patients during the night shift. During the medication pass, the LPN/LVN asks one of the patients about pain experienced during the night. The patient states that she has not had any pain at night for a long time. Which action by the LPN/LVN would be appropriate? O Contacting the nursing supervisor and relating any suspicions O Confronting the night shift nurse during the next day's narcotic count O Keeping the information private because there is no proof it's true O Telling all of the other nurses on the day and evening shifts so that they can be on the lookout

Contacting the nursing supervisor and relating any suspicions Rationale It is important for nursing colleagues to report suspected medication diversion or dependency, it is the duty of every nurse to uphold the standards of the profession. Reporting suspicions to the nursing supervisor would meet the obligation. Confronting an addicted nurse is not likely to stop diversion and does not meet the professional obligation. Reasonable suspicion is adequate to support reporting Proof of diversion is not required. Subsequent investigations by administrative staff or legal authorities can establish proof. Telling other nurses does not meet the professional obligation and may result in unexpected negative consequences.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? O Rubbing the application into the skin O Placing the area under a heat lamp for 20 minutes O Applying a dry sterile dressing over the affected area O Covering the application with a warm, moist dressing and an occlusive outer wrap

Covering the application with a warm, moist dressing and an occlusive outer wrap

The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion

The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?

Darken the room for the examination.

adolescence pt 2

Daydreaming can be developmentally appropriate and a useful safety valve for strong emotions. . By middle adolescence, career goals may become more practical and realistic. • In late adolescence, moral principles are based on the adolescent's own beliefs. Culture plays a role in how adolescents think and interact, and traditions can help stabilize identity. • It is important to allow adolescents to begin to behave independently and to make their own decisions. Peer groups have a major impact on the social and emotional growth and development of adolescents. • In late adolescence, intimacy with a peer can be sexual, intellectual, or social. • Effective health education and care include availability, visibility, high quality, confidentiality, affordability, and flexibility.

Which domains are the id responsible for? Select all that apply. Demand for constant gratification O Reducing tension and increasing pleasure O Formation of ideals O Striving for perfection O Determining decisions about how to act

Demand for constant gratification Reducing tension and increasing pleasure

A patient with type 2 diabetes and a blood sugar level of 415 is eating candy bars and drinking soda. The nurse identifies this as an example of which defense mechanism?

Denial

A patient who has just been sexually assaulted has come to the emergency department and is very calm and quiet. The nurse identifies this behavior as part of which defense mechanism? O Denial O Projection O Suppression O Rationalization

Denial Rationale Denial is a response by victims of sexual abuse. Reality is denied; it does not exist. Suppression is the intentional exclusion of painful thoughts, experiences, or impulses. Rationalization is a process of constructing plausible reasons to explain and justify one's behavior. Projection is blaming personal shortcomings on someone else.

Which assessment does finding indicate to the nurse that a patient is experiencing withdrawal from long-term use of dextroamphetamine (Dexedrine)? O Depression O Hypopyrexia O Hyporeflexia O Decreased respirations

Depression Rationale Depression, fatigue, lack of energy, loss of memory, and inability to manipulate information are symptoms of withdrawal from the amphetamine stimulant dextroamphetamine (Dexedrine). Respirations may increase with withdrawal from dextroamphetamine (Dexedrine). Hyperreflexia and hyperpyrexia, not hyporeflexia and hypopyrexia, may occur with withdrawal from dextroamphetamine (Dexedrine)

The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure?

Discontinue the prescribed antihistamine 2 days before the test.

A patient is having trouble abstaining from alcohol. Which drug is often prescribed to encourage abstinence?

Disulfiram

The nurse documents that a patient who is restricted from physical activity is using denial as a defense mechanism. Which patient behavior led the nurse to this conclusion?

Doing sit-ups and push-ups

Which nurse is credited as developing mental hospitals throughout the United States in the 19th century?

Dorothea Dix

While teaching a group of older adults at the senior center, the nurse encourages which health-promoting behaviors? Select all that apply. O Maintain a sedentary lifestyle O Use herbal remedies to prevent Alzheimer's diease O Eat a low-cholesterol diet O Have regular medical checkups O Take medications as prescribed by the primary health care provider

Eat a low-cholesterol diet Have regular medical checkups Take medications as prescribed by the primary health care provider

While assessing a female patient, the nurse finds that the patient has been prescribed an estrogen supplement. Which symptoms does the nurse expect to find in the patient? Select all that apply. O Swollen neck O Edema O Sweating during the night O Excess hair growth O clubbing of the fingernails

Edema Sweating during the night

A nurse is caring for an older adult resident in a long-term care facility. While the nurse is talking with this resident, the older adult reminisces about life, family, and career accomplishments. Based on Erickson's stages, you know this resident is in which stage of development? O Ego integrity versus despair O Intimacy versus isolation O identity versus role confusion O Generativity versus stagnation

Ego integrity versus despair

The nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg in which position?

Elevated and immobilized

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg

The nurse is caring for a patient who reports having an illness every time his child leaves town to go on vacation. Which defense mechanism is the patient displaying? O Emotional conflict O Threat to self-concept O Frustration due to stress O Moderate level of anxiety

Emotional conflict Rationale The sick role often produces secondary gains as well as personal attention. A patient who becomes very ill every time the child plans a trip out of town, or a person who obtains renewal of disability benefits because the injury flares up when reevaluation is scheduled, are examples of patients seeking secondary gains. Secondary gains are sometimes used as a ploy to manipulate and cope with various emotional conflicts. Threats to self-concept, frustration due to stress, and moderate anxiety do not produce secondary gains

Which nursing intervention to help a patient with cancer frequently experiencing episodes of stress and depression is best? O Encourage the patient to develop adaptive patterns of behavior. O Encourage the patient to avoid events that may cause stress. O Offer the patient as much flexibility in visiting hours as possible. O Use therapeutic communication techniques, such as active listening.

Encourage the patient to develop adaptive patterns of behavior. Rationale The stress of being ill greatly influences a person's emotional well-being and coping ability. A person's reaction to a stressor can greatly affect the stress response. The nurse can serve as a resource in helping the patient develop adaptive patterns of behavior, which, in turn, reduce stress and depression. Developing adaptive patterns of behavior is more beneficial than avoiding stressors because this is not possible in daily life. Offering flexible visiting hours to patients' relatives is an effective intervention in helping patients who are going through crisis and patients who are dealing with dysfunctional family relationships. Therapeutic communication is a general intervention for all kinds of mental health disturbances.

A 74-year-old woman with stage 3 breast cancer is crying in her room. Which intervention should the nurse perform to help the patient through the grief process?

Encourage venting of feelings.

A young parent brings a toddler to the clinic for a routine checkup. While the nurse is taking the health history, the mother inquires about methods to promote healthy sleeping patterns. What is the best advice the nurse can give the mother? O Enjoy quiet activities such as a story and establish a bedtime ritual. O Allow the toddler to play until exhausted and then prepare for bed O Avoiding daytime naps will cause the toddler to sleep through the night O engage in mommy baby exercises immediately before preparing for bed.

Enjoy quiet activities such as a story and establish a bedtime ritual.

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

Who provided a framework for understanding personality development in terms of task mastery? O Hippocrates O Philippe Pinel O Erik Erikson O Sigmund Freud

Erik Erikson

Which condition is associated with delirium tremens (DTs)?

Excessive alcohol consumption

While caring for a patient, a nurse learns that the patient lives in the same house as the patient's grandparents. Which type of family is this considered? O Nuclear O Blended O Extended O Homosexual

Extended An extended family consists of a nuclear family plus some additional family members living in the same household. A blended family arises when adults remarry and bring together their children from previous marriages. A nuclear family is a unit consisting of biological parents and their offspring. A homosexual family is a family group that includes a same-sex couple:

While caring for a patient, a nurse learns that the patient lives in the same house as the patient's grandparents. What type of family is this considered?

Extended family

A nurse is caring for a patient who has anxiety attacks. Which symptoms would indicate that the patient is experiencing a severe anxiety attack?

Feeling of impending danger

An adolescent has no recollection of any events that transpired after consuming alcohol the previous night. Which drug was most probably added to the adolescent's drink? O Alprazolam O Clonidine O Methadone O Flunitrazepam

Flunitrazepam Rationale Flunitrazepam is a benzodiazepine that causes amnesia and muscle relaxation in the patient. These effects are increased if the patient consumes it with alcohol. Alprazolam is used for the treatment of acute anxiety, Clonidine is used to reduce the withdrawal effects of opioids. Methadone is used to suppress withdrawal symptoms in morphine or heroin addicts.

Which drug gained notoriety in the 1990s, is associated with club drug use, and is often called the "date-rape drug"?

Flunitrazepam (Rohypnol)

Which drug gained notoriety in the 1990s, is associated with club drug use and is often called the "date-rape drug"? O Morphine O Opioid analgesic heroin O Flunitrazepam (Rohypnol) O Gamma-hydroxybutyrate (GHB)

Flunitrazepam (Rohypnol) Rationale Flunitrazepam (Rohypnol) has been misused in many sexual assaults and can have a lethal effect when combined with alcohol GHB, hemin, and morphine are often abused, but they are not considered the date rape drug

According to Piaget, during the adolescent stage of growth and development, an individual's cognitive function reaches maturity. What stage is this considered? O Peroperational O Formal operational O Formal operational thought stage O Concrete operational

Formal operational thought stage

Ulcer Stage 3

Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.

The nurse is caring for a client on transmission-based precautions who has herpes zoster or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply.

Full-thickness skin necrosis can result. Lesions are very contagious when they are fluid-filled blisters. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. To reduce the risk of transmitting the virus to others, keep clients with lesions separated from other clients until lesions have crusted.

A 17-year-old female high school student presents to the emergency room and speaks to the nurse stating that she can't remember anything about a party she attended last night, including whether she was engaged in sexual activity. The nurse asks if the young woman consumed any drinks prepared by someone else at the party. The young woman states that she did. The primary care provider recommends a SANE (Sexual Assault Nurse Examiner) exam. For which medication will the young woman be screened during the exam?

Gamma-hydroxybutyrate (GHB)

A 17-year-old female high school student presents to the emergency room and speaks to the nurse stating that she can't remember anything about a party she attended last night, including whether she was engaged in sexual activity. The nurse asks if the young woman consumed any drinks prepared by someone else at the party. The young woman states that she did. The primary care provider recommends a SANE (Sexual Assault Nurse Examiner) exam. For which medication will the young woman be screened during the exam? O Alprazolam O Gabapentin O Valproic acid O Gamma-hydroxybutyrate (GHB)

Gamma-hydroxybutyrate (GHB) Rationale GHB is a central nervous system depressant that has become the most commonly used substance in drug-facilitated sexual assaults (DFSAs) in the United States. Unconsciousness and amnesia are effects of the drug that make it desirable for use by sexual predators. The drug shows up in urine screens for only 6 to 12 hours after ingestion. Gabapentin and valproic acid are antiepileptics, which cause sedation and are not recognized for use in sexual assaults. Alprazolam is an anxiolytic that may cause some memory problems but is not known to cause amnesia.

A mother is ordering a food tray for a 10-month-old infant in a pediatric hospital. Which food item would the nurse remove from the tray to increase patient safety? O Grapes O Jell-O O Crackers O Yogurt

Grapes

A patient on a neurologic unit is experiencing a decrease in taste and smell distortion. Which intervention, if carried out by the nurse during meals, can assist the patient with neurologic deficits? O Have dietary prepare foods that are very attractive and colorful O Have family members provide all meals O Change the patient's diet to soft or puree O offer liquid nutritional drinks immediately before meals

Have dietary prepare foods that are very attractive and colorful

A student nurse has been assigned to the pediatric clinic. During the assessment, which set of data should the nurse expect to be considered normal when measuring the preschooler's vital signs? O Heart rate 90, respiratory rate 30, and blood pressure 82/64 O Heart rate 80, respiratory rate 23, and blood pressure 110/60 O Heart rate 120, respiratory rate 30, and blood pressure 50/60 O Heart rate 72, respiratory rate 20, and blood pressure 120/70

Heart rate 80, respiratory rate 23, and blood pressure 110/60

When the nurse suspects withdrawal symptoms in a patient, which assessments would take priority? Select all that apply. O Hydration O Nutritional status O Electrolyte balance O Psychiatric symptoms Impairment of attention

Hydration Nutritional status Electrolyte balance Rationale a patient with withdrawal symptoms should be quickly assessed for hydration, nutritional status, and electrolyte balance. These changes are due to prolonged intake of alcohol. Psychiatric symptoms and changes) in air impairment of attention are related to intoxication.

Which signs and symptoms are associated with cocaine withdrawal? Select all that apply. O Hypersomnia O Hallucinations O Unpleasant dreams O Respiratory depression O Increased appetite

Hypersomnia Unpleasant dreams Increased appetite Rationale Hypersomnia, increased appetite, and unpleasant dreams are complaints commonly described by patients going through cocaine withdrawal. Hallucinations are symptomatic of alcohol intoxication. Respiratory depression may be seen in patients with chronic use of cocaine.

The health care provider prescribes blood tests for a patient brought to the emergency room after a motor vehicle accident (MVA), including blood alcohol levels. When reviewing the results, which laboratory results does the nurse note to indicate long-term alcohol abuse? Select all that apply.

Hypoglycemia Increased liver enzymes Abnormal blood protein levels

Erickson trust vs mistrust

If needs are dependably met, infants develop a sense of basic trust

pressure injury diagnoses

Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance

which phrase accurately defines substance abuse? O Use of illegal drugs or alcohol O Regular ingestion of mind-altering chemicals O Dependence on drugs caused by repeated use O Impairment caused by the periodic, purposeful use of chemical substances

Impairment caused by periodic, purposeful use of chemical substances Rationale Substance abuse is best defined as the periodic, purposeful use of a substance that leads to clinically significant impairment. Substance abuse is not limited to illegal drugs or alcohol. Dependence (commonly known as addiction) can develop as a result of repeated substance abuse. Regular ingestion of mind-altering chemicals may not lead to clinically significant impairment, which is a characteristic of substance abuse.

How do you prevent granulation?

In an overgranulated wound, the use of a dressing that promotes granulation should be stopped and changed to one that provides a warm moist environment, reduces overgranulation and promotes epithelialisation, such as a foam dressing.

Which clinical signs of are associated with severe anxiety? Select all that apply.

Increased pulse rate Increased respiration Increased perspiration Increased blood pressure

A parent reports to the nurse, "My child gets upset and won't eat his dinner when he loses in school games." Which stage of Erikson's theory would the nurse correlate the child's activity with? O Basic trust versus mistrust O Intimacy versus isolation O Industry versus inferiority O Autonomy versus shame and doubt

Industry versus inferiority

A nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. Which symptoms would the nurse assess for with regard to tardive dyskinesia?

Involuntary movements of the mouth and tongue

A patient with the attention-deficit disorder has prescribed a drug that may cause abuse. Which withdrawal symptoms may be observed after discontinuation of the drug? Select all that apply. O Anxiety O Insomnia O Lack of energy O Lack of memory O severe depression

Lack of energy Lack of memory Severe depression Rationale Methamphetamine (Desoxyn) can be prescribed to treat attention-deficit disorder. Abrupt discontinuation of methamphetamine (Desoxyn) after long-term use may result in withdrawal symptoms including lack of energy, lack of memory, and severe depression. Anxiety and insomnia are chronic withdrawal symptoms of opioids.

The nurse is teaching a group of student nurses about the biological theories of aging. Which points should the nurse include in the teachings? O Aging is a chronological process and does not depend on lifestyle changes O Lipofuscin is a pigmented material that promotes aging in individuals. O Immunity is reduced with age because the thymus gland increases in size O Changes is elastin in the body can enhance flexibility in the elderly

Lipofuscin is a pigmented material that promotes aging in individuals.

A nurse is instructing a wife about giving heparin injections to her husband. The wife is unable to focus and frequently asks the nurse to repeat instructions. Which degree of anxiety is the wife experiencing? O Mild O Panic O Severe O Moderate

Moderate

Which intervention is a priority while providing care for an addicted patient being treated with chlordiazepoxide?

Monitoring the patient's intake and output

Which signs and symptoms are associated with anxiety? Select all that apply.

Nausea Tremors Increased heart rate

A patient is being evaluated in the emergency room for a possible drug overdose. The nurse notes that the patient is stuporous, has pinpoint pupils, and has severe respiratory depression. The health care provider orders a urine toxicology screen, stat. Which substance does the nurse anticipate receiving a positive result for in the urine screen?

Opiates

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information?

Palms of the hands

A nurse is assisting a patient with dementia. In addition to reality orientation, which intervention would be important to implement in caring for patients with dementia?

Place bed in lowest position.

A new clinic nurse is interviewing a male patient. The patient's chief complaint is constipation. What suggestion should the nurse give to the patient to prevent constipation?

Practice regular toilet habits

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which?

Punch biopsy of the cutaneous lesions

Which condition is associated with delirium tremens (DTS)? O Fetal alcohol syndrome O Overdose of opioid analgesics O Excessive alcohol consumption O Amotivational cannabis syndrome

Rationale Delirium tremens is a psychotic reaction seen in a patient who consumes excessive alcohol and abruptly quits. The patient experiences tremors, panic reactions, and hallucinations; there is a risk of death. Fetal alcohol syndrome is a congenital condition seen in infants due to the maternal consumption of alcohol. during pregnancy. An overdose of opioids will cause respiratory depression, pinpoint pupils, and stupor or coma. Amotivational cannabis syndrome is seen in patients addicted to cannabis, or marijuana.

Which is an important instruction to increase alcohol abstinence in a patient?

Referring to Alcoholics Anonymous (AA)

Which signs and symptoms are associated with morphine (MS Contin) withdrawal? Select all that apply. O Seizures O Rhinorrhea. O Piloerection O Hallucination O Pupillary dilation

Rhinorrhea. Piloerection Pupillary dilation Rationale The signs and symptoms associated with withdrawal of opioids such as morphine (MS Contin) and hydromor phone (Dilaudid) are rhinorrhea, piloerection, and pupillary dilation. Seizures and hallucinations are withdrawal symptoms of alcohol

A patient diagnosed with depression is prescribed fluoxetine. On assessment the nurse finds that the patient has a history of Parkinson's disease as well. Which risks are increased in the patient due to drug interactions?

