SD- Ch. 3, 22, 9, 18, 46
8. Which potential client should a nurse identify as a candidate for involuntarily commitment? 1.The client living under a bridge in a cardboard box 2.The client threatening to commit suicide 3.The client who never bathes and wears a wool hat in the summer 4.The client who eats waste out of a garbage can
ANS: 2 Feedback: 1 This client's personal safety is not in jeopardy. 2 The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment. 3 This client seems capable of making decisions regarding personal safety. 4 This client does not meet the requirements for involuntary commitment.
17. Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? (Select all that apply.) 1.Encourage members to provide feedback to each other about individual progress. 2.Ensure that group rules do not interfere with goal fulfillment. 3.Work with group members to establish rules that will govern the group. 4.Emphasize the need for and importance of confidentiality within the group. 5.Help the leader to resolve conflicts and foster cohesiveness within the group.
ANS: 2, 3, 4 Feedback 1. Individuals should not be providing feedback to each other on progress. 2. The leader should ensure that group rules do not interfere with goal fulfillment. 3. During the orientation phase of group development, the nurse leader should work together with members to establish rules that will govern the group. 4. The leader should establish the need for and importance of confidentiality within the group. Members need to establish trust and cohesion in order to move into the working phase. 5. During the orientation phase it would not be appropriate to implement feedback or resolve conflict.
10. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? 1.The nurse refuses to give any information to the caller, citing rules of confidentiality. 2.The nurse hangs up on the caller. 3.The nurse confirms that the person has been at the facility but adds no additional information. 4.The nurse suggests that the caller speak to the client's therapist.
ANS: 1 Feedback 1 The most appropriate action by the nurse is to refuse to give any information to the caller. 2 This would be an inappropriate and unprofessional action by the nurse. 3 Admission to the facility would be considered protected health information and should not be disclosed by the nurse without prior client consent. 4 Giving this information would violate the client's right to privacy.
3. A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa should the nurse provide? 1.The emesis produced during purging is acidic and corrodes the tooth enamel. 2.Purging causes the depletion of dietary calcium. 3.Food is rapidly ingested without proper mastication. 4.Poor dental and oral hygiene leads to dental caries.
ANS: 1 Feedback 1 The nurse should explain to the client diagnosed with bulimia nervosa that his or her teeth will eventually deteriorate, because the emesis produced during purging is acidic and corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance. 2 This does not correlate with tooth enamel deterioration. 3 This does not lead to tooth enamel deterioration. 4 This statement does not educate the client about tooth enamel deterioration caused by vomiting.
8. The nurse is working with a client diagnosed with binge eating disorder. Which medication should the nurse expect to teach the client about? 1.Lisdexamfetamine (Vyvanse) 2.Dexfenfluramine (Redux) 3.Sibutramine (Meridia) 4.Pemoline (Cylert)
ANS: 1 Feedback 1 The nurse should teach the client about Lisdexamfetamine (Vyvanse). This medication has shown to be successful in the treatment of binge eating disorder. 2 Dexfenfluramine has been removed from the market because of its association with serious heart and lung disease. 3 Several deaths have been associated with the use of sibutramine by high-risk clients. Based on pressure from the U.S. Food and Drug Administration, the manufacturer issued a recall of the drug in October 2010. 4 Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.
9. A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? 1.Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2.Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3.Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4.Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.
ANS: 1 Feedback 1 The nurse should understand that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia do not. 2 Clients with anorexia can experience amenorrhea. 3 Clients with bulimia nervosa typically do not experience these symptoms. 4 Clients with bulimia often have tooth enamel erosion.
15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home-health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? 1.Allow the client to decline the medication and document the decision. 2.Tell the client that if the medication is refused, hospitalization will occur. 3.Arrange with a relative to add the medication to the client's morning orange juice. 4.Call for help to hold the client down while the injection is administered.
ANS: 1 Feedback It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way. It would be unethical for the nurse to force hospitalization. It would be unethical for the nurse to trick the client into taking the medication. It would be unethical for the nurse to force the client to take the medication.