Serotonin syndrome- occurs when you take medications that cause high levels of the chemical serotonin to accumulate in your body.

Which common behaviors are seen with illness? Select all that apply. O Shock O Anxiety O Acceptance O Forgiveness O Withdrawal O Questioning

Shock Rationale Denial, anxiety, shock, anger, and withdrawal are all common behaviors seen in those with illness. Questioning is often seen during an acceptance phase. Acceptance is usually seen after the patient has come to terms with the reality of the illness. Forgiveness may be seen during an acceptance phase.

During shift change, the evening nurse reports that a patient displays pseudoparkinsonism. Which assessment findings would the nurse document in the patient record to support this nursing report?

Shuffling gait, tremor, rigidity

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? O Oily skin O Silvery-white scaly lesions O Patchy hair loss and round, red macules with scales O The presence of wheal patches scattered about the trunk

Silvery-white scaly lesions

Which condition will be seen in a patient who abuses cocaine by snorting? O Sinusitis O Paranoia O Hemoptysis O Pneumonitis

Sinusitis Rationale The process of snorting cocaine erodes the nasal septum and causes sinusitis. Paranoia is seen in a patient addicted to methylphenidate (Ritalin) for a long time. The caustic chemicals used in cocaine can cause hemoptysis and pneumonitis in patients who smoke cocaine.

What are ways to assess and document a patient's emotional status? Select all that apply.

Speech pattern Content of thought Insight and judgment

During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of which stage of pressure ulcer?

Stage 2 pressure ulcer

Ulcer stage 4

Stage 4 ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone. There is a high risk of infection at this stage.

Which defense mechanism has a positive influence on the person's behavior?

Sublimation

A nurse is caring for an older adult who lives in a long-term care facility on the Alzheimer's unit. Every evening at around 5:00 p.m., the resident becomes increasingly agitated and more confused, lasting throughout the evening. Which behaviour would the nurse document in the patient's record?

Sundowning syndrome

A graduate nurse is caring for a patient with difficulty hearing. Which action would best facilitate patient-nurse interaction? O Speaking loudly O conversing in a quick firm manner O Talking slowly in a low tone O Standing at the patient's side during interaction

Talking slowly in a low tone

The nurse is observing the behavior of schoolchildren from an extended democratic family. The nurse finds that one child clings to the parents every morning before school. What could the nurse understand from the child's behavior? O The child is experiencing stress. O The child is afraid of the parents O One of the parents has died O Child has been adopted recently

The child is experiencing stress.

anxiety

The condition of feeling uneasy or worried about what may happen

While reviewing the medical record of a patient, the nurse finds that the patient's height has decreased compared to the previous year's report. If this reading is accurate, which age group would the patient most likely belong to? O School-age children O The elderly O Adolescent children O The middle-aged

The elderly

A registered nurse is completing a psychosocial component of the nursing care plan. What behavior, if observed, indicates the patient has successfully completed the developmental task of late adulthood? O Refusing to socialize outside of the home O Verbalizing unhappiness with family relationships O Admitting to being unhappy with life choices O The patient has accepted illness and has prepared a will.

The patient has accepted illness and has prepared a will.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? O The return of distal pulses O Decreasing edema formation O Brisk bleeding from the injury site O The formation of granulation tissue

The return of distal pulses

A school nurse asks a group of high school-age students to write down the last time they used alcohol or other illicit substance and to describe O The student who had two glasses of wine with family members at dinner. O The student who drank three cans of beer and vomited at an after-prom party. O The student who had a "puff" of marijuana with an older brother who was home from college. O The student who removed several ounces of vodka from the parents' supply and replaced it with water.

The student who removed several ounces of vodka from the parents' supply and replaced it with water. Rationale The indicator that substance abuse has become a problem or disease appears to be loss of control-in other words, when the desire for the substance exceeds one's ability to resist, even in the face of negative consequences. The teenager who removed several ounces of vodka and replaced the liquid with water is engaging in subterfuge to acquire a substance, which is very likely to be discovered.

Which goals are associated with crisis intervention? Select all that apply. O The victim will have a positive self-image. O The victim's emotional stress will be decreased. O The victim will deny having any suicidal or homicidal ideation. O The nurse will help the victim organize and mobilize resources: O The victim will be educated on relaxation techniques.

The victim's emotional stress will be decreased. The nurse will help the victim organize and mobilize resources: Rationale The goals of crisis intervention include that the victim's emotional stress will be decreased and the nurse will protect the victim; the nurse will help the victim organize and mobilize resources; and the victim will return to precrisis status. Educating the victim on relaxation techniques is not a goal but can be used to achieve the goal of decreasing emotional stress. Suicidal or homicidal ideation is not a goal for crisis intervention. Having a positive self-image is not one of the core goals of crisis intervention.

The nurse observes a loss of appetite in a patient being treated for addiction. Which prescription would most likely be prescribed by the health care provider?

Thiamine

The mother of a teenage girl says that the girl is always trying to dress like her favorite pop star and is not willing to dress normally. Which concept would explain this behavior?

Threat to self-concept

Which occurrence may precipitate feelings of anxiety?

Threats to self-esteem

While counseling the parents of a 2-month-old infant, the nurse informs them, "Babies should always sleep on their backs." Why would the nurse say this?

To prevent sudden death of the infant

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

An older client is complaining of chronic dry skin and occasional pruritus. The nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition?

Using astringents to clean the skin

Which individuals are at greatest risk for abusing their children? Select all that apply. O Abused as a child O Mature O Very strict O No self-control O High self-esteem

Very strict No self-control Abused as a child

Which assessment helps determine a patient's level of anxiety?

Vital signs

A patient is admitted to the substance abuse treatment facility with a diagnosis of heroin addiction and is expected to go into withdrawal within 6 hours. For which signs and symptoms will the nurse monitor the patient? O Bradycardia, hypotension, and hypothermia O Vomiting, cramps, diarrhea, and hypertension O Pinpoint pupils, hypotension, fever, and vomiting O Tachycardia, hypoglycemia, and severe constipation

Vomiting, cramps, diarrhea, and hypertension Rationale Opiate withdrawal signs and symptoms in people addicted to heroin typically begin about 6 hours after the last dose and include vomiting, cramps, diarrhea, hypertension, flulike signs and symptoms, dilated pupils, watery eyes, runny nose, chills, fever, and diaphoresis. Pinpoint pupils are associated with acute opioid overdose. Hypotension, bradycardia, hypothermia, severe constipation, and hypoglycemia are not symptoms of acute opiate withdrawal.

A patient is being discharged from the psychiatric unit with a prescription for an antipsychotic. Which information should the nurse educate the patient about before discharge?

Wear sunscreen and sunglasses when outside.

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which? A rash Dermatitis Reddened skin Weeping of the skin

Weeping of the skin

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? O A pink edematous hand O Red skin with edema in the nail beds O White skin that is insensitive to touch O Black fingertips surrounded by an erythematous rash

White skin that is insensitive to touch

A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient, knowing that tremors from alcohol cessation are usually seen how long after cessation?

Within 6 hours

5. Which social group form is typical during the teenage years? a. Cliques b. Same-sex peers c. Heterosexual peers d. Parallel groups

a. Cliques

3. Which method of contraception, if used properly, can prevent the transmission of sexually transmitted diseases? a. Condoms b. Birth control pills c. Intrauterine devices d. Spermicides

a. Condoms

2. A major developmental task of middle childhood includes: a. developing positive self-esteem and a positive self-image. b. eruption of permanent teeth. c. ability to play video games. d. prevention of injury.

a. developing positive self-esteem and a positive self-image.

5. In early childhood the best disciplinary technique includes: a. rewarding good behavior. b. punishing bad behavior. c. setting rigid, structured rules. d. posting rules on the refrigerator door.

a. rewarding good behavior. b. punishing bad behavior.

1. Tasks to be mastered during early childhood include: a. walking. b. bowel control. c. abstract thinking. d. visual maturity.

a. walking. b. bowel control. d. visual maturity.

4. A women's fertile period occurs: a. 14 days after the last menstruation. b. 14 days before the beginning of the next menstruation. c. midway between menstrual periods. d. right after menstruation ceases.

b. 14 days before the beginning of the next menstruation.

1. The period of infancy occurs between: a. birth and 1 month. b. 4 weeks and 1 year. c. 1 and 3 years. d. 1 and 12 years.

b. 4 weeks and 1 year.

1. Middle childhood includes children between the ages of: a. 3 and 5 years. b. 6 and 12 years. C. 13 and 15 years. d. 16 and 19 years.

b. 6 and 12 years.

3. Separation anxiety typically begins at what age? a. 3 months b. 6 months c. 1 year d. 2 years

b. 6 months

2. A 1-year-old who regards all toys in relation to his or her own body is exhibiting which type of behavior? a. Dysfunctional b. Selfish C. Sexual d. Egocentric

b. Selfish

3. The type of play activities typical in the middle-childhood age group include: a. parallel play. b. competitive games. c. solitary play. d. reading and fantasy.

b. competitive games.

4. By 9 months of age, a pincer action is well developed, enabling the infant to: a. increase locomotion. b. grasp small objects with the thumb and forefinger. c. scoop up toys within reach. d. achieve increased depth perception.

b. grasp small objects with the thumb and forefinger.

4. The Wechsler intelligence test is used to determine: a. the overall intelligence of the child. b. verbal and nonverbal intelligence. c. presence of mental retardation. d. whether the child has college potential.

b. verbal and nonverbal intelligence.

2. The toddler-age child is in Erikson's stage of: a. trust versus mistrust. b. initiative versus guilt. c. autonomy versus shame and doubt. d. identity versus role confusion.

c. autonomy versus shame and doubt.

separation anxiety

emotional distress seen in many infants when they are separated from people with whom they have formed an attachment

pincer action

enables the infant to grasp with the thumb and finger 9 months

Teeth in the infant

first 20 decidious teeth (baby teeth) begin at 5 to 7 months

Cephalocaudal

head to toe

defense mechanisms

in psychoanalytic theory, the ego's protective methods of reducing anxiety by unconsciously distorting reality

The parents ask the nurse why their alcohol-addicted adolescent has prescribed disulfiram (Antabuse) during the rehabilitation phase. Which is the best response by the nurse? O "It will have a calming effect. O It will help increase appetite." O "It will prevent the risk for seizure activity" O it will encourage abstinence from alcohol consumption."

it will encourage abstinence from alcohol consumption." Rationale If the patient consumes alcohol during treatment with disulfiram (Antabuse), there is facial flushing, nausea, tachycardia, dyspnea, dizziness, and confusion. The patient is encouraged to abstain from alcohol consumption. Disulfiram (Antabuse) does not have a calming effect on the patient but causes distress if alcohol is consumed. Multivitamins and thiamine (Vitamin B) are used to increase the patient's appetite. Phenytoin (Dilantin) is an anticonvulsant medication used to treat seizures in an addicted patient.

Ulcer stage 1

nonblanching erythema

Suspected Deep-Tissue Injury

purple or maroon or blood-filled blister

ordinal position

whether the infant is an only child, an oldest child, a youngest child, or a middle child

Alcohol Withdrawal Delirium

•Agitation •Anxiety •Delirium •Diaphoresis •Disorientation •Hallucination & Delusions •Insomnia •Tachycardia & hypertension •Seizures

School Age: 6 -12 years

•Growth is gradual & subtle ("Growing pains") •Being to lose deciduous teeth by age 6 •Concrete Operational Phase: (Capable of understanding the views of others, Support learning environment) •Obesity to this age correlates to obesity at a later age •Physical activity •Gun safety •FON pg717 Safety Alert

Interventions 1-12 months

•Supine position for sleep •Choking hazard (Popcorn, grapes, hotdogs, Toys) •Avoid microwaving formula •Iron deficiency •Baby-proof home •Falling •Protect from stairs •Do not leave unattended in the bath even if a couple of inches •Protect from stairs •Protect from burns (Uses back burner on the stove) •Cover electrical outlets •Remove chemicals, medication & poisons out of reach •Never shake a baby shaken baby syndrome- closed head injury

12 -19 years Interventions

•Teach about •Danger of drugs & alcohol •Danger associated w/ guns, violence & drugs •Complication w/ body piercing, tattooing & sun tanning •Driver's education •Water safety training •Drugs, Alcohol, cigarettes •Use a seat belt •Discuss STI •Safe sex practices •Signs of Depression

Prevention of Pressure Ulcers

•Thorough assessment •Braden scale-Scoring system. Evaluates patient's risk of developing a pressure ulcer. •Assess skin turgor •Turn @2hrs •Keep skin clean & dry •Prevent shearing •Adequate nutrition & hydration •Specialty devices (air mattress, waffle boots, pillows, foams)

Alcohol Abuse Early Withdrawals Symptoms

•Tremors •Anorexia •Irritability •Easily startled

Weight Management

•Underlying causes of obesity •genetic, environmental & psychologic •Body mass index (BMI) •Total body weight relative to height •Body composition •Ex: Body fat calipers •Realistic Goals•½ to 1 lb loss/week •Negative energy balance 500-1000cal/day

Opioids Naloxone (Narcan)

•Used to treat respiratory depression from opioid overdose •Monitor BP, P & RR •Q5 min, tapering q15min & then q30min •Place on cardiac monitoring •Monitor for withdrawal symptoms

Adolescence: 12 -19 years

•transition from childhood to adulthood (Begins at puberty, Menarche) •Sebaceous & sweat glands become active (Are risk-takers) •Becomes capable of reasoning & formal logic •Are risk-takers

Alcohol Abuse Interventions

•Initiate seizure precaution •Small frequent high-CHO foods •Vitamin B complex •Thiamine •Vitamin C •fluid & electrolyte •Benzodiazepine •Chlordiazepoxide (Librium) q6 •Lorazepam (Ativan) •Administer medication •Psychotherapy •Individual, group, family •Support groups •Alcohol Anonymous •Al-Anon•For friends & family •Adult Children of Alcoholics •Treatment centers

Opioids

•Opium, heroin, meperidine, morphine, codeine, methadone, Dilaudid, fentanyl, etc •CNS depressants

School Age: 6 -12 years interventions

•Refinement of fine motor skills •Wear protective gear •Traffic safety rules •Stranger danger •Gun safety •Bullying

Opioid Intoxication

•Respiratory Depression •Pinpoint pupils •Drowsiness •Euphoria Hypotension •Slurred speech, impaired memory, attention & judgment •Coma •Shock •Seizure •Death

3-5 years Interventions

•Safety •Teach full names, addresses & telephone # 911 •Can be taught fire drills •Gun secured under lock & key •Safety from drowning •Socialization

Isotretinoin (Accutane)

•Severe cystic acne •Discontinue Vit A supplement •Nosebleed, inflammation of eyes & lips, drying or itching of the skin, stiffness in joints, bones or muscles & back pain •Photosensitivity •Teratogenic

A mother tells the nurse that her 3-year-old son has been acting out against others and throwing temper tantrums. What is the most important instruction to provide this mother? O Punish the child every time he says "No" to change his behavior O Acknowledge the child's actions to discipline appropriately O Set limits on your son's behavior. O Allow the behavior because it is normal at this age

Set limits on your son's behavior.

3. The preschool-age child, between 4 and 6 years of age, is in Erikson's stage of: a. trust versus mistrust. b. initiative versus guilt. c. autonomy versus shame and doubt. d. identity versus role confusion.

b. initiative versus guilt.

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? O "I will apply the ointment once a day and leave it open to the air." O "I will apply the ointment twice a day and leave it open to the air." O "I will apply the ointment once a day and cover it with a sterile dressing." O "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."

"I will apply the ointment once a day and cover it with a sterile dressing."

How would the nurse describe a person who constantly seeks pleasure and keeps discomfort to a minimum? O In the state of preconsciousness O Under the leadership of the id O Under the leadership of the ego O Under the leadership of the superego

Under the leadership of the id

The nurse is teaching an infant's parents to take precautionary measures against accidents and injury to the infant. What instruction should the nurse give to the parents to ensure safety? Select all that apply. O Place the infant in the walker when you need to step away O "Do not give the infant popcorn and hard candies." O "Avoid placing pillows near the infant while he or she is sleeping." O encourage the infant to play only with plush toys and balloons O "Keep the sides of the crib up and set the mattress at its lowest position."

"Do not give the infant popcorn and hard candies." "Avoid placing pillows near the infant while he or she is sleeping." "Keep the sides of the crib up and set the mattress at its lowest position."

An experienced nurse is educating an elderly patient about common changes that occur with aging. What information if given by the nurse would best help the patient to adjust to changes associated with the heart? O consume adequate food and fluid intake O "Engage in daily exercise, rest, and a decreased-sodium diet." O turn, cough, and deep breathe as needed O Allow frequent rest periods during the day

"Engage in daily exercise, rest, and a decreased-sodium diet."

A student nurse is participating in data collection from newly pregnant patients who are starting routine prenatal visits. The student nurse becomes concerned when the patient makes which reply?

"I enjoy a nice wine, but I limit myself to two glasses with dinner."

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 am."

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? O "I need to have clear fluids only on the morning of the test." O "I need to take my prednisone on the morning of the test." O "I need to shower on the morning of the test using povidone-iodine." O "I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

The nurse is caring for a patient who is in crisis because of the death of a spouse. Which statement by the patient indicates the final phase of the crisis?

"I plan to find a job so I can take care of my child."

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area."

Which statement by a patient indicates the need for further teaching regarding ways to reduce anxiety?

"I should play baseball when I am anxious."

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

A parent of a preschooler is concerned about the child's behavior. Which statements if made by the parent would indicate to the nurse that instructions on setting limits on behavior were effective? O "I will explain acceptable behavior." O "I should reinforce positive behavior." O " I must stay calm when arguing with the child." O Rules should change based on the behavior O I am keeping a record of all the bad behavior

"I will explain acceptable behavior." "I should reinforce positive behavior." " I must stay calm when arguing with the child."

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching?

"I will remove the dressing when I get home and wash the site with tap water."

A pediatric nurse is educating a young mother about feeding a toddler. Which statement, if made by the mother, indicates teaching has been ineffective? O I will introduce cereal first O I will not mix different foods together O "I will try several new foods at the first feeding." O I will avoid fast foods such as chicken nuggets

"I will try several new foods at the first feeding."

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it."

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat."

Which statements by the nursing student indicate effective learning about acamprosate (Campral)? Select all that apply. O "It reduces the rewarding effects of alcohol." O "It helps patients maintain abstinence from alcohol." O "It is contraindicated in patients with severe renal failure." O "It causes nausea and vomiting when alcohol is consumed." O "It helps in relapse prevention associated with opioid abuse."

"It is contraindicated in patients with severe renal failure." "It causes nausea and vomiting when alcohol is consumed." Rationale Acamprosate (Campral) is used to help individuals maintain abstinence from alcohol. Acamprosate (Campral) is contraindicated in patients with severe renal failure, which is indicated by a renal clearance of less than 30 mL/min. Acamprosate (Campral) does not reduce the rewarding effects of alcohol, may not induce nausea and vomiting when alcohol is consumed, and is not used to prevent relapse in patients with opioid abuse.

A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. Which is the most appropriate response to the client?

"It is skin from another species."

Which statements by a nursing student indicate the need for further learning about acamprosate (Campral)? Select all that apply. O "It reduces the rewarding effects of alcohol." O "It helps in maintaining abstinence from alcohol." O "It is contraindicated in patients with severe renal failure." O "It does cause nausea and vomiting when alcohol is consumed." O "It enhances abstinence and reduces drinking rates in alcohol-dependent patients.

"It reduces the rewarding effects of alcohol." "It does cause nausea and vomiting when alcohol is consumed." Rationale Acamprosate (Campral) helps individuals maintain abstinence from alcohol, enhances abstinence, and controls drinking rates in alcohol-dependent patients. Acamprosate (Campral) is contraindicated in patients with severe renal failure with a renal clearance of less than 30 mL/min because it may result in renal toxicity. It does not reduce the rewarding effects of alcohol, and it does not cause nausea and vomiting when alcohol is consumed.

What does the nurse teach the parents of a 7-month-old infant about good oral hygiene to prevent tooth decay in the infant? Select all that apply. O Add milk to the infant's nighttime feeding bottle O Add a moderate quantity of sugar to the formula milk O "Massage the infant's gums and wipe them slowly." O "Use fluoride toothpaste if the water contains no fluorine." O "Start brushing as soon as the child's teeth start to appear."

"Massage the infant's gums and wipe them slowly." "Use fluoride toothpaste if the water contains no fluorine." "Start brushing as soon as the child's teeth start to appear."

Which statement by the nurse about the use of ketamine indicates effective learning?

"Most of it is sold as an anesthetic drug for veterinary use."

Which statement by the nurse about the use of ketamine indicates effective learning? O It is consumed by dissolving in alcohol." O "It is unlikely to cause any serious injuries. O "Most of it is sold as an anesthetic drug for veterinary use." O It has been a popular club drug since the 1980s."

"Most of it is sold as an anesthetic drug for veterinary use." Rationale Ketamine is an anesthetic drug approved by the U.S. Food and Drug Administration for human and veterinary use, and most of it that is sold legally in the United States is intended for veterinary use. The drug cannot be dissolved in alcohol but is snorted or injected. Ketamine use causes hallucinations and may cause fatal respiratory problems at higher doses. There has been an increased use in the drug since 2008, but 3,4-methylenedioxymethamphetamine (MDMA), also known as Ecstasy, has been a popular club drug since the 1980s.

On interacting with a newborn's parent, the nurse understands that the newborn is sufficiently breastfed. Which statement by the newborn's parent has enabled the nurse to reach this conclusion? Select all that apply. O My baby passes watery stools four times a day O My baby passes rust-colored urine immediately after feeding O "My baby passes seedy stools about three times a day." O "My baby passes urine frequently and wets six diapers a day." O My baby breasts-feeds continuously for 5 minutes

"My baby passes seedy stools about three times a day." "My baby passes urine frequently and wets six diapers a day."

A mother of a 5-year-old child complains to the school nurse, "My child is behaving very stubbornly these days and does not follow my instructions." The nurse explains to the mother Piaget's stages of development in children. Which statement by the mother indicates a better understanding? O My child requires more attention from us O My child needs to be restricted from playing O "My child has age-appropriate behavior." O My child needs counseling by a therapist

"My child has age-appropriate behavior."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

A patient is worried that the use of opioids for pain management after surgery might develop into an addiction. Which response by the nurse would be appropriate? O "You have to take medications that are prescribed for you." O You will be referred for rehabilitation in case of addiction. O "It is more important to control pain than worry about addiction." O "Nonopioids, which do not cause addiction, will be used after a few days."

"Nonopioids, which do not cause addiction, will be used after a few days." Rationale Opioid need and the severity of pain in postoperative patients reduce gradually; therefore the patient is administered nonopioids by the third postoperative day. As a result, there is no risk for addiction. The nurse should share this information with the patient to relieve the patient's anxiety. Telling the patient that the medications are necessary will increase the patient's anxiety. Telling the patient about rehabilitation indicates that there is a possibility of addiction, which may make the patient anxious. Telling the patient that it is more important to control pain than to worry about addiction will not help to reduce the patient's fears.

While providing care to patients that include a large population of Native Americans, the student notices that several of the patients seen during the rotation are exhibiting the consequences of long-term alcohol abuse. The student nurse has heard stories that Native Americans drink more and asks the nurse practitioner to validate her perception. Which response from the nurse practitioner would be appropriate? O They don't drink any more than anyone else; they just get sicker from it. O " They drink a lot because all of their liquor is discounted or free at the casinos." O "They drink because that is all they have left to do. Everything else has been taken from them." O "Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater

"Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater Rationale Deficiencies in some hepatic enzymes necessary to metabolize alcohol contribute to the development of alcoholism in some people, including many Native Americans, Asians, and Inuit. Alcoholism rates are higher in these ethnic groups. The effect of alcohol consumption varies by many factors. Long-term abuse has serious, significant effects regardless of one's ethnicity. The ideas that Native Americans drink more because of a discounted cost or in response to historical treatment support a stereotypical perspective and are not based on evidence.

A patient with a visual impairment is accompanied to the clinic by a family member. The family member asks the nurse what can be done at home to help the patient function. What would be the most appropriate response for the nurse to give? O Avoid the use of night-lights O "Place essential items in the direct visual path." O Make sure that the lighitng in the room is dim O Dark colors such as gray, black, and blue are best

"Place essential items in the direct visual path."

The parents inform the nurse, "Our child has bad dreams and wakes up in the night crying." What suggestion would the nurse give to the parents to improve the sleep patterns in the child? Select all that apply. O Sleep along with the child at night O "Read stories to the child at night." O "Play soothing music in the child's room." O "Bathe the child with warm water before sleep." O Encourage the child to watch TV before sleep

"Read stories to the child at night." "Play soothing music in the child's room." "Bathe the child with warm water before sleep."

Parents of a toddler have brought their child to the health care center for a routine checkup. The nurse learns that the toddler's parents are planning to send the child to a day-care center. What should the nurse suggest to the parents regarding the selection of a day-care center? Select all that apply. O Select one where the caretaker supervises the child's calorie intake O "Select one that separates children by age group." O "Select one that has ample space for the children to play." O "Select one that has proper educational structures for the children." O Select one where a nurse effectively takes care of all the children

"Select one that separates children by age group." "Select one that has ample space for the children to play." "Select one that has proper educational structures for the children."

The nurse is teaching a group of mothers in a community regarding toddler diet requirements. What does the nurse inform the mothers? O "wheat bread during breakfast should be avoided O Two eggs per day will prevent allergies O "Serve at least one serving of meat a day." O serve a bowl of grapes and carrots daily

"Serve at least one serving of meat a day."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? O "Come to the emergency department." O "Apply calamine lotion immediately to the exposed skin areas." O "Take a shower immediately, and lather and rinse several times." O "It is not necessary to do anything if you cannot see anything on your skin."

"Take a shower immediately, and lather and rinse several times."

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? O "It is caused by oily skin." O "The exact cause of acne is not known." O "It occurs as a result of exposure to heat and humidity." O "Acne is caused by eating chocolate, nuts, and fatty foods."

"The exact cause of acne is not known."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client?

"The local anesthetic may cause a burning or stinging sensation."

A young mother comes to the clinic with her 2-month-old daughter. While taking vital signs, the nurse finds that the baby's heart rate is 120 bpm. The mother expresses concern about the fast heart rate. What is the best response by the nurse? O Her pulse is okay O Has your daughter been having trouble breathing O "This is a normal heart rate for a 2-month-old baby." O Don't worry; I'll let the health care provider

"This is a normal heart rate for a 2-month-old baby."

Which statement by the nurse about alcohol withdrawal syndrome indicates effective learning?

"Tremors are seen in a patient who abruptly quits drinking."

A nurse is assessing a toddler on evening rounds. The mother is upset and explains to the nurse that the toddler consistently has temper tantrums. What should the nurse teach the parent about the behavior? O "use a thin belt and tap the thighs of the toddler to break the bad habit" O "Place the child in a time-out for an hour after each temper tantrum takes place" O "Unless the child or others may be harmed, ignore the negative behavior." O "It is best to give toddlers whatever they want to prevent the tantrums from occuring

"Unless the child or others may be harmed, ignore the negative behavior."

The nurse is assessing an elderly patient who reports pain in the joints. On assessment, the nurse finds that the patient also has stiffness in the joints. What suggestion should the nurse provide? Select all that apply. O "Walk on a regular basis." O "Avoid walking on sloped surfaces." O "Use a walking stick while walking." O You require full bed rest O Use weights to strengthen your muscles

"Walk on a regular basis." "Avoid walking on sloped surfaces." "Use a walking stick while walking."

Which question by the nurse is best to help identify a patient's addictive behavior pattern during an assessment? O "What do you do to relieve stress?" O Do you often feel overwhelmed?" O "When was the last time you used drugs? O How often do you have the urge to drink?"

"What do you do to relieve stress?" Rationale Patients who suffer from depression or chronic medical conditions often have problems with substance abuse. The nurse should ask the patient what the patient does to relieve stress or pain. It will help the nurse to understand whether the patient is addicted to alcohol or other substances. The patient may feel overwhelmed due to anxiety or other psychological issues, so it may not be an indication of addiction. Asking when the patient last used drugs will not help obtain an honest answer. The patient may not be honest and may try to hide a substance abuse problem if the nurse asks directly about the patient's urge to drink.

A nurse is caring for a patient who is suspected of drug dependence. Which questions are the most appropriate for the nurse to ask?

"What type, how much, and what effects do the drugs have on you?"

A patient is scheduled for electroconvulsive therapy (ECT) tomorrow morning. She has been pacing the halls and biting her nails for the past 10 minutes. The patient tells the nurse, "I don't know if I can go through with this. I don't remember any side effects to expect!" Which response by the nurse would be best at this time?

"You might experience short-term amnesia and headache after the procedure."

Erickson: Initiative vs Guilt

- early childhood - favorable relationships with family members result in an ability to set goals and devise and carry out plans without infringing on the rights of others

Erickson: Industry vs. Inferiority

- school age - most important influences are people in the neighborhood and school - child must master certain social and academic skills

Erickson: Autonomy vs. Shame and Doubt

- toddlerhood - a sense of self develops out of positive interactions with one's parents and other caregivers

Piaget: Sensorimotor Stage

0-2 years- first stage, children learn entirely through the movements they make and the sensations that result. They learn they cause things to happen, they are separate from objects and people around them, things continue to exist even if they can't see them.

Which lab value would represent the therapeutic index for lithium maintenance?

0.6 to 1.2 mEq/L

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning? 1 "Nicotine gum will help decrease nicotine dependence." 2 "CNS stimulants are helpful in treating nicotine addiction." 3 "The nicotine transdermal patch is the least beneficial option." 4"Only 10% of people who quit smoking will experience relapse."

1 "Nicotine gum will help decrease nicotine dependence."

When assessing an adolescent in the early stages of drug addiction, which information does the nurse provide to the parents about the adolescent's recovery? 1 "Recovery is possible even without treatment." 2 "There will be severe impairment in all areas of function." 3 "There is no chance of improvement with any treatment." 4 "There is low chance of recovery without any treatment."

1 "Recovery is possible even without treatment."

In preparing for a position at a treatment addiction center, a new nurse reviews research materials related to addiction and identifies which main elements of addiction? Select all that apply. 1 Display of psychological disturbance 2 Excessive use or abuse of a substance 3 Decline of social and economic function 4 Preoccupation with substance, including talking about it constantly 5 Uncontrollable consumption of the substance, including dependence 6 Incarceration or hospitalization for actions or behaviors related to use or misuse of the substance

1 Display of psychological disturbance 2 Excessive use or abuse of a substance 3 Decline of social and economic function 5 Uncontrollable consumption of the substance, including dependence

A patient who smokes heavily decides to suddenly quit smoking and refrains for a couple of days. Which withdrawal symptoms are likely to be seen in the patient? Select all that apply. 1 Irritability 2 Pneumonitis 3 Disturbed sleep 4 Severe depression 5 Increased appetite

1 Irritability 3 Disturbed sleep 5 Increased appetite

A young patient says that he gets annoyed when friends tell him that he drinks too much. He also reports that sometimes he thinks he should try and cut down a little on his drinking. The nurse in the clinic would draw which conclusion about the likelihood that the patient has alcoholism based on the CAGE questions? 1 It is probable that the patient has alcoholism. 2 The patient probably does not have alcoholism. 3 There is an increased risk to develop alcoholism. 4 The information provided is inadequate for making any determination.

1 It is probable that the patient has alcoholism.

Which drugs does the nurse list while informing a group of adolescents about different hallucinogenic drugs? Select all that apply. 1 Phencyclidine (PCP) 2 Amantadine (Symmetrel) 3 Gamma-hydroxybutyrate (GHB) 4 Lysergic acid diethylamide (LSD) 5 3,4-Methylenedioxymethamphetamine (MDMA)

1 Phencyclidine (PCP) 4 Lysergic acid diethylamide (LSD) 5 3,4-Methylenedioxymethamphetamine (MDMA)

Which are naturally occurring hallucinogens? Select all that apply. 1 Psilocybin 2 Mescaline 3 Ketamine 4 Phencyclidine (PCP) 5 Lysergic acid diethylamide (LSD)

1 Psilocybin 2 Mescaline

The nurse is providing care for a patient who was recently admitted to the hospital for the treatment of marijuana addiction. Which conditions does the nurse expect to see in the patient? Select all that apply. 1 Stuffy nose 2 Panic reactions 3 General myalgia 4 Suicidal thoughts 5 Distorted perception

1 Stuffy nose 2 Panic reactions 4 Suicidal thoughts 5 Distorted perception

Which factor does the success of a patient going through a substance abuse treatment program depend on? 1 The motivation of the user 2 The effectiveness of group therapy 3 The type of assistance received while in the program 4 The treatment plan established by the health care provider

1 The motivation of the user

Which interventions does the nurse implement while providing care for an intoxicated patient? Select all that apply. 1 Using padded side rails and floor pads 2 Keeping the bed in a flat position at all times 3 Placing the patient in a side-lying position 4 Ensuring that the patient has a patent airway 5 Monitoring the patient's intravenous sites often

1 Using padded side rails and floor pads 3 Placing the patient in a side-lying position 4 Ensuring that the patient has a patent airway 5 Monitoring the patient's intravenous sites often

Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. Chest and Stomach

19%

The clinical tests of a patient indicate elevated levels of liver enzymes, hypoglycemia, and abnormal blood protein levels. The patient does not have any chronic diseases. For which condition does the nurse assess? 1 Pneumonitis 2 Alcohol addiction 3 Delirium tremens 4 Altered perception

2 Alcohol addiction

Which drugs are classified as central nervous system (CNS) depressants? Select all that apply. 1 Caffeine 2 Barbiturates 3 Amphetamines 4 Benzodiazepines 5 Opioid analgesics

2 Barbiturates 4 Benzodiazepines 5 Opioid analgesics

A licensed practical/vocational nurse (LPN/LVN) is facilitating a group therapy session for patients with substance misuse and abuse problems. The nurse actively works to direct group communication, aware that the positive effect of group therapy is realized through which therapeutic effects? Select all that apply. 1 Helping the patient identify persons who may have caused addictive behaviors 2 Enabling and encouraging family members to participate in the patient's therapy 3 Helping the patient acknowledge the consequences of his or her addictive behaviors 4 Providing a formal mechanism for addicted patients to meet other addicted patients 5 Allowing the patient an opportunity to share interesting stories about intoxicated adventures 6 Confronting the patient's use of negative defense mechanisms such as denial or displacement

2 Enabling and encouraging family members to participate in the patient's therapy 3 Helping the patient acknowledge the consequences of his or her addictive behaviors 6 Confronting the patient's use of negative defense mechanisms such as denial or displacement

A student nurse confides in a classmate that she is concerned about her own risks for addiction because both her mother and father misused and abused certain substances, especially marijuana. She understands that she may be more likely to use drugs because her parents did. Which lifestyle changes will the classmate encourage her to continue to develop to make her more resistant to addiction? Select all that apply. 1 Eat a healthy diet and drink plenty of water. 2 Maintain a positive self-image and a positive attitude. 3 Earn enough money to always stay above the poverty level. 4 Learn effective and healthy stress management techniques. 5 Use a different substance than her parents, such as alcohol, to reduce risk. 6 If at all possible, choose to live in a rural area as opposed to an urban area.