11. A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) 1.Binge eating with a diagnosis of obesity 2.Bingeing and purging with a diagnosis of bulimia nervosa 3.Weight loss with a diagnosis of anorexia nervosa 4.Amenorrhea with a diagnosis of anorexia nervosa 5.Emaciation with a diagnosis of bulimia nervosa
ANS: 1, 2 Feedback 1. The nurse should identify that topiramate is the drug of choice when treating binge eating with a diagnosis of obesity. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight. 2. The nurse should identify that topiramate is the drug of choice when treating bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight. 3. Topiramate (Topamax) is not the drug of choice for weight loss with a diagnosis of anorexia nervosa. 4. Topiramate (Topamax) is not the drug of choice for amenorrhea with a diagnosis of anorexia nervosa. 5. Topiramate (Topamax) is not the drug of choice for emaciation with a diagnosis of bulimia nervosa.
11. A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) 1.Binge eating with a diagnosis of obesity 2.Bingeing and purging with a diagnosis of bulimia nervosa 3.Weight loss with a diagnosis of anorexia nervosa 4.Amenorrhea with a diagnosis of anorexia nervosa 5.Emaciation with a diagnosis of bulimia nervosa
ANS: 1, 2 Feedback 1. The nurse should identify that topiramate is the drug of choice when treating binge eating with a diagnosis of obesity. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight. 2. The nurse should identify that topiramate is the drug of choice when treating bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight. 3. Topiramate (Topamax) is not the drug of choice for weight loss with a diagnosis of anorexia nervosa. 4. Topiramate (Topamax) is not the drug of choice for amenorrhea with a diagnosis of anorexia nervosa. 5. Topiramate (Topamax) is not the drug of choice for emaciation with a diagnosis of bulimia nervosa.
12. A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.) 1."In this disorder, binge eating occurs exclusively during the course of bulimia nervosa." 2."In this disorder, binge eating occurs, on average, at least once a week for three months." 3."In this disorder, binge eating occurs, on average, at least two days a week for six months." 4."In this disorder, distress regarding binge eating is present." 5."In this disorder, distress regarding binge eating is absent."
ANS: 1, 3, 5 Feedback 1. According to the DSM-5 criteria for the diagnosis of binge-eating disorder, binge eating should not occur exclusively during the course of anorexia nervosa or bulimia nervosa. 2. This statement regarding binge eating is accurate, indicating that teaching has been effective. 3. The new time frame criteria in the DSM-5 states that binge eating must occur, on average, at least once a week for three months not two days a week for six months. 4. This statement indicates that teaching has been effective. 5. The DSM-5 criteria states that distress regarding binge eating would be present.
9. During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development? 1."It's hard for me to tell my story when I'm not sure about the reactions of others." 2."I think Joe's Antabuse suggestion is a good one and might work for me." 3."My situation is very complex, and I need professional, not peer, advice." 4."I am really upset that you expect me to solve my own problems."
ANS: 2 Feedback 1 Stating, "It's hard for me to tell my story when I'm not sure about the reactions of others," does not demonstrate that the group has progressed to the working phase. 2 The nurse should recognize that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and use it constructively to create change. 3 Stating, "My situation is very complex, and I need professional, not peer, advice," does not demonstrate that the group has progressed to the working phase. 4 Stating, "I am really upset that you expect me to solve my own problems," does not demonstrate that the group has progressed to the working phase.
6. The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response? 1."Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." 2."Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." 3."Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." 4."Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."
ANS: 2 Feedback 1 This statement is not therapeutic to the family. 2 The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of anorexia nervosa. 3 This statement is untrue, as family dynamics are linked to eating disorders. 4 This statement may cause family members to become defensive.
7. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1.The client gained two pounds in one week. 2.The client focused conversations on nutritious food. 3.The client demonstrated healthy coping mechanisms that decreased anxiety. 4.The client verbalized an understanding of the etiology of the disorder.
ANS: 3 Feedback 1 Gaining two pounds in one week is not an appropriate indicator of a positive client behavioral change. 2 Focusing on conversations on nutritious foods is not an appropriate indicator of a positive client behavioral change. 3 The nurse should identify that a client who demonstrates healthy coping mechanisms to decrease anxiety indicates a positive behavioral change. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behavior. 4 Verbalizing an understanding of eating disorders in important, but is not appropriate indicator of a positive client behavioral change.
1. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client's home environment should a nurse associate with the development of anorexia nervosa? 1.The home environment maintains loose personal boundaries. 2.The home environment places an overemphasis on food. 3.The home environment is overprotective and demands perfection. 4.The home environment condones corporal punishment.
ANS: 3 Feedback 1 Home environments that maintain loose personal boundaries do not typically lead to anorexia nervosa. 2 Home environments that place an overemphasis on food do not typically lead to anorexia nervosa. 3 The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against the parents viewed by the child as a means of gaining and remaining in control. 4 Home environments that condone corporal punishment do not typically lead to anorexia nervosa.
9. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? 1.A client makes inappropriate sexual innuendos to a staff member. 2.A client constantly demands attention from the nurse by begging, "Help me get better." 3.A client physically attacks another client after being confronted in group therapy. 4.A client refuses to bathe or perform hygienic activities.
ANS: 3 Feedback Making inappropriate sexual innuendos does not give the nurse reason to medicate the client against wishes. Demanding attention does not give the nurse reason to medicate the client against wishes. The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others. Refusing to bathe does not give the nurse reason to medicate the client against wishes.
10. A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time? 1.Altered nutrition less than body requirements 2.Altered social interaction 3.Impaired verbal communication 4.Altered family processes
ANS: 4 Feedback 1 Altered nutrition less than body requirements is not the priority at this time. 2 Altered social interaction is not the priority at this time. 3 Impaired verbal communication is not the priority at this time. 4 The nurse should determine that once the client has been medically cleared, the diagnosis of altered family process should take priority. Clients diagnosed with anorexia nervosa have a need to control and feel in charge of their own treatment choices. Behavioral-modification therapy allows the client to maintain control of eating.
5. A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder? 1."Skaters need to be thin to improve their daily performance." 2."All the skaters on the team are following an approved 1,200-calorie diet." 3."The exercise of skating reduces my appetite but improves my energy level." 4."I am angry at my mother. I can only get her approval when I win competitions."
ANS: 4 Feedback 1 Stating that skaters need to be thin is not likely to contribute to the development of anorexia nervosa. 2 Stating that all skaters are following an approved diet is not likely to contribute to the development of anorexia nervosa. 3 This statement is not likely to contribute to the development of anorexia nervosa. 4 The client reflects insight when referring to feelings toward family dynamics that may have influenced the development of the disease. Families who are overprotective and perfectionistic can contribute to the development of anorexia nervosa.
10. Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development? 1.The group leader establishes the rules that will govern the group after discharge. 2.The group leader encourages members to rely on each other for problem solving. 3.The group leader presents and discusses the concept of group termination. 4.The group leader helps the members to process feelings of loss.
ANS: 4 Feedback 1 This option is not appropriate after the group has ended. 2 Group members should have gained independence while in the group. 3 This option does not have the group members move through the termination phase. 4 The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss as they are losing the support of their group as it disbands. The leader should encourage members to review goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.
7. Which statement should a nurse identify as correct regarding a client's right to refuse treatment? 1.Clients can refuse pharmacological but not psychological treatment. 2.Clients can refuse any treatment at any time. 3.Clients can refuse only electroconvulsive therapy (ECT). 4.Professionals can override treatment refusal by an actively suicidal or homicidal client.
ANS: 4 Feedback 1 Clients can refuse both pharmacological and psychological treatment. 2 Clients may not be able to refuse emergency treatment. 3 Clients can refuse pharmacological and psychological treatment in a nonemergent situation. 4 The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.
6. An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? 1.Verbally redirect the client, and then refuse one-on-one interaction. 2.Involve the hospital's security division as soon as possible. 3.Notify the client that documenting personal staff information is against hospital policy. 4.Continue professional attempts to establish a positive working relationship with the client.
ANS: 4 Feedback The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed. This option is likely important, but it is not the most appropriate action for decreasing the possibility of a lawsuit. This option is not therapeutic for the client. The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client.