2 Maintain a positive self-image and a positive attitude. 4 Learn effective and healthy stress management techniques.

The nurse is caring for a patient who has been abusing a central nervous system (CNS) depressant and anticipates finding which signs and/or symptoms during the assessment process? Select all that apply. 1 Agitation 2 Memory loss 3 Dilated pupils 4 Slurred speech 5 Decreased respirations 6 Increased hunger and thirst

2 Memory loss 4 Slurred speech 5 Decreased respirations

Which conditions are seen in a patient who has been taking methylphenidate (Ritalin) for a long time? Select all that apply. 1 Sinusitis 2 Paranoia 3 Weight loss 4 Hallucinations 5 Severe depression

2 Paranoia 3 Weight loss 4 Hallucinations

The nurse caring for a patient admitted to the health care facility for drug overdose observes track marks on the patient. Which potential health problems does the nurse expect the provider to evaluate for in the patient? Select all that apply. 1 Septal necrosis 2 Phlebitis 3 HIV/AIDS 4 Hepatitis B and C 5 Chronic sinusitis

2 Phlebitis 3 HIV/AIDS 4 Hepatitis B and C

The mother of a 2-year-old is concerned that her child is not eating enough at each meal. What education should the nurse provide when the mother asks how much this child should consume at each meal? O 4 teaspoons of each solid food O 2 teaspoons of each solid food O 1 tablespoon of each solid O 2 tablespoons of each solid food

2 tablespoons of each solid food

A patient diagnosed with depression has been prescribed a tricyclic antidepressant. The nurse educates the patient to expect improvement in the depression within which period of time?

2 to 4 weeks

Piaget Preoperational Stage

2-7 years- Once children acquire langage they can use symbols to represent objects. Still egocentric thinking and they assume everyone sees things from the same viewpoint. Understand concepts like counting, classifying according to similarity, and past-present-future but focused on present and concrete rather than abstract.

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5%

A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand?

A white color of the skin, which is insensitive to touch

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36 %

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36%

A school nurse asks a group of high school-age students to write down the last time they used alcohol or other illicit substance and to describe the circumstances associated with that occurrence. The nurse then examines them for evidence of a problem with dependence. The nurse identifies which student in the group as exhibiting the strongest indicator of dependence? 1 The student who had two glasses of wine with family members at dinner. 2 The student who drank three cans of beer and vomited at an after-prom party. 3 The student who had a "puff" of marijuana with an older brother who was home from college. 4 The student who removed several ounces of vodka from the parents' supply and replaced it with water.

4 The student who removed several ounces of vodka from the parents' supply and replaced it with water.

Braden Scale for Predicting Pressure Sore Risk

6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?

54%

The nurse is physically examining a 5-month-old healthy infant. On reviewing the birth report, the nurse finds that the infant's weight was 3 kg at the time of birth. What would be the present approximate weight of the infant? O 4 kg O 9.5 kg O 6 kg O 11.5 kg

6 kg

Which individuals is least likely at risk for the development of psoriasis?

A 32-year-old African American

Which clients are at risk for developing skin breakdown? Select all that apply.

A client who is underweight A client diagnosed with heart failure A client diagnosed with spinal cord injury

The nurse learns that a patient is apathetic, hostile, and in denial after losing a friend in an accident. What does the nurse expect the patient to be experiencing? O A crisis O Anxiety O Conflict O Frustration

A crisis Rationale A crisis is an unstable period in a person's life characterized by an inability to adapt to a sudden change from a precipitating event. A crisis often tends to resolve itself over a 4- to 6-week period. If the crisis is not resolved, it may result in physical illness or an emotional breakdown. Apathy, hostility, and denial are features of an unresolved crisis. Anxiety is a vague feeling of apprehension that results from a perceived threat to one's self, although the source is often unknown. Conflict results from the presence of opposing or incompatible thoughts. Frustration is an emotional response to anything that interferes with goal-directed activity.

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data?

A superficial injury to tissue from the radiation

mental illness

a disorder that affects a person's thoughts, emotions, and behaviors

What is a sinus tract?

a narrow, elongated channel in the body that allows the escape of fluid

addictive personality

a person who exhibits a pattern of compulsive and habitual use of a substance or practice to cope with psychic pain from conflict and anxiety.

According to American Psychiatric Association, what are the long-term goals associated with the treatment of substance abuse? Select all that apply. O Prevention of drug misuse and abuse O Abstinence in the use and effects of substances O Reduction in the frequency and severity of relapse O Improvement in psychological and social functioning O Development of professional attitudes and behaviors

Abstinence in the use and effects of substances Reduction in the frequency and severity of relapse Improvement in psychological and social functioning Rationale According to the American Psychiatric Association, the long-term goals of treating substance abuse are abstinence in the use and effects of substances, reduction in the frequency and severity of relapse, and improvement in psychological and social functioning Prevention of drug misuse and abuse is an important priority in the practice of every healthcare profession. The curricula of healthcare profession educational programs should ensure that students have multiple opportunities for the development of professional attitudes and behaviors.

When the laboratory report of a chronic alcoholic patient shows a creatinine clearance of 25 mL/min, which medication would be contraindicated in this patient? O Phenytoin (Dilantin) O Warfarin (Coumadin) O Disulfiram (Antabuse) O Acamprosate (Campral)

Acamprosate (Campral) Rationale Acamprosate (Campral) is prescribed to help chronic alcoholic patients abstain from alcohol. It is contraindicated in patients with a creatinine clearance of less than 30 mL/min because it may aggravate the renal toxicity. Phenytoin (Dilantin) is contraindicated with disulfiram (Antabuse) because it may result in phenytoin toxicity. Disulfiram (Antabuse) may enhance the anticoagulant effects of warfarin (Coumadin) and should be used with caution. Patients who use phenytoin (Dilantin) and disulfiram (Antabuse) concurrently should be monitored for signs of phenytoin toxicity.

A patient who has prescribed a medication for rehabilitation for chronic alcohol abuse complains of diarrhea after discontinuing the medication. Which medication is responsible for this side effect? O Naltrexone (ReVia) O Disulfiram (Antabuse) O Clorazepate (Tranxene) O Acamprosate (Campral)

Acamprosate (Campral) Rationale Acamprosate (Campral) is used in alcohol rehabilitation programs to help chronic alcoholic patients maintain sobriety. This drug causes diarrhea as a side effect upon sudden discontinuation. Naltrexone (ReVia) is an opioid antagonist that is prescribed to block the pharmacologic effects associated with opioids and alcohol. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting and may cause drowsiness and fatigue as side effects. Clorazepate (Tranxene) is a benzodiazepine that is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion.

When does the healthcare provider want to prescribe a medication that reduces the drinking rates of alcohol, which medication combination would the nurse anticipate to be ordered? O Naltrexone and disulfiram O Disulfiram and acamprosate O Clorazepate and disulfiram O Acamprosate and Naltrexone

Acamprosate and Naltrexone Rationale Acamprosate helps patients maintain abstinence from alcohol. Naltrexone blocks the high from drinking. Higher success rates are documented when these drugs are used together rather than individually. Disulfiram reduces the desire for alcohol by inducing nausea and vomiting. Clorazepate is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion.

Which antidote would be appropriate to reverse oral methamphetamine (Desoxyn) intoxication? O Diazepam (Valium) O Haloperidol (Haldo) O Methadone (Dolophine) O Activated charcoal (Charcoal Plus DS)

Activated charcoal (Charcoal Plus DS) Rationale 10 methamphetamine (Desoxyn) has been taken orally, activated charcoal (Charcoal Plus DS) should be administered to reverse intoxication. Diazepam (Valium) is used to sedate a patient with severe agitation. Haloperidol (Haldol) may lower the seizure threshold in patients who are risk for seizures Methadone (Dolophine) is used to reduce severe withdrawal symptoms in patients with opioid toxicity.

An older patient comes to the clinic for a routine visit. During the taking of the health history, the patient admits to engaging in daily exercise and attending field trips at the local adult day care center. Which life theory best explains the patient's lifestyle behavior?

Activity theory- also known as the implicit theory of aging, normal theory of aging, and lay theory of aging, proposes that successful ageing occurs when older adults stay active and maintain social interactions

Which processes does the nurse teach a patient with anxiety due to depression to encourage positive emotional growth? Select all that apply. O How to avoid stress in the person's daily life O Adaptive mechanisms to deal with stress O How to avoid thoughts that may lead to conflict O Using coping mechanisms to deal with anxiety O Techniques of reminiscence and life review to cope with life changes

Adaptive mechanisms to deal with stress Using coping mechanisms to deal with anxiety Rationale Learning adaptive or corrective ways to deal with stress and anxiety is a positive part of emotional growth. Coping mechanisms are a form of adaptive behaviors. Learning ways to avoid stress is not possible because stress in daily life is inevitable. Learning adaptive patterns helps an individual deal with and resolves stress. The techniques of reminiscence and life review are effective for helping older adults deal with changing life circumstances

Which concept do the four elements of excessive use or abuse-display of psychological disturbance, a decline of social and economic function, and uncontrollable consumption indicating dependence define? O Abuse O Addiction O Alcoholism O Addictive personality

Addiction These are the four elements of addiction that are often used as a synonym for drug dependence and substance abuse. Alcoholism refers to the addiction to alcohol Abuse is the misuse of alcohol, tobacco, caffeine, nicotine, or other drugs. A person with an addictive personality exhibits a pattern of compulsive and habitual use of a substance or practice to cope with psychic pain from conflict and anxiety.

When a patient who has been hospitalized for heavy alcohol consumption displays symptoms of dehydration, which action would be taken first to prevent Wernicke's encephalopathy? O Initiation of glucose infusion O Initiation of intravenous therapy O Administration of oxazepam (Serax) O Administration of thiamine (vitamin B₁)

Administration of thiamine (vitamin B₁) Rationale Thiamine should be administered on priority to prevent Wernicke's encephalopathy. Glucose infusion should be initiated after administration of thiamine (vitamin B1). Intravenous therapy may be necessary, but thiamine (vitamin B1) administration should be on priority. Oxazepam (Serax) is administered to treat withdrawal symptoms.

adolescence

Adolescence is the bridge between childhood and adulthood. Adolescence is divided into three phases: early adolescence (10 to 13 years of age), middle adolescence (14 to 16 years of age), and late adolescence (17 to 20 years of age). The major tasks of adolescence include establishing a sense of identity, separation from family, establishing intimacy and peer relationships, and career planning. The physical, psychological, cognitive, and emotional aspects of development may mature at different rates. • Puberty refers to sexual maturity. The reproductive system is controlled by hormones regulated by the hypothalamus and secreted by the anterior pituitary glands and the ovaries or testes. Ovulation occurs 14 days before the menstrual period begins. • The changing body plays a role in the adolescent's development of self-image, self-esteem, and social interactions. Adolescents should engage in at least 60 minutes of physical activity every day and activity of vigorous-intensity at least 3 days per week. Adolescents engaging in competitive sports can benefit from strength training. Young adolescents are in the concrete phase of thinking.

The clinical tests of a patient indicate elevated levels of liver enzymes, hypoglycemia, and abnormal blood protein levels. The patient does not have any chronic diseases. For which condition does the nurse assess?

Alcohol addiction

A patient says that he drinks alcohol on a regular basis. During his discussion with the nurse, the patient admits to "having a problem." To which support group would the nurse refer the patient?

Alcoholics Anonymous

Which individual is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record?

An irregularly shaped lesion

The nurse is preparing a client for skin grafting and identifies that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which source?

Another species

What is the patient at risk for with Stage IV pressure injury?

Anyone with existing bedsore may be at risk of developing a stage 4 bedsore. In assisted living facilities, this may happen when residents are left to lie in bed, in a chair, or in a wheelchair without being properly tended to. Anemia Decreased mental awareness Diseases that affect blood flow, such as diabetes Fever Fragile skin Hypoxemia (low oxygen levels in the blood) Immobility or limited mobility Infection Ischemia (restriction of blood flow to a part of the body) Neurological disease Neuropathy (nerve damage that causes pain, weakness, and/or numbness) Obesity Poor nutrition or dehydration Spinal cord injury Urinary or fecal incontinence

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?

Appearance

A female patient is complaining of vaginal discomfort caused by dryness during intercourse. What advice should the nurse give to the patient? O Perform pelvic exercises to increase lubrication O Apply a liberal amount of lubricant O use a vaginal suppository before activity O Avoid sexual activity if pain continues

Apply a liberal amount of lubricant

The nurse is reinforcing sun exposure precautions to a group of older clients. Which should the nurse include in the instructions? Select all that apply. O Sunscreen is not needed on cloudy days. O Wear loosely woven clothing for protection. O Apply sunscreen liberally 15 to 30 minutes before sun exposure. O Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. O It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

Apply sunscreen liberally 15 to 30 minutes before sun exposure. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

Which nursing intervention would be appropriate in managing a patient who has been admitted to the emergency room with delirium, sweating, and hyperthermia due to alcohol withdrawal? O Encouraging psychiatric evaluation O Administering naltrexone (Vivitrol) O Administering disulfiram (Antabuse) O Assessing quickly for electrolyte and nutritional status

Assessing quickly for electrolyte and nutritional status Rationale Delirium, sweating, and hyperthermia are symptoms of alcohol withdrawal. Excessive fluid and electrolyte loss may occur through vomiting, sweating, and hyperthermia; therefore the nurse should quickly assess the patient's hydration and his or her electrolyte and nutritional status. A. patient who is taking methamphetamines should be encouraged to undergo a psychiatric evaluation because the drug may damage dopaminergic and serotonergic neurons in the brain, which may result in parkinsonism, depression, and anxiety. Naltrexone (Vivitrol) is used to maintain alcohol and opioid abstinence. Disulfiram (Antabuse) is prescribed to promote alcohol abstinence.

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods between 10:00 am and 3:00 pm

Alcohol Abuse Medications

Benzodiazepine: chlordiazepoxide (Librium), lorazepam (Ativan), diazepam (Valium), oxazepam (Serax) •anxiety reducing, sedative-hypnotic, muscle relaxing & anticonvulsant actions S/E: sedation, dizziness, HA, hypotension Naltrexone (Revia) •Blocks "high" or opiate effect S/E: tiredness, N/V

Acne Vulgaris

Benzoyl peroxide Clyndamycin & Erythromycin •Produce drying & peeling •Severe local irritation •Assess for allergic reaction •Suppress growth of Propionibacterium acnes •Can be given clindamycin/benzyl combination

Which drug is used in opioid programs housed in practitioner offices in patients with opioid intoxication? O Haloperidol (Haldol) O Disulfiram (Antabuse) O Acamprosate (Campral) O Buprenorphine (Subutex)

Buprenorphine (Subutex) Rationale Buprenorphine (Subutex) is used in oploid programs in practitioner offices in patients with opioid intoxication. Haloperidol (Haldol) reduces the seizure threshold in patients with amphetamine toxicity. Disulfiram (Antabuse) and acamprosate (Campral) are used to prevent relapse in patients with alcohol toxicity.

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE? O Spider rash O Butterfly rash O Lilac bush rash O Christmas trees rash

Butterfly rash

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? Select all that apply.

Clean with mild soap and water. Encourage adequate nutritional intake. Apply a dressing that allows oxygen to pass through.

Sublimation is a defense mechanism that helps the patient do which action?

Channel unacceptable impulses into socially acceptable ones

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which?

Characteristic of a thrush infection

A patient is detached from family members and is having an emotional crisis because of unemployment. Which nursing action should be the primary intervention to help the patient during this crisis? O Encourage the patient to develop problem-solving and decision-making skills. O Explain the patient's emotional status to the health care provider. O Encourage the patient to recognize constructive aspects of mild or moderate anxiety. O Consult the health care provider to include other psychosocial professionals.

Consult the health care provider to include other psychosocial professionals. Rationale Identifying family supports and adequate coping mechanisms helps the nurse recognize family communication patterns. Dysfunctional relationships indicate a need to include other psychosocial professionals in an individual's care. The other interventions, such as encouraging decision-making skills, assessment of emotional status, and recognizing constructive aspects of anxiety, are common for all patients undergoing crisis.

A woman discovers that her spouse is having an affair and starts to experience sudden blindness with no medical cause. The nurse understands this to be an example of which defense mechanism?

Conversion

a woman discovers that her spouse is having an affair and starts to experience sudden blindness with no medical cause. The nurse understands this to be an example of which defense mechanism? O Conversion O Sublimation O Displacement O Rationalization

Conversion Rationale Conversion is when a person turns emotional conflicts into a physical symptom, which provides the individual with some sort of benefit (secondary gain, such as more attention). Displacement is the expression of emotions toward someone other than at the actual source of the emotion. Sublimation is the discharge of sexual or aggressive energy and impulses in a socially acceptable way. Rationalization is a process of constructing plausible reasons to explain and justify one's behavior.

Which type of drug preparation is contraindicated for a patient taking disulfiram (Antabuse)? O Cough elixir O Laxative emulsion O Antacid suspension O Extended-release antihistamine

Cough elixir Rationale A cough elixir contains alcohol. Alcohol in any amount or form must be avoided by patients taking disulfiram (Antabuse) because of the intense interaction, which induces nausea, vomiting, and other symptoms. Antihistamines, antacids, and laxatives do not contain alcohol and are not contraindicated.

Acamprosate (Campral), given for the treatment of alcohol abuse, works by which mechanism? O Cravings for alcohol are decreased. O The absorption of alcohol is blocked. O The sedative effects of alcohol are blocked. O It causes severe flushing of the face and hands with alcohol ingestion.

Cravings for alcohol are decreased. Rationale Acamprosate (Campral), an N-methyl-D-aspartate inhibitor, is used to reduce the craving for alcohol to extend periods of abstinence. Acamprosate (Campral) does not block the absorption of alcohol, block the sedative effects of alcohol, or cause severe flushing of the face and hands with alcohol ingestion.

When the patient with skeletal muscle spasms due to opioid abuse is admitted to the hospital, which drug does the nurse suspect will be prescribed? O Clonidine (Catapres) O Dicyclomine (Dicyclocot) O Methadone (Dolophine) O Cyclobenzaprine (Flexeril)

Cyclobenzaprine (Flexeril) Rationale Cyclobenzaprine (Flexeril) reduces skeletal muscle spasms in patients with opioid abuse. Clonidine (Catapres) is used to reduce tremors, sweating, and agitation. Dicyclomine (Dicyclocot) reduces gastrointestinal cramping and diarrhea. Methadone (Dolophine) reduces the severity of withdrawal symptoms of opioid poisoning

Which major change would the nursing instructor include in a discussion about the changes brought about by the introduction of psychotherapeutic drugs in the treatment of mental illness? O The development of electroconvulsive therapy O Deinstitutionalization of patients with psychiatric disorders O Reduction of funding for the mental health system O Establishment of the National Institute of Mental Health

Deinstitutionalization of patients with psychiatric disorders Rationale Psychotherapeutic drugs allow individuals to control their behavior and thus spend more time in the community, in the 20th century, the government started the movement of deinstitutionalization, the release of patients with psychiatric disorders from institutions to live and receive treatment in the community setting Mental health practitioners developed electroconvulsive therapy and insulin shock therapy to treat schizophrenia during the 1930s. The passage of the Omnibus Budget Reconciliation Act reduced funding for the mental health system. This information does not help in a discussion about the treatment of mental illness. The National institute of Mental health was established in the 1940s. This is irrelevant to the changes brought about by the introduction of psychotropic drugs.

Which lessons would the nurse include to help a group of patients improve their mental health? Select all that apply.

Develop assertive communication skills. Recognize the power of positive thinking. Identify personal characteristics of anxiety. Incorporate progressive muscle relaxation.

Which lessons would the nurse include to help a group of patients improve their mental health? Select all that apply. O Develop assertive communication skills. O Recognize the power of positive thinking. O Seek help from family in decision making. O Identify personal characteristics of anxiety. O Incorporate progressive muscle relaxation.

Develop assertive communication skills. Recognize the power of positive thinking. Identify personal characteristics of anxiety. Incorporate progressive muscle relaxation. Rationale The nurse can help the individuals get through a crisis by providing accurate information that aids in realistic perception of the situation. Patients should develop assertive communication skills to improve mental health. The nurse should advise the patients to recognize the healing power of positive thinking. The patients should recognize their personal characteristics of anxiety. The nurse should encourage the use of muscle relaxation to reduce stress, Decision-making and problem-solving skills should be developed by the patients

Which drug enhances gamma-aminobutyric acid (GABA) activity that has been suppressed by chronic alcohol ingestion? O Diazepam (Valium) O Naltrexone (Vivitrol) O Clonidine (Catapres) O Disulfiram (Antabuse)

Diazepam (Valium) Rationale Benzodiazepines such as diazepam (Valium) are commonly used for detoxification because they enhance GABA activity that has been suppressed by chronic alcohol ingestion. Naltrexone (Vivitrol) is an opioid antagonist that is prescribed to block the pharmacologic effects of opioid and alcohol abuse. Clonidine (Catapres) is used to reduce tremors, sweating, and agitation associated with excess opioid ingestion. Disulfiram (Antabuse) helps reduce the desire for alcohol by inducing vomiting and nausea.

According to the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA Ar) protocol, which statement is true regarding the administration of diazepam? O Diazepam should be administered at regular intervals. O Diazepam should be administered according to a fired dosage regimen. O Diazepam should be administered when the patient shows withdrawal symptoms. O Diazepam should be administered in large doses on the second day of treatment.

Diazepam should be administered when the patient shows withdrawal symptoms. Rationale There are two approaches for benzodiazepine dosing for the treatment of alcohol withdrawal symptoms. The symptom-triggered schedule depends on the use of a rating scale such as the CIWA-Ar protocol, which indicates that benzodiazepines should be administered when the patient shows withdrawal symptoms. According to the fixed dosage regimen, benzodiazepine should be administered at specific intervals. According to the CIWA-Ar protocol, the drug should be administered when required but not according to fixed-dosage regimen. On the second day of treatment, small doses of benzodiazepines should be administered on a fixed schedule.

A person has an argument at the office and then comes home and yells at family members. Which defense mechanism is this person using? O Denial O Displacement O Projection O Rationalization

Displacement

A 9-year-old tells a story, while smiling and joking, about witnessing a house burning down across the street. The nurse recognizes this as an example of which defense mechanism?

Dissociation

When a patient with a history of alcohol abuse is undergoing long-term treatment, which agent does the nurse anticipate will be ordered for this patient? O Caffeine O Verapamil O Disulfiram O Buprenorphine

Disulfiram Rationale Disulfiram is indicated for long-term treatment of alcohol abuse. It prevents the patient from drinking alcohol by causing an unpleasant reaction if alcohol is consumed, Buprenorphine is used for maintenance opioid programs and is not indicated for long-term alcohol abuse. Caffeine is a stimulant and is not indicated for long-term alcohol abuse. Verapamil is used for the treatment of cocaine abuse and is not indicated for long term alcohol abuse.

A patient who is on disulfiram (Antabuse) presents with ecchymoses, nosebleeds, and bleeding gums. Which medication administered concurrently might have caused these effects? O Phenytoin (Dilantin) O Isoniazid (Nydrazid) O Metronidazole (Flagyl) O Disulfiram (Antabuse)

Disulfiram (Antabuse) Rationale Disulfiram (Antabuse) may enhance the anticoagulant effects of warfarin (Coumadin) and result in ecchymosis, nosebleeds, and bleeding gums. The concurrent use of disulfiram (Antabuse) and phenytoin (Dilantin) will not produce these side effects. Disulfiram (Antabuse) may cause reduced alertness and coordination when used concomitantly with isoniazid (Nydrazid). Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychosis and confusion.

Alcohol Abuse

Disulfiram (Antabuse) •Abstain at least 12 hours prior If you take anything before the 12 hours Adverse effects •Facial flushing, sweating, throbbing HA, neck pain, N/V, hypotension, tachycardia •Avoid alcohol •Cough medicines, vinegar, mouthwashes, aftershave lotions •Read labels

Which statement is true regarding disulfiram (Antabuse)? O Disulfiram (Antabuse) helps reduce the desire for alcohol O Disulfiram (Antabuse) helps in maintaining abstinence from alcohol. O Disulfiram (Antabuse) enhances gamma-aminobutyric acid (GABA) activity. O Disulfiram (Antabuse) blocks pharmacologic effects associated with alcohol.

Disulfiram (Antabuse) helps in maintaining abstinence from alcohol. Rationale Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting after ingesting alcohol. Acamprosate (Campral) helps patients maintain abstinence from alcohol. Diazepam (Valium) enhances GABA activity that has been suppressed by chronic alcohol ingestion. Naltrexone (ReVia) is an opioid antagonist prescribed to block pharmacologic effects associated with opioids and alcohol.

Which statements are true regarding disulfiram (Antabuse) therapy? Select all that apply. O Disulfiram (Antabuse) is contraindicated in patients with low creatinine clearance. O Disulfiram (Antabuse) is contraindicated in patients with liver disease who are on naltrexone (ReVia). O Disulfiram (Antabuse) must be used very cautiously in patients with diabetes mellitus or hypothyroidism. O Disulfiram (Antabuse) should not be administered until the patient has abstained from alcohol for at least 12 hours. O Patients who take disulfiram (Antabuse) should carry a patient identification card stating the use of the drug.

Disulfiram (Antabuse) must be used very cautiously in patients with diabetes mellitus or hypothyroidism. Disulfiram (Antabuse) should not be administered until the patient has abstained from alcohol for at least 12 hours. Patients who take disulfiram (Antabuse) should carry a patient identification card stating the use of the drug. Rationale Disulfiram (Antabuse) therapy must be used very cautiously in patients with diabetes mellitus or hypothyroidism because this drug may cause a disulfiram-alcohol reaction. The nurse should instruct the patient to avoid alcoholic beverages, and therapy should be started after at least 12 hours of abstinence because alcohol may aggravate the patient. The patient should be provided an identification card that states the use of therapy, the symptoms that may occur because of therapy, and the emergency contact. Acamprosate (Campral) is contraindicated in patients with liver disease who take naltrexone (ReVia) because it may cause an alcoholic reaction and intoxication. Acamprosate (Campral) is contraindicated in patients with a creatinine clearance of less than 30 mL/min.

Which statement by a nursing student indicates a need for further teaching about disulfiram? Select all that apply. O Disulfiram increases the effects of caffeine. O Disulfiram inhibits the metabolism of diazepam. O Disulfiram has no drug interactions with metronidazole.. O Disulfiram inhibits the metabolism of phenytoin. O Disulfiram inhibits the anticoagulant effect of warfarin.

Disulfiram has no drug interactions with metronidazole Disulfiram inhibits the anticoagulant effect of warfarin. Rationale Disulfiram is used to treat alcohol abuse and may enhance the anticoagulant effect of warfarin. Concurrent administration of disulfiram and metronidazole may result in psychotic episodes and confusion: therefore these drugs are not recommended in combination. The cardiovascular and central nervous system effects of caffeine may be increased by disulfiram. Disulfiram inhibits the metabolism of specific benzodiazepines such as diazepam and phenytoin.

The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? Select all that apply.

Dressing if present Nails for shape, contour, color, thickness and cleanliness Skin for color, integrity, scars, lesions, and signs of breakdown Facial and body hair for distribution, color, quantity and hygiene

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

The nurse is informing a pregnant patient about the effects of alcohol consumption during pregnancy. Which fetal effects does the nurse include in the education? Select all that apply. O Macrosomia O Growth disorders O Delirium tremens O Mental retardation O Craniofacial abnormalities

Growth disorders Mental retardation Craniofacial abnormalities Rationale Alcohol consumption during pregnancy affects the fetus and causes fetal alcohol syndrome. The infant may have mental retardation or a growth disorder after birth. There may be craniofacial abnormalities, such as wide-set eyes and a flattened face or malformed body parts. Macrosomia is excessive weight in an infant after birth, seen in infants born to diabetic patients. Delirium tremens is a psychotic reaction seen in patients due to abrupt cessation of alcohol.

Which objective data are included in the assessment of a patient with a dependence problem? Select all that apply. O Gum and tooth problems O Needle tracks on forearms O Positive blood sample for drugs O Drug quantity is taken by the patient O Height, weight, vital sign measurements

Gum and tooth problems Needle tracks on forearms Positive blood sample for drugs Height, weight, vital sign measurements Rationale Gum and tooth problems may indicate methamphetamine ("meth") use. Needle tracks on forearms indicate the use of intravenous drugs. A blood sample is objective data; if it is positive, the nurse may need to investigate further. Height, weight, and vital sign measurements are objective data. The drug quantity used by each patient differs and is a subjective datum.

When a patient being treated for methamphetamine intoxication develops seizures, which drug does the nurse suspect to have caused this? O Clonidine (Catapres) O Haloperidol (Haldol) O Naltrexone (ReVia) O Buprenorphine (Buprenex)

Haloperidol (Haldol) Rationale Haloperidol (Haldol) is an antipsychotic agent used in the treatment of methamphetamine intoxication. However, it may lower seizure threshold in patients already at high risk for seizures. Clonidine (Catapres) is used to decrease tremors and agitation in patients with opioid toxicity. Naltrexone (ReVia) along with psychosocial treatment may reduce alcohol craving in patients with opioid abuse. Buprenorphine (Buprenex) has ceiling effects on analgesia and reduces respiratory depression in a patient with opioid abuse. However, these drugs are not used for the treatment of methamphetamine intoxication and may not cause seizures.

Which drug should be used cautiously in patients with amphetamine toxicity because it decreases the seizure threshold in a patient? O Oxazepam (Serax) O Haloperidol (Haldol) O Acamprosate (Campral) O Buprenorphine (Subutex)

Haloperidol (Haldol) Rationale Haloperidol (Haldol) reduces the seizure threshold in patients with amphetamine toxicity. Oxazepam (Serax) is used to treat anxiety. Buprenorphine (Subutex) has been approved for maintenance of opioid programs. Acamprosate (Campral) is used to prevent relapse in patients who abuse alcohol.

Who developed the humoral theory of mental illness? O Erik Erikson O Hippocrates O Philippe Pinel O Sigmund Freud

Hippocrates Rationale Hippocrates viewed mental illness as an imbalance of humors pertaining to body fluids. Pinel is the incorrect answer, he classified mental illness on the basis of behaviors. Freud is the incorrect answer, he theorized that personality has three parts-the id, the ego, and the superego. Erikson is the incorrect answer; he provided the framework for understanding personality development in terms of task mastery.

The health care provider prescribes blood tests for a patient brought to the emergency room after a motor vehicle accident (MVA), including blood alcohol levels. When reviewing the results, which laboratory results does the nurse note to indicate long-term alcohol abuse? Select all that apply. O Hypoglycemia O Hyperglycemia O Increased liver enzymes O Increased urinary alcohol O Abnormal blood protein levels O Elevated magnesium and hemoglobin

Hypoglycemia Increased liver enzymes Abnormal blood protein levels Rationale Hypoglycemia, increased liver enzymes, and abnormal blood protein levels occur with alcoholism. Hyperglycemia is not a consequence of long-term alcohol abuse. Alcohol in the urine is an indicator of a recent ingestion of alcohol and not long-term use. Lower magnesium levels and anemia are associated with long-term alcohol use.

Which statements by a patient indicate a need for further learning regarding precautions when taking disulfiram (Antabuse)? Select all that apply. O "I should avoid coffee." O "I Should avoid cough and cold elixirs for few days. O I should consume soups containing cooking sherry." O "I should use mouthwash regularly," O "I should wait at least 2 hours after taking the drug before consuming alcohol.

I should consume soups containing cooking sherry." "I should use mouthwash regularly," "I should wait at least 2 hours after taking the drug before consuming alcohol. So close! Rationale Disulfiram (Antabuse) is prescribed to promote abstinence in a patient who abuses alcohol. The patient should not consume soups containing cooking sherry because they may contain alcohol. Because mouthwashes mostly contain alcohol, the patient should be advised to avoid them. Because disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting if alcohol is ingested, the patient should avoid alcohol completely. Cardiovascular and central nervous system effects may be increased by disulfiram (Antabuse) and may lead to tachycardia and nervousness. Therefore the patient should be advised to avoid coffee. The patient should avoid cold and cough elixirs for some time because they may contain alcohol.

An older patient who has been recently admitted to a long-term care facility has been staying in his room and not attending meals or activities since his son was killed in a car accident. Which concern would be the highest priority for this patient? O Grieving related to loss of son O Isolation related to loss of son O Grief related to relocation to a nursing home O Inability to cope related to the number of personal losses

Inability to cope related to the number of personal losses Rationale Losses occur with age. The number of losses and the rapidity with which they occur may affect the coping ability of the older person and result in anxiety, fear, or depression. Hopelessness related to relocation is not a priority; the patient is dealing with loss rather than relocation. Social isolation is not the highest priority. The patient is showing signs of depression as a result of his losses. The patient is not effectively grieving, so this concern would not be a priority at this

The infant

Infancy includes the period between 4 weeks and 1 year of age. Developmental tasks involve the goals of developing social competence and mastery of skills necessary for functioning in an environment. • Some developmental tasks of infancy include weaning, locomotion, self-feeding, and acquiring language. The development of a sense of trust begins in infancy. The infant's birth weight doubles by 6 months and triples by 1 year of age. • The infant is in Piaget's sensorimotor stage of development. Object permanence involves knowing an object is there even though it is not in sight. The infant is in Freud's oral stage of development. Sucking and exploring textures with the mouth are normal behaviors. Separation anxiety begins at 6 months of age when the infant protests if the parent leaves the room. • Language development involves both verbal language and body language. Verbal language involves expression and receiving (understanding) communication from others. Egocentric behavior is evidenced by the 1-year-old, who relates all toys to his or her own body.

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

Inflammatory or (lag) phase Maturation or (remodeling) phase Proliferative or (connective tissue repair) phase

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable.

An elderly patient on an orthopedic unit is experiencing joint stiffness. Which intervention should the nurse implement to assist the patient to feel more comfortable? O Perform passive range-of-motion exercises O Decrease mobility O Maintain strict bed rest O Limit any physical activity

Perform passive range-of-motion exercises

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which condition in a patient is a sign of Wernicke's encephalopathy?

Involuntary eye movement the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).

A patient on disulfiram (Antabuse) therapy has altered mental status. Which medication could be responsible for this condition? O Phenytoin (Dilantin) O Isoniazid (Nydrazid) O Estazolam (ProSam) O Metronidazole (Flagyl)

Isoniazid (Nydrazid) Rationale Disulfiram (Antabuse) inhibits the metabolism of isoniazid (Nydrazid), which results in alterations in mental status: Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychotic episodes and confusion. Disulfiram (Antabuse) inhibits the metabolism of phenytoin (Dilantin), resulting in nystagmus, sedation, and lethargy. Disulfiram (Antabuse) inhibits the metabolism of benzodiazepines such as estazolam (Flagyl), resulting in benzodiazepine toxicity.

The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions?

It is caused by a tick carried by deer.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is melanoma. Does the nurse understand that which describes a characteristic of this type of lesion? O Metastasis is rare. O It is encapsulated. O It is highly metastatic. O It is characterized by local invasion. O Lesion is a nevus that has changed in color.

It is highly metastatic.

A young patient says that he gets annoyed when friends tell him that he drinks too much. He also reports that sometimes he thinks he should try and cut down a little on his drinking. The nurse in the clinic would draw which conclusion about the likelihood that the patient has alcoholism based on the CAGE questions? O It is probable that the patient has alcoholism. O The patient probably does not have alcoholism. O There is an increased risk to develop alcoholism. O The information provided is inadequate for making any determination.

It is probable that the patient has alcoholism. Rationale There are four CAGE questions. Two affirmative answers on the CAGE questions indicate probable alcoholism. The patient answered affirmatively to two of the questions. That is sufficient to indicate probable alcoholism. The CAGE questions do not indicate risk for developing alcoholism. Even though answers to only two of the four questions are revealed, those two answers are enough to make a determination.