30. The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A. Impaired skin integrity B. Hypoxia C. Malignant hyperthermia D. Hypothermia
ANS: B Feedback: If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity.
20. A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care? A) Confirm placement of the tube prior to each medication administration. B) Have the patient sip cool water to stimulate saliva production. C) Keep the patient in a low Fowlers position when at rest. D) Connect the tube to continuous wall suction when not in use.
Ans: A Feedback: Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the patient should be positioned in a Fowlers position. Oral fluid administration is contraindicated by the patients dysphagia.
38. The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? A) Ensure that IV fluids are warmed to the patients body temperature. B) Transfuse packed red blood cells to increase oxygen carrying capacity. C) Place warmed bags of normal saline at strategic points around the patients body. D) Monitor the patients blood pressure and heart rate vigilantly.
Ans: A Feedback: Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the patient is not common practice. The patient is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.
27. A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. A) To remove gas from the stomach B) To administer clotting factors to treat a GI bleed C) To remove toxins from the stomach D) To open sphincters that are closed E) To diagnose GI motility disorders
Ans: A, C, E Feedback: GI intubation may be performed to decompress the stomach and remove gas and fluid, lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility and other disorders, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. GI intubation is not used for opening sphincters that are not functional or for administering clotting factors.
34. The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has a more angular bone structure than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.
Ans: B Feedback: Factors that affect the elderly surgical patient in the intraoperative period include the following: impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not have more angular bones than younger people.
26. The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A) Hypothermia B) Anaphylaxis C) Infection D) Malignant hyperthermia
Ans: B Feedback: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because of the use of tissue adhesives.
39. A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteralfeeding. What intervention should the nurse identify as best meeting this patients nutritional needs? A) Administration of parenteral feeds via a peripheral IV B) TPN administered via a peripherally inserted central catheter C) Insertion of an NG tube for administration of feeds D) Maintaining NPO status and IV hydration until treatment completion
Ans: B Feedback: If malabsorption is severe, or the cancer involves the upper GI tract, parenteral nutrition may be necessary. TPN is administered by way of a central line, not a peripheral IV. An NG would be contraindicated for this patient. Long-term NPO status would result in malnutrition.
3. A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate? A) Stop the tube feed and aspirate stomach contents. B) Increase the hourly feed rate so it finishes earlier. C) Dilute the concentration of the feeding solution. D) Administer fluid replacement by IV.
Ans: C Feedback: Dumping syndrome can generally be alleviated by starting with a dilute solution and then increasing the concentration of the solution over several days. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.
35. A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response? A) It eliminates the risk for infection. B) Feeds can be infused at a faster rate. C) Regurgitation and aspiration are less likely. D) It allows caregivers to provide personal hygiene more easily.
Ans: C Feedback: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, makingregurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.
9. A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN? A) TNA can be mixed by a certified registered nurse. B) TNA can be administered over 8 hours, while PN requires 24-houradministration. C) TNA is less costly than PN. D) TNA does not require the use of a micron filter.
Ans: C Feedback: TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.
37. The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery? A) Respiratory depression B) Hypothermia C) Anesthesia awareness D) Moderate sedation
Ans: C Feedback: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.
31. The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia? A. Increased temperature B. Oliguria C. Tachycardia D. Hypotension
Ans: C Feedback: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.
13. The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse.
Ans: C Feedback: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.
20. Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner? A) Historical precedence B) Patient requests C) Physicians needs D) Evidence-based practice
Ans: D Feedback: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal patient care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.
11. A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair and perform deep breathing exercises. B) Ambulate the patient as early as possible. C) Limit the patients fluid intake for the first 24 hours postoperatively. D) Keep the patient positioned supine.
Ans: D Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.
17. A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action? A) Perform chest physiotherapy. B) Reduce the height of the patients bed and remove the NG tube. C) Liaise with the dietitian to obtain a feeding solution with lower osmolarity. D) Report possible signs of aspiration pneumonia to the primary care provider.
Ans: D Feedback: The patient should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.