The purpose of the Clinical Institute Narcotic Assessment (CINA) rating scale is to perform which function? O it evaluates the patient's level of addiction. O It estimates the patient's degree of tolerance. O It determines the need for narcotics for pain relief. O It is used to assess patients undergoing opioid withdrawal.

It is used to assess patients undergoing opioid withdrawal Rationale The CINA rating scale is helpful in assessing and monitoring patients undergoing opioid withdrawal. The CINA rating scale is not used to determine the need for narcotics for pain relief, does not measure a patient's level of addiction, and does not estimate the patient's degree of tolerance.

What instruction should the nurse give to an elderly patient diagnosed with presbyopia? O Avoid exposure to direct sunlight O Keep bright-colored objects in your home. O Drink 1000 mL of liquids per day O Eat five protein-rich meals er day

Keep bright-colored objects in your home.

The family member of an elderly patient living alone is concerned about safety. During family teaching, what should the nurse focus on to prevent accidents from occurring? O Taking all measure to prevent accidents from ever happening O Addressing any accidents after the occurrence O Knowledge and recognition of factors that can cause accidents O Manipulation of the environment to eliminate all accidents

Knowledge and recognition of factors that can cause accidents

The nurse is caring for a patient with bipolar disorder. What should the nurse expect to be prescribed to the patient to manage the mood swings of this disorder?

Lithium carbonate- prescription medicine used to treat the symptoms of Bipolar Disorder

The infant pt

Major risk factors for heart disease begin developing in early childhood. Regular physical activity can help slow the development of these risk factors. • Infants should be placed in environments that stimulate movements and exercise. • A natural pattern of intermittent play is age-appropriate physical activity for infants. Breast milk is the best food for infants under 6 months of age, and mothers should be encouraged to continue to provide breast milk until 1 year of age. To prevent SIDS, infants should be placed on their backs to sleep. By 1 year of age, the infant eats table food three times a day. • At 1 year of age, whole milk can be introduced, but low-fat milk should not be provided to children under 2 years of age. • The most common type of dental caries in infants is nursing caries, which are preventable. • A childproof home is essential for preventing accidents.

A patient on disulfiram (Antabuse) therapy is reported to have frequent psychotic episodes and confusion. Which medication is responsible for this condition? O Phenytoin (Dilantin) O Isoniazid (Nydrazid)) O Estazolam (ProSom) O Metronidazole (Flagyl)

Metronidazole (Flagyl) Rationale Disulfiram (Antabuse) is used in alcohol rehabilitation programs: Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychotic episodes and confusion. Disulfiram (Antabuse) inhibits the metabolism of phenytoin (Dilantin), resulting in nystagmus, sedation, and lethargy. Disulfiram (Antabuse) inhibits the metabolism of isoniazid (Nydrazid), which results in alterations in mental status. Disulfiram (Antabuse) inhibits the metabolism of estazolam (ProSom), resulting in benzodiazepine toxicity.

Which drug is the most commonly used illegal drug in the United States? O Cocaine O Marijuana O Phencyclidine (PCP) and lysergic acid diethylamide (LSD) O 3,4-methylenedioxymethamphetamine (MDMA; Ecstasy)

Marijuana Rationale Marijuana is considered a gateway drug and remains the most commonly used illicit drug used in the United States. Cocaine, MDMA, PCP, and LSD are often abused, but they are not the most commonly used illegal drugs in the United States.

Which factors determine the sensorial function of a patient? Select all that apply. O Speech O Memory O Attention O Orientation. O impulse control

Memory Attention Orientation. Rationale Nursing assessments of a patient's emotional status make it possible to adjust the plan of care appropriately. Sensory function describes the patient's memory, attention, orientation, and ability to think abstractly. Speech patterns describe the patient's speech. Degree of impulse control is assessed to know the patient's potential for danger. Other factors in a patient's potential for danger indude the patient's potential for self-harm and previous history of violence or aggression toward others.

Which inference would the nurse make about a patient who is demonstrating maladaptive behavior and has lost contact with reality?

Mental illness

A patient with anxiety who reports nausea and vomiting is exhibiting argumentative behavior. Which degree of anxiety is the patient experiencing? O Mild O Moderate O Severe O Panic

Moderate Rationale A patient's degree of anxiety is described in levels. Each level consists of certain behaviors. Moderate anxiety is characterized by feelings of tension, decreased perception, and some alertness in certain situations. Patients with moderate anxiety may tend to argue, tease, or complain. Headaches, diarrhea, nausea, vomiting, and low back pain are physical signs and symptoms exhibited by patients with moderate anxiety. Increased motivation is seen in patients with mild anxiety. Extreme terror and distortion of reality are seen in patients who are at the panic level of anxiety. Patients with severe anxiety feel fatigue.

patient with anxiety who reports nausea and vomiting is exhibiting argumentative behavior. Which degree of anxiety is the patient experiencing? O Mild O Moderate O Severe O Panic

Moderate Rationale A patient's degree of anxiety is described in levels: Each level consists of certain behaviors Moderate anxiety is characterized by feelings of tension, decreased perception, and some alertness in certain situations Patients with moderate anxiety may tend to argue, tease; or complain, Headaches, diarrhea, nausea, vomiting, and low back pain are physical signs and symptoms exhibited by patients with moderate anxiety. Increased motivation is seen in patients with mild anxiety Extreme terror and distortion of reality are seen in patients who are at the panic level of anxiety, Patients with severe anxiety feel fatigue.

The nurse is examining a patient who has been prescribed hormone replacement therapy (HRT). Which intervention should the nurse follow to ensure safe administration of the medication? Select all that apply. O Vision O Monitor for changes in the patient's breasts. O Monitor for changes in the patient's blood pressure. O Oral Cavity O Urine output

Monitor for changes in the patient's breasts. Monitor for changes in the patient's blood pressure.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

Which intervention is a priority while providing care for an addicted patient being treated with chlordiazepoxide? O Avoiding between-meal snacks: O Monitoring the patient's blood reports. O Avoiding night-lights in the patient's room O Monitoring the patient's intake and output

Monitoring the patient's intake and output Rationale Chlordiazepoxide may cause urinary retention in the patient. The nurse must monitor the patient's intake and output so any change can be reported promptly to the health care provider. The patient may also suffer from loss of appetite; between-meal snacks are helpful to meet nutritional deficits. Blood reports are monitored for some medications, but not for chlordiazepoxide. The patient may experience disorientation at night, night-lights should be used in the room, along with frequent visits by the nurse.

Over the years, several theories have evolved about the cause of alcoholism, and treatment modalities have changed in accordance with new information and understanding. The nurse who has worked for many years in the treatment of substance misuse and abuse based on which cause of alcoholism will have difficulty including the newer theories in his or her care? O Familial trait O Ethnic trait O Moral failing O Biologic cause

Moral failing Rationale The belief that alcoholism is a moral failing or is caused by moral fault provided the basis for much of the early treatment of alcoholic patients. The theory's influence on treatment modalities has largely been replaced by recognition of biologic influences, including familial and ethnic influences; those providers who base their regimen on the moral theory have difficulty assimilating the new biologic theories into their care.

An adolescent is admitted to the medical facility with severe respiratory depression and risk for coma. Which drug will be administered to the adolescent? O Naloxone O Diazepam O Flurazepam O Methadone

Naloxone Rationale Severe respiratory depression and a risk for coma are signs of opioid overdose. Naloxone is administered to the patient along with ventilation support. Diazepam and flurazepam are benzodiazepines that are used as anticonvulsants. Methadone is used to suppress withdrawal symptoms in morphine or heroin addicts..

An adolescent is admitted to the medical facility with severe respiratory depression and a risk for coma. Which drug will be administered to the adolescent?

Naloxone- is a medication designed to rapidly reverse opioid overdose. It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids.

Which medication is prescribed to block the pharmacologic effects of opioids and alcohol? O Naltresone (ReVia) O Disulfiram (Antabuse) O Clorazepate (Tramene) O Acamprosate (Campral)

Naltresone (ReVia) Rationale Naltrexone (ReVia) is prescribed to block the pharmacologic effects associated with opioids and alcohol. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting. Clorazepate (Transene) is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Acamprosate (Campral) helps patients maintain alcohol abstinence.

In addition to psychosocial treatment, which therapy does the nurse anticipate will be ordered for a patient admitted for morphine abuse? O Verapamil (Calan), O Naltrexone (ReVia) O Propranolol (inderal) O Flumazenil (Romazicon)

Naltrexone (ReVia) Rationale Naltrexone (ReVia) is an opioid antagonist prescribed to block the pharmacologic effects of the high associated with alcohol and opioids, such as morphine. Flumazenil (Romazicon) is a benzodiazepine antagonist and is used to treat benzodiazepine overdose. Propranolol (Inderal) is an adrenergic beta blocker and is indicated for treating high blood pressure and tachycardia, which may occur with amphetamine toxicity. Verapamil (Calan) is used for the treatment of cocaine abuse.

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage?

Neurological deficits

A client has a non-infected pressure ulcer on the left heel. The nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure?

Normal saline

Which statements by a patient recovering from alcoholism come from the 12 steps of Alcoholics Anonymous (AA)? Select all that apply. O "Take control of our lives. O "Admit that we have power over alcohol. O "Humbly ask Him to remove our shortcomings." O "Make a searching and fearless moral inventory of ourselves." O "Rely on ourselves to obtain power over the abuse of alcohol." O "Make amends to others wherever possible, except when to do so would injure them or others."

O "Humbly ask Him to remove our shortcomings." O "Make a searching and fearless moral inventory of ourselves." O "Make amends to others wherever possible, except when to do so would injure them or others." Rationale AA purports that individuals are powerless over alcohol. AA supports reliance on a higher power to restore one to sanity and to stop abusing alcohol. It puts the higher power in control, not personal control. It asks the higher power to remove shortcomings. The individual must make an inventory of one's self. Additionally, the individual must make amends to others unless doing so would injure them.

The school nurse is speaking to a group of adolescents about drug and alcohol abuse. When listening to the school nurse talk about drug and alcohol abuse, a student asks the nurse, "Why do people make such a big deal about drinking alcohol? Having a beer every now and then doesn't seem that dangerous. In France, there isn't even a legal drinking age. O " The school nurse correctly makes which response? O "It's my job to make a big deal about drug and alcohol abuse, that's why." O "A person must be 21 years of age to buy and consume alcohol in the United States." O "Alcohol carries the highest risk of dependence and addiction of all known substances." O "Many multidrug users began by abusing alcohol and progress to abusing other substances."

O "Many multidrug users began by abusing alcohol and progress to abusing other substances." Rationale Alcohol is considered a gateway drug, which may lead to the use and abuse of other substances. It is not the school nurse's job to make a "big deal" about drug and alcohol abuse. Although a person does need to be 21 years of age to buy and consu

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning? O "Nicotine gum will help decrease nicotine dependence." O CNS stimulants are helpful in treating nicotine addiction." O "The nicotine transdermal patch is the least beneficial option" O Only 10% of people who quit smoking will experience relapse

O "Nicotine gum will help decrease nicotine dependence." Rationale Nicotine gum helps deliver decreasing doses of nicotine and blocks the reinforcing effect of smoking making it an effective treatment option to decrease nicotine dependence. Central nervous system (CNS) stimulants are not effective in treating nicotine dependence; they cause hypertension, diarrhea, and nausea and have other adverse effects. The nicotine transdermal patch works in the same way as nicotine gum and is an effective treatment option. 70% of people who quit smoking will have a relapse within a year,

The nurse finds that a patient is overusing the mechanisms of introjection, denial, eating and reaction formation in daily life. Which suspicion would the nurse have about the patient's mental health? O May be undergoing a crisis O Has maladaptive behavior O Has a high level of anxiety O May have low self-esteem

O Has maladaptive behavior

When a patient with a history of alcoholism is admitted for treatment of alcohol withdrawal and is dehydrated, which vitamin would the nurse administer to the patient before administering IV glucose for rehydration? O A O B1 O D O E

O B1 O D O E Rationale A history of alcoholism may result in vitamin B1 (thiamine) deficiency, which is a factor in underlying alcohol-induced brain damage. Thiamine should be given before administering IV glucose to prevent Wernicke's encephalopathy. Vitamins A, D, and E are not given before administering IV glucose.

A patient reports an inability to control alcohol cravings because of withdrawal symptoms. Which medications are beneficial to treat this condition? Select all that apply. O Beta-blockers O Alpha agonists O Opioid agonists O Narcotic antagonists O N-methyl-D-aspartate receptor (NMDA) antagonists

O Beta blockers O Alpha agonists Rationale Beta blockers block the beta-adrenergic receptor in the heart and alpha agonists show agonistic action on presynaptic alpha receptors; these drugs can be used to treat withdrawal symptoms and cravings associated with alcohol. Opioid agonists show antagonist properties that involve a ceiling effect on analgesia and respiratory depression. Narcotic antagonists are prescribed for opioid maintenance programs. NMDA antagonists are administered in alcohol rehabilitation programs for chronic alcoholic patients who want to maintain sobriety

A patient who is addicted to alcohol is undergoing detoxification in a drug treatment facility. Approximately 8 hours after admission, the nurse notes that the patient is experiencing tremors of the hands, nervousness, and restlessness, which are worsening. When the nurse contacts the provider, which prescriptions does the nurse expect from the primary care provider? O Naloxone or disulfiram O Haloperidol or risperidone O Furosemide or spironolactone O Chlordiazepoxide or lorazepam

O Chlordiazepoxide or lorazepam Rationale Chlordiazepoxide and lorazepam are benzodiazepines. They are classified as antianxiety medications, or anxiolytics. They are frequently used to treat the tremors and heightened anxiety associated with alcohol withdrawal. Haloperidol and risperidone are antipsychotic agents used to treat schizophrenia and psychosis. Furosemide and spironolactone are diuretics used to treat congestive heart failure. Naloxone is the antidote to opiate overdose, and disulfiram is used as aversion therapy for patients to avoid a relapse of alcohol consumption.

A patient is having trouble abstaining from alcohol. Which drug is often prescribed to encourage abstinence? O Disulfiram O Bupropion O Chlordiazepoxide O Chlorpromazine

O Disulfiram Rationale Disulfiram is the drug of choice if medication is given. It causes facial flushing, nausea, tachycardia, dyspnea, dizziness, and confusion. Chlordiazepoxide is an antianxiety drug. Chlorpromazine is an antipsychotic drug. Bupropion is an antidepressant drug.

A patient undergoing treatment for withdrawal symptoms of alcohol abuse complains of drowsiness, headache, and fatigue. Which drug may be responsible for the patient's condition? O Naltrexone (ReVia) O Clonidine (Catapres) O Disulfiram (Antabuse) O Acamprosate (Campral)

O Disulfiram (Antabuse) Rationale Disulfiram (Antabuse) is used to treat withdrawal symptoms of alcohol abuse and causes side effects such as drowsiness, headache, and fatigue. Naltrexone (ReVia) reduces the rewarding effects of alcohol; it does not cause drowsiness, headache, and fatigue. Clonidine (Catapres) is used to treat rigidity and tremors in patients with opioid abuse. Acamprosate (Campral) is prescribed to chronic alcoholic patients who want to maintain sobriety. It mainly causes diarrhea and suicidal tendencies.

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which condition in a patient is a sign of Wernicke's encephalopathy? O Involuntary eye movement O Hypoglycemia O Potential for violence O Increased serum magnesium levels

O Involuntary eye movement Rationale Eye abnormalities such as nystagmus or paralysis of the lateral rectus muscles indicate Wernicke's encephalopathy. Hypoglycemia is not indicative of Wernicke's encephalopathy; however, administration of glucose-containing intravenous (IV) solutions to the patient may precipitate Wernicke's encephalopathy in a previously unaffected patient. Most patients with Wernicke's encephalopathy have decreased serum magnesium levels and other signs of malnutrition. Potential for violence is not related to Wernicke's encephalopathy.

Which inference would the nurse make about a patient who is demonstrating maladaptive behavior and has lost contact with reality? O Large ego O Mild anxiety O Mental illness O Poor self-concept

O Mental illness Rationale Maladaptive behavior is a characteristic of mental illness. Loss of contact with reality can result when an individual is suffering from mental illness. Distortion of reality is one of the symptoms that can be seen in patients with panic-level anxiety but not in patients with mild anxiety. Patients with large egos are in contact with external reality. Self-concept includes all perceptions and values held and all behaviors and interactions performed. Poor self-concept is a characteristic identified in mental illness.

A patient is being evaluated in the emergency room for a possible drug overdose. The nurse notes that the patient is stuporous, has pinpoint pupils, and has severe respiratory depression. The health care provider orders a urine toxicology screen, stat. Which substance does the nurse anticipate receiving a positive result for in the urine screen? O Opiates O Cocaine O Amphetamines O Cannabis

O Opiates Rationale Decreased level of consciousness, pinpoint pupils, and respiratory depression are indicators of opiate overdose. Cannabinol is the active ingredient in marijuana and does not cause central nervous system (CNS) depression. Both cocaine and amphetamines are CNS stimulants.

The nurse observes a loss of appetite in a patient being treated for addiction. Which prescription would most likely be prescribed by the health care provider? O Phenytoin O Propranolol O Thiamine O Chlordiazepoxide

O Thiamine Rationale The administration of thiamine helps improve the patient's nutritional state. Phenytoin is an anticonvulsant medication used to treat seizures in an addicted patient. Propranolol is useful in treating cardiorespiratory distress. Chlordiazepoxide is used to treat tremors and nervousness in an addicted patient.

Which statement by the nurse about alcohol withdrawal syndrome indicates effective learning? O "Gastrointestinal bleeding can occur if a heavy drinker abruptly quits drinking." O Tremors are seen in a patient who abruptly quits drinking." O "Seizures occur in the patient a few days after alcohol cessation." O "Younger people are more at risk for alcohol withdrawal syndrome."

O Tremors are seen in a patient who abruptly quits drinking." Rationale Abrupt cessation of alcohol in an alcoholic patient may cause withdrawal symptoms such as tremors, agitation, and hallucinations. The tremors can occur in the hands and may also be seen in the tongue, the chin, the trunk, and the feet, 6 to 48 hours after the last drink. Gastrointestinal bleeding can occur as a result of chronic alcohol use, rather than abruptly stopping ingestion. Seizures can occur 12 to 24 hours after alcohol cessation. Withdrawal symptoms are seen more often in older adults, those who have suffered from delirium tremens, and those who have another acute illness or are malnourished.

A chronic alcoholic patient reports an inability to control alcohol cravings and the nurse plans to admit the patient into an alcohol rehabilitation program. Which medication is beneficial to treat this condition? O Alpha agonist O Opioid agonist O Narcotic antagonist O ON-methyl-D-aspartate receptor (NMDA) antagonist

ON-methyl-D-aspartate receptor (NMDA) antagonist Rationale NMDA antagonists are administered in alcohol rehabilitation programs to chronic alcoholic patients who want to maintain abstinence from psychoactive drug use. Alpha agonists are prescribed to reduce cravings and treat alcohol withdrawal symptoms. Opioid agonists show antagonist properties that involve a ceiling effect on analgesia and respiratory depression. Narcotic antagonists are prescribed for opioid maintenance programs.

A patient who is admitted involuntarily to a psychiatric facility is angry and wants to leave to see his wife. Which nursing intervention would be appropriate? O Encouraging the patient to talk to other patients O Has maladaptive behavior O Offering as much flexibility in visiting hours as possible O Offering the patient as-needed (PRN) lorazepam (Ativan) O Refusing to let him see family because his admission is involuntary)

Offering as much flexibility in visiting hours as possible Rationale The nurse should offer as much flexibility in visiting hours as possible to reduce the frustration of separation in the individual and the family. Encouraging the patient to talk to peers does not address the source of his frustration. Refusing to let him see family is incorrect; involuntarily admitted patients still have the right to visitors. Offering the patient PRN lorazepam (Ativan) at this time does not address the source of his anger.

What is responsible for rapid deinstitutionalization as a result of severe fiscal cuts? O Electroconvulsive therapy O Committee for Mental Hygiene O President's Commission on Mental Health O Omnibus Budget Reconciliation Act (OBRA))

Omnibus Budget Reconciliation Act (OBRA)) Rationale The OBRA, passed during President Reagan's administration, is responsible for drastically reducing funding for the mental health system. The President's Commission on Mental Health assessed mental health care needs of the nation and made recommendations of action for the government to take. The Committee for Mental Hygiene was developed in response to a book that a mental patient wrote while hospitalized for 3 years, detailing beatings, isolation, and confinement. Electroconvulsive therapy is a treatment option that was developed during the 1930s; it is not credited with deinstitutionalization.

The nurse is caring for a patient who is experiencing a mental health crisis after losing his spouse. Which patient outcome indicates that the nursing interventions are effective? O Organizes resources O Rationalizes his behavior O Returns to a precrisis state O Finds ways to engage himself O Emotional stress is decreased

Organizes resources Returns to a precrisis state Finds ways to engage himself Emotional stress is decreased Rationale Short-term active support provided by the nurse focuses on problem-solving and helps facilitate a positive resolution to the crisis. The nurse should assist the patient to organize and mobilize the resources for support. The patient returning to precrisis state is an outcome expected after performing interventions and indicates that the patient has overcome the crisis. The nurse should help the patient find out ways to engage himself to avoid loneliness. Rationalizing one's behavior is a defense mechanism.

What are woman at the highest risk for because of the gradual physical changes that occur during middle adulthood (ages 40 to 65)? O Osteoporosis O Diabetes O Heart Disease O Respiratory problems

Osteoporosis

A patient with chronic alcohol ingestion presents for detoxification. Which medications would be beneficial for this condition? Select all that apply. O Oxazepam (Serax). O Disulfiram (Antabuse) O Clorazepate O Acamprosate (Campral) O Carbamazepine (Tegretol)

Oxazepam (Serax) Clorazepate Rationale Oxazepam (Serax) and clorazepate (Tranxene) are administered for detoxification from chronic alcohol ingestion. They enhance gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Disulfiram (Antabuse) is used to reduce the desire for alcohol in patients with chronic alcohol ingestion. Acamprosate (Campral) is used to treat chronic alcoholic patients who want to maintain sobriety. Carbamazepine (Tegretol) is used to decrease seizure frequency and some psychiatric symptoms associated with alcohol withdrawal.

An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply.

Palpation Induration

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area? O Intact skin O The presence of tunneling O A deep, crater-like appearance O Partial-thickness skin loss of the epidermis

Partial-thickness skin loss of the epidermis

A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury?

Pat the skin dry after bathing.

A patient is scheduled to retire within the next year. Which action if taken by the patient will lead to positive outcomes related to the psychological adjustment during the retirement phase? O Making sure retirement is desired before strategic plans are finalized O Focusing on the family and planning retirement to accommodate these needs O Waiting until retirement occurs and then planning how to spend the retirement period O Planning and discussing hopes and expectations for the retirement period

Planning and discussing hopes and expectations for the retirement period

The use of toys to assist a child to express feelings is known as which type of treatment?

Play therapy

Which characteristics are associated with a patient with mental illness? Select all that apply.

Poor self-concept Maladaptive behavior Avoidance of problems

Which characteristics does the nurse expect in a mentally ill patient as evidence of improved mental health? Select all that apply.

Positive self-concept Adaptability to change Acceptance of emotions

Which function does naloxone serve in Suboxone sublingual film? O Reduces respiratory depression O Minimizes withdrawal symptoms O Decreases tremors and agitation O Prevents abuse of buprenorphine

Prevents abuse of buprenorphine Rationale Suboxone is a combination of naloxone and buprenorphine that is used to treat opioid toxicity. The naloxone in the Suboxone product is used to prevent abuse of the buprenorphine as a narcotic antagonist. Buprenorphine has a ceiling effect on analgesia and respiratory depression in a patient with opioid abuse. Naloxone may not be helpful in minimizing withdrawal symptoms, Clonidine is used to decrease tremors and agitation in patients with oploid toxicity.

After assessing an infant, the nurse finds that the infant is at a high risk of developing the bottle-mouth syndrome. What feeding activity would be advisable to ensure the infant's safety? O Adding a bit of sugar to the formula O Providing only water in the bottle during a bedtime feeding O Avoiding breast-feeding the infant late at night or early in the morning O Providing only natural juices when feeding the infant from a bottle

Providing only water in the bottle during a bedtime feeding

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? O Rapid and continual rewarming of the toes when flushing occurs O Rapid and continual rewarming of the toes in cold water for 45 minutes O Rapid and continual rewarming of the toes in hot water for 15 to 20 minutes O Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The parents of a child are worried because the child tattles on others to justify his or her mistakes. Which defense mechanism should the nurse document in the child's medical record?

Rationalization

The parents of a child are worried because the child tattles on others to justify his or her mistakes. Which defense mechanism should the nurse document in the child's medical record? O Regression O Introjection O Identification O Rationalization

Rationalization Rationale Rationalization is a process of constructing plausible reasons to explain and justify one's behavior. People who use rationalization as a defense mechanism deny their actual thoughts and justify their actions by giving untrue, but seemingly more acceptable, reasons for their behavior. Regression is exhibition of behavior, thoughts, or feelings that characterize the earlier stages of a person's development. A quality or attribute of another person is internalized in people with introjection behavior. Identification is the defense mechanism where the person incorporates a characteristic thought or behavior of another person or group in his own

The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection?

Red, shiny skin around the nail bed

A patient with schizophrenia is admitted to the hospital. Which objectives does the nurse consider in planning the interventions to help the patient? Select all that apply.

Reducing anxiety Improving social interactions Improving orientation to reality

Which outcome is expected by the nurse after administering loperamide to a patient with substance abuse? O Decrease in seizure frequency O Decrease in tremors and sweating O Reduction of skeletal muscle spasms O Reduction of gastrointestinal cramping

Reduction of gastrointestinal cramping Rationale Loperamide reduces gastrointestinal cramping and diarrhea in patients with opioid abuse. Carbamazepine, decreases seizure frequency and relieves some of the psychiatric symptoms associated with alcohol withdrawal. Clonidine is used to decrease tremors, sweating, and agitation in patients with opioid abuse Cyclobenzaprine reduces skeletal muscle spasms.

After assessing a patient with substance abuse, the healthcare provider prescribes cyclobenzaprine (Flexeril). Which outcome is expected? O Decrease in seizure frequency O Decrease in tremors and sweating O Reduction of skeletal muscle spasms O Reduction of gastrointestinal cramping

Reduction of skeletal muscle spasms Rationale Cyclobenzaprine (Flexeril) reduces skeletal muscle spasms without interfering with muscle function. Carbamazepine (Carbatrol) is effective in decreasing seizure frequency and some psychiatric symptoms associated with alcohol withdrawal. Clonidine (Catapres) is used to decrease tremors, sweating, and agitation with opioid abuse. Dicyclomine (Dicyclocot) reduces gastrointestinal cramping and diarrhea in patients with opioid abuse.

The parents of a 10-year-old child report that the child wets the bed when tests are scheduled at school. Which defense mechanisms does the nurse suspect the child is using?

Regression

Which effective technique is used to help older adults cope with changing life circumstances? O Meditation O Reminiscing O Vigorous exercise O Listening to music

Reminiscing

The nurse observes that one of the team members is often absent from the unit. The team member also exhibits excessive discrepancies in documenting procedures that are related to controlled substances. Which action should the nurse take?

Report the behavior to the supervisor.

A school nurse is asked to provide an in-service on inhalants to high school students. During the in-service, the nurse discusses the variety of volatile chemical substances that can alter thinking and emotions when inhaled. Which risks associated with ingesting high doses of inhalants should be included in the in-service?

Respiratory arrest, brain damage, and kidney damage

Which goal in planning care for a patient in crisis is the nurse's primary concern? O Reinforce positive behaviors. O Schedule counseling for the patient. O Restore the patient's psychological equilibrium. O Have the patient develop insight regarding the crisis.

Restore the patient's psychological equilibrium. Rationale Restoring the patient's psychological equilibrium is the correct answer because the primary goal of crisis intervention is that the patient will return to precrisis status. Having the patient develop insight is important, but not a priority. Once the patient's condition is stable, the nurse could work with the patient on developing insight. Scheduling counseling is an action, not a goal in planning care for a patient in crisis.

Which symptoms are associated with alcohol withdrawal? Select all that apply. O Seizures O Hyperactivity O Hypersomnia O Hallucinations O Increased appetite

Seizures Hyperactivity Hallucinations Rationale Alcohol withdrawal symptoms can begin within a few hours of discontinuation of drinking and may continue for 3 to 10 days. Withdrawal symptoms include visual and auditory hallucinations, seizures, and hyperactivity. Hypersomnia and increased appetite are withdrawal symptoms of cocaine.

An elderly patient is lying in the room crying. When questioned, the patient admits to being frustrated about having to live alone, the loss of a spouse, and not being able to see the grandchildren. This patient is experiencing which stage of development? O Senescence stage O Parenthood stage O committed stage O establishment stage

Senescence stage

A fatigued patient tells the nurse, "I have a feeling that something will go wrong." The nurse is having difficulty communicating with the patient because the patient's communication is distorted. The nurse also notices a marked increase in the patient's blood pressure. Which level of anxiety would the nurse document in the patient's medical record? O Mild O Panic O Severe O Moderate

Severe Rationale Feelings of impending danger, distorted communication, fatigue, and changes in vital signs are characteristic features of a severe level of anxiety. Mild anxiety is characterized by a slight increase in vital signs, heightened awareness, and increased motivation. Panic is characterized by extreme terror, possible immobilization, and distortion of reality. A patient with moderate anxiety feels tense, has decreased perception, and may be prone to arguing, teasing, or complaining

Which behaviors are common with mental illness? Select all that apply. O Shock O Anger O Denial O Excitement O Vargaining

Shock Anger Denial

The nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect which amount of discomfort during the procedure?

Slight because the local anesthetic may burn or sting

A patient reports, "I've had a kidney stone for the past 3 months." On diagnosis the health care provider finds the patient's renal function is normal. Which mental disorder is the patient suffering from?

Somatic delusions- defined as fixed false beliefs that one's bodily function or appearance is grossly abnormal. They are a poorly understood psychiatric symptom and pose a significant clinical challenge to clinicians.

Nursing interventions during detoxification are geared toward ensuring the safety of the patient and assisting the patient to progress through the detoxification process. Which nursing interventions would be appropriate for all patients undergoing detoxification? Select all that apply.

Speaking in a calm voice Keeping instructions and explanations simple Monitoring cardiovascular, respiratory, and neurologic function Facilitating a peaceful environment with reduced environmental stimul

Nursing interventions during detoxification are geared toward ensuring the safety of the patient and assisting the patient to progress through the detoxification process. Which nursing interventions would be appropriate for all patients undergoing detoxification? Select all that apply. O Speaking in a calm voice O Keeping instructions and explanations simple O Administering sedative-hypnotics for insomnia O Monitoring cardiovascular, respiratory, and neurologic function O Facilitating a peaceful environment with reduced environmental stimuli O Maintaining nothing by mouth (NPO) status and intravenous (IV) hydration

Speaking in a calm voice Keeping instructions and explanations simple Monitoring cardiovascular, respiratory, and neurologic function Facilitating a peaceful environment with reduced environmental stimuli Rationale Speaking in a calm voice and facilitating an environment with reduced stimuli helps to reduce stress experienced by the patient, as does keeping instructions and explanations simple. Detoxification can result in life-threatening cardiovascular, respiratory, and neurologic complications, so monitoring for changes in vital functions is essential. Many addicted patients are malnourished and have a lack of appetite. Incorporating nutritious foods and inquiring about food preferences will help address nutritional deficits. NPO orders with IV hydration only would not be a standard approach. Offering the patient a snack or a back rub for insomnia would be preferred to providing medications such as sedative hypnotics, which could further impair neurologic function and mask adverse neurologic responses to detoxification.

The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category?

Stage II

Which defense mechanism has a positive influence on the person's behavior? O Denial O Regression O Sublimation O Displacement

Sublimation Rationale Sublimation is a defense mechanism characterized by the discharge of sexual or aggressive energy and impulses in a socially acceptable way. This would include investing the energy in sports or any other activities with a positive influence on mental health. Denial is disregard for reality. Regression is a defense mechanism characterized by the exhibition of behavior, thoughts, or feelings used at an earlier stage of development, like a 10-year-old child regressing to thumb sucking, Displacement is the process of expressing emotions toward someone or something other than the actual source of the emotion, such as yelling at family members because of issues at the office.

A 17-year-old patient who plays competitive sports has trouble dealing with aggression. Which defense mechanism is this patient displaying? O Regression O Sublimation O Displacement O Rationalization

Sublimation Rationale Sublimation is the discharge of sexual or aggressive energy and impulses in a socially acceptable manner, such as sports or exercise. Rationalization is justification of one's behavior by giving untrue but seemingly more acceptable reasons for behavior. Regression is the display of behavior used at an earlier stage of development. Displacement is the expression of emotions toward someone other than the actual source of the emotion.

A nurse on a pediatric unit is rounding on assigned patients. What interaction, if witnessed by the nurse during rounds, would be of great concern? O A rocking chair is used to put an infant to sleep O A baby's bottle is propped on a pillow during feeding O The baby's bottle is propped on a pillow during feeding. O A father is gently massaging his infant's scalp

The baby's bottle is propped on a pillow during feeding.

The nurse is observing a toddler's psychosocial development based on Erikson's theory. What should be assessed in the child to find if the child has achieved age-appropriate development? O Feels inferior to his or her peers O feels guilty for not performing well O The child can say a four-word sentence. O Acts like an adult

The child can say a four-word sentence.

The nurse is assessing the cognitive development of a 4-year-old child using Piaget's method. Which observation by the nurse indicates that the child has good cognitive development? O Interacts actively with family members O The child identifies the pictures in the chart. O Shows interest in saving water and planting trees O Separate cards by identifying both colors and pictures

The child identifies the pictures in the chart.

During a home visit, the nurse observes a child and concludes that the family pattern is autocratic. What made the nurse conclude so? O Child is attached to the grandparents O Child's mother makes financial decisions O Child is very mischievous and ill-mannered O The child needs to follow the parents' strict rules.

The child needs to follow the parents' strict rules.

Which condition would be a factor in placing a child in foster care rather than with his or her nuclear family? O The child's parents are economically unstable. O The child has poor grades at school O The child has frequent mood swings O The child's parents both work long hours

The child's parents are economically unstable.

During the examination, the nurse suspects that an elderly patient has presbycusis. What behavioral changes would the nurse have observed in the patient? O Irritation while the nurse takes the medical history O Needing support while standing O The patient constantly asked the nurse to speak louder. O Rubbing the eyes

The patient constantly asked the nurse to speak louder.

The nurse is caring for a patient diagnosed with depression. The patient weighs less than normal because of poor nutrition. Which patient outcome would the nurse evaluate in the patient after providing effective nursing interventions to improve nutrition?

The patient eats 50% to 60% of each meal.

Early child hood

The early childhood period is between 1 and 6 years of age and is separated into the toddler phase and the preschool phase. Tasks to be mastered during early childhood include understanding and speaking words, social interaction, mastery of self-control in feeding and toileting, and beginning to develop a self-concept and a sense of autonomy. • Toilet training occurs as sphincter control develops and the child masters basic communication skills to indicate the need to use the toilet. Complete bowel and bladder control is typically complete by age 2 ½ to 3 years. Adequate nutrition is essential for optimum physical and mental development. A 2-year-old child exhibits negativistic behavior and tantrums because of frustrations and struggles for independence. • Preschool thinking involves Piaget's preoperational or prelogical characteristics. A 2-year-old cannot distinguish between intentional acts and mistakes. Impulse control is typically achieved by age 4. A 3-year-old is ritualistic and feels all rules must be obeyed. According to Kohlberg, the preconventional stage of moral development begins during the preschool age. Discipline should have as its purpose the guiding, teaching, or correcting of behavior rather than punishment. • Toddlers and preschoolers do not completely understand the rights of others.

The nurse asks an infant's mother to reduce the frequency of feeding. What symptoms would the nurse have observed in the infant? O The infant passes watery stools. O Fussy O Wrinkled skin O Poor weight gain

The infant passes watery stools.

The nurse is teaching a group of student nurses about the sexual differentiation of a zygote. The instructor asks the student nurse to explain the pattern of chromosomal fusion for a male zygote. What would be a relevant answer given by the student nurse? O The male sperm's X chromosome fuses with the female ova's X chromosome O The male sperm's Y chromosome fuses with the female ova's X chromosome. O The male sperm's Y chromosome fuses with the female ova's Y chromosome O The male sperm's X chromosome fuses with the female ova's Y chromosome

The male sperm's Y chromosome fuses with the female ova's X chromosome.

The nurse is observing an elderly patient with benign prostatic hypertrophy. What finding would the nurse obtain during the observation? O Pigmented skin O The patient has impaired urinary flow. O blood in stools O yellow, discolored nails

The patient has impaired urinary flow.

A student nurse is administering medications to a patient who has recently undergone detoxification with a diagnosis of alcohol abuse. The medications that have been prescribed include B1 (thiamine), B, (folic acid), and B 12 (cobalamin). The patient questions whether the student nurse is giving him something to "knock him out" or "shut him up. Which response by the student nurse would be appropriate? O The medications are relaxing, but not to the point of knocking you out." O The medications are part of the facility therapy. Every patient gets them." O The medications are supplements only. You can always refuse them if you want. O The medications are supplements to address vitamin deficiencies common to alcohol abuse.

The medications are supplements to address vitamin deficiencies common to alcohol abuse. Rationale B8 and B are all 8 complex vitamins Prolonged use of alcohol has a toxic effect on the intestinal mucosa that results in decreased absorption of vitamins B (thiamine), B, (folic acid), and B(cobalamin) Providing factual information about medications is an important nursing action: B vitamins do not cause relaxation and are prescribed based on individual patient needs, not as a facility protocol. Offering the patient the opportunity to refuse needed medications does not provide the appropriate encouragement

Experts have identified the disease of dependence as a chronic, incurable, progressive one. In the course of interviewing the patient, the nurse discovers that the patient has been consuming alcohol on a daily basis for a couple of years." He says he just doesn't feel "right" until he gets a drink or two. He recently was fired from his job after he got into a physical confrontation with a coworker. The patient appears slender, somewhat malnourished, and anxious. The nurse identifies that the patient is most likely in which stage of dependence? O The late-stage O The early stage: O The middle stage O The stage cannot be identified.

The middle stage Rationale The middle stage of dependence is characterized by using the drug to feel normal, an established pattern of use, noticeable weight loss, financial and legal problems, and job loss or frequent job changes. The early-stage has fewer, less severe health and life consequences; in the late stage, health and life consequences are more severe. Enough information is provided to identify the patient's stage of dependence.

Which factor does the success of a patient going through a substance abuse treatment program depend on?

The motivation of the user

The nursing instructor is teaching the student nurses about caring for a patient who is undergoing a crisis and showing symptoms of anger and hostility. Which statement by the practicing nurse indicates a need for further teaching? O The nurse should provide empathic gestures, such as giving a hug to the patient." O The nurse should instruct the patient to develop assertive communication skills." O "The nurse should encourage the patient to describe the current state of anxiety. O "The nurse should advise the patient to use progressive muscle relaxation techniques

The nurse should provide empathic gestures, such as giving a hug to the patient." Rationale A crisis can be defined as an unstable period in a person's life characterized by the inability to adapt to change from a precipitating event. Providing empathic gestures, such as holding a hand or giving a hug, should not be done for a person who is angry and hostile. Assertive communication skills help the patient regain mental wellness. If a patient clearly describes the state of anxiety, it helps the nurse plan the interventions to reduce anxiety, Progressive muscle relaxation techniques enable the patient in crisis to reduce the mental, physical, and emotional stress that accompanies crisis.

According to Freud, the superego is responsible for which concept? O The reality factor O Reducing tension O Immediate gratification O The parental or societal value system

The parental or societal value system

Which statement is true regarding amphetamine-type stimulants? O They cause respiratory depression and pupillary dilation. O "They reduce the desire for alcohol by inducing nausea and vomiting. O They block the transmission of nerve impulses when applied to tissues. O They can be used to treat schizophrenia, depression, and nicotine addiction.

They can be used to treat schizophrenia, depression, and nicotine addiction. Rationale Amphetamine-type stimulants can be used to treat schizophrenia, depression, and nicotine addiction. Opioids cause respiratory depression and pupillary dilation and block the transmission of nerve impulses when applied to tissues. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting

Which medication can be prescribed to treat Wernicke's encephalopathy? O Haloperidol Haldol) O Naltrexone (ReVia) O Thiamine (Thiamilate). O Carbamazepine (Tegretol)

Thiamine (Thiamilate) Rationale Thiamine (Thiamilate) is used to treat Wernicke's encephalopathy. Haloperidol (Haldol) is prescribed to treat hallucinations and delirium. Naltrexone (ReVia) is an opioid antagonist that is prescribed to block the pharmacologic effects associated with opioids and alcohol. Carbamazepine (Tegretol) is prescribed to prevent or treat seizures

Which occurrence may precipitate feelings of anxiety? O Emotional growth O Threats to self-esteem O Threats to those around us O Encouragement in physical strengths

Threats to self-esteem Rationale Loss of significant relationships, loss of a spouse, difficulty at work, or loss of job are all threats to self-esteem and influence the amount of anxiety a person has. Encouragement and emotional growth are positive to self esteem. Threats to others do not affect self-esteem..

An elderly patient is feeling hopeless and depressed due to social isolation. Encouraging the patient to do which action would best help the patient overcome these feelings? O To improve decision-making skills O To do a life review, and reminisce O To perform progressive muscle relaxation O To develop assertive communication skills

To do a life review, and reminisce Rationale Reminiscence and life review are effective techniques to help older adults cope with life changing circumstances. Reminiscence is the act of recollecting past experiences or events; this helps the older adults relieve their stress and depression. Interventions such as encouraging decision-making skills, progressive muscle relaxation, and helping the patient develop assertive communication skills are common for any patient with mental illness.

The nurse counsels the mother of an infant to avoid milk in the nighttime bottle. What is the reason for giving this advice to the infant's mother? O To promote proper sleep O To prevent crib death O To promote oral hygiene O To prevent chocking hazard

To promote oral hygiene

During a home visit, the nurse is assessing a toddler's toys. Which type of toys does the nurse suspect could cause harm and hurt the toddler? Select all that apply. O Toys with long strings O Toys containing balloons O Toys with detachable parts O Smooth contours O one-piece construction

Toys with long strings Toys containing balloons Toys with detachable parts

A male patient on a psychiatric unit admits to obtaining sexual gratification by wearing his wife's clothing. Which type of sexual disorder do these symptoms indicate?

Transvestic fetishism

Acne Vulgaris

Tretinoin (Retin-A) •Derivative of Vitamin A •Blistering, peeling, crusting, burning & swelling •Apply sunscreens or protective clothing

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion?

Venous circulation is being impaired.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care?

Warm compresses

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

After assessing an infant, the nurse suggests the infant's parents to avoid giving excess water to the infant. Why did the nurse give this instruction to the infant's parents? O Decreased calcium levels O Decreased blood pressure O Edema present O Water intoxication causes poor weight gain in an infant.

Water intoxication causes poor weight gain in an infant.

A community health nurse is planning a health fair. An information booth will be included to educate the adolescent population. Which essential topics should the nurse include as part of the discussion? Select all that apply. O Financial independence O Water safety O Drug education O Accident prevention O Water safety

Water safety Drug education Accident prevention

A nurse is caring for a patient who is suspected of drug dependence. Which questions are the most appropriate for the nurse to ask? O Why and when did you start doing illegal drugs?" O "How long were you going to try to hide this from your friends?" O What type, how much, and what effects do the drugs have on you?" O The nurse does not ask questions about drugs for fear the patient might deny any problems.

What type, how much, and what effects do the drugs have on you?" Rationale During the assessment process, the nurse obtains subjective data that include the patient's normali patterns of use and what effects are seen. The remaining options involve casting blame or being judgmental and are insensitive toward the patient, or they avoid garnering subjective data pertinent to the concern.

A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient, knowing that tremors from alcohol cessation are usually seen how long after cessation? O Within 6 days O Within 1 week O Within 6 hours O Within 2 to 3 weeks

Within 6 hours Rationale Tremors from alcohol cessation are seen 6 to 48 hours after the last drink and may last for 3 to 5 days.

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

Wound from repair of a perforated appendix Gunshot wound that punctured the small intestine Traumatic wound to the abdomen and intentionally left open for several days Wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect

Opioids Withdrawal Symptoms

Yawning Insomnia Irritability Rhinorrhea Diaphoresis Cramps N/V Muscles aches Fever "Cold Turkey" Diarrhea I

ulcer stage 2

a deeper loss of epidermis and dermis; may bleed and scar

delirium tremens

a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol

2. The definition of puberty is: a. exhibiting secondary sex characteristics. b. having the ability to reproduce. c. the decrease of gonadotropic hormones. d. becoming fertile.

b. having the ability to reproduce.

1. A developmental task of adolescence includes: a. concrete thinking. b. stabilizing identity. c. accepting competition. d. social interaction.

b. stabilizing identity.

5. Middle childhood includes Erikson's stage of: a. trust. b. autonomy. c. industry. d. identity.

c. industry.

5. By 1 year of age, the normal infant should weigh approximately: a. twice the birth weight. b. quadruple the birth weight. c. triple the birth weight. d. 30 pounds.

c. triple the birth weight.

Middle childhood

children between the ages of 6 and 12. In the school-age child, the body develops a lower center of gravity than it had in preschool years. The loss of primary teeth begins at about age 6, and approximately four permanent teeth erupt each year. Regular dental checkups are an important part of routine health care. • Visual maturity is complete between preschool age and 6 years, and therefore large-print books are no longer necessary at this time. • Excessive time spent with computers and video games can contribute to a sedentary lifestyle, which may result in obesity, poor health, and poor social development. • By ages 9 and 10, an understanding of rules and teamwork enables the child to participate in competitive team games. • School-age children, according to Piaget, are concrete thinkers, and hands-on learning is retained best. School-age children often tell jokes to entertain peers and to tease elders. School-age children are less egocentric than they were at earlier ages, and they can understand how their actions affect others. • Moral behavior is based on logical understanding and feeling pride or guilt as a result of the behavior. Knowing a rule is right does not guarantee behavior according to that rule.

Unstageable

covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) •None, Adherent film, gauze, enzymes,

4. Between 12 and 24 months of age, the child's speech normally includes: a. only vowel sounds. b. both vowels and consonants. c. frequent babbling. d. three- to four-word sentences.

d. three- to four-word sentences.

Hallucinogens

psychedelic ("mind-manifesting") drugs, such as LSD, that distort perceptions and evoke sensory images in the absence of sensory input

Early childhood pt 2

• According to Freud, a conscience begins to develop in the preschool phase, and children begin then to understand how their behavior affects others. • Age-appropriate, daily, moderate and vigorous physical activities are important to maintain the health of children. Children should be kept well hydrated by offering water before, during, and after exercise. Sports-appropriate protective equipment should be worn by children to prevent injuries. • Play is an important part of a child's life. Appropriate toys can promote growth and development. Twenty primary teeth erupt by age 2. Half the adult height is reached by age 2, and the birth weight quadruples as well. The preschool child can more easily learn more than one language when the different languages are used in the home. Language milestones can be used to assess the child's development. • In a preschool child, the number or words in a typical sentence is equal to the child's age in years. A preschool child learns socially acceptable behavior by positive reinforcement. Time-outs should last 1 minute per year of age. A 2-year-old exhibits parallel play, whereas a 3-year-old engages in cooperative play with groups using a high level of imagination. • Parents who hold, hug, and rock their children can influence the ability of the child to establish intimate relationships later in life. • Accident prevention techniques should be discussed with parents. An active immunization program schedule starts at 2 months and continues through the preschool years. Many communicable diseases in childhood can be prevented through immunization.

Anorexia Nervosa:

• Associated w/ stressful life event • Distorted body image • Overachiever & perfectionist • Can be life-threatening • Starvation, suicide, cardiomyopathy, electrolyte imbalance

Compulsive Eating

• Binge-like overeating w/o purging • Eating relieves tension but does not produce pleasure • Feels helpless & hopeless about weight • Guilts, anger, depression, boredom, loneliness, inadequacy & ambivalence by eating

middle childhood pt 2

• In later childhood, the 10-year-old may enjoy creating new rules or changing the rules of a game. • Kohlberg believed that moral reasoning develops as cognitive skills mature. A school-age child may have a maximum attention span of 45 minutes. School-age children use language as an effective communication tool in relationships with others. • Intelligence tests were designed for use in predicting scholastic ability and future performance. • The primary developmental task of the school-age child is to attain a sense of industry by mastering skills and achieving goals. • Belonging to a peer group is very important to a school-age child. • The home, school, and neighborhood each affect the growth and development of school-age children. • Creativity should be encouraged because it helps develop problem-solving skills. • Information concerning sexuality should be age-appropriate, culturally relevant, and treated as a healthy aspect of life. • Discipline should be used for teaching and reinforcing good behavior, which plays an important role in social and emotional development. • Strength, endurance, and coordination can be nurtured by daily physical activity. Physical activity can also decrease risk factors for illness in later life. The major health-teaching needs of the school-age child include prevention of injury; maintenance of adequate nutrition; providing regular dental care; screening for scoliosis, vision, and hearing problems; and developing an active lifestyle.

Substance Abuse

•A pattern of repeated use of the substance •Result in tolerance, withdrawal symptoms, compulsive behavior •Michigan Alcohol Screening Test (MAST) •Drug Abuse Screening Test (DAST) •CAGE Screening questionnaire

Toddler: 1 -3 years

•Anterior fontanel closes 12-18M •Walking climbing stairs (2 years), hoping (3 years) •Fine motor skills- picking up foods •Toilet training until 18-24M Erickson: Autonomy vs. Shame & Doubt •Piaget: Preoperational Stage

Opioid interventions

•Assess for Respiratory Depression •Antagonist (naloxone (Narcan)) •Methadone (Dolophine) •Tapering dosage •Clonidine (Catapres) •Withdrawal symptoms •Narcotics Anonymous

Eating Disorders Interventions

•Assess nutritional status & complications •Restore fluid & electrolytes •Identifying precipitants to eating disorder •Establish Trust •Encourage to express feelings •Weight daily •Assess & limit physical activity •Assess suicidal ideation •Administer medication •Psychotherapy •Support group

Risk Factors for Pressure Ulcer Development

•Being elderly (thinner and less elastic) •Being emaciated or malnourished •Being incontinent of bowel or bladder (moisture leading to maceration (softened)) •Being immobile •Having impaired circulation or chronic metabolic conditions

Bulimia Nervosa

•Binging & purging syndrome •Diet, vomiting, enemas, cathartics, amphetamines or diuretics •Normal weight range •Asses for dehydration •Low self-esteem & mood swings •Poor interpersonal relationships

Alcohol Abuse

•CNS depressants Signs/Symptoms •Slurred speech, unsteady gait, confusion, decrease inhibitions, denial, isolation, irritability, belligerent, hostile Complications •Peripheral neuropathies •Vitamin B deficiency •Thiamine deficiency •Korsakoff's syndrome (a form of amnesia) •Wernicke's encephalopathy •Cirrhosis, pancreatitis•Anemia

Interventions 1-3 years

•Choking hazard •Visit dentist (Oral hygiene, Never sleep w/ a bottle) •Intake of 2-3 glasses of milk •Iron intake •Assess for readiness for toilet training •WIC Women infant children •Keep dangling cords away •Safety gates on stairways •Safety from drowning •Remove chemicals, medication & poisons out of reach •Use highchairs

Acne Vulgaris

•Chronic skin disorder •Begins in puberty •Face, neck chest, shoulders & back •Comedones, pustules, papules & nodules interventions •Gentle cleansing •Avoid oil-based products •Mild: Topical antimicrobials & retinoids •Moderate: oral antibiotics •Severe: isotretinion

Frostbite

•Damage to tissue & blood vessels •Prolonged exposure to cold •Fingers, toes, face, nose & ears Interventions •Rewarm rapidly 105-108 •Immobilize •Analgesia, tetanus, antibiotics •Avoid compression of tissues •Loose & nonadherent sterile dressing •Monitor for compartment syndrome •Debridement

Poison Ivy

•From poison ivy, oak, or sumac plant •Papulovesicular lesions •Severe pruritisInterventions: •Cleanse the oil off the skin •Calamine lotion, hydrocortisone, Glucocorticoids •Burning, dryness, thinning of skin

Infancy: 1 -12 Months

•Growth is rapid the first 6 months of life (Double birth weight 4-6M, 3x birth weight 1Y) •Teething begins at 5-6M •Bottle-mouth syndrome tooth decay because the bottle is propped up •Anterior fontanel closes 12-18M •7M sit up w/o support (Safety, Car seat) •Human breast milk preferred •Introduction of solid food (4-6M, Cereal, Choking) •9-10 hours of sleep •SIDS sudden infant death syndrome. Should be sleeping on the back, no pillows no bed rails

Preschool: 3-5 years

•Growth is slow & steady (Taller & thinner) •Gross motor skills improve dramatically •Piaget (Use symptoms to represent objects) •Trial & error •If not talking by 3 years (Evaluation by PCP, Hearing test, Pathologic speech disturbances?) •High protein & Calcium •Pretend play •Imaginary playmate •Safety (Teach full names, addresses & telephone # 911)