2023 NCLEX Review by

Which statements by the student nurse indicate an understanding of caring for clients for various cultures? (Select all that apply. One, some, or all responses may be correct)

" The focus is on understanding the traditions, beliefs, and values of the client's culture" " I will be aware of my own cultural background and beliefs when attending to clients who belong to different cultures" To provide individualized care to the client, the nurse would focus on the client's traditions, beliefs, and values. The nurse would be aware of their own cultural background and beliefs to ensure the stereotypes and prejudices do not get in the way of client care.

A client asks if the nurses agrees with the other group members that the client is intellectualizing to avoid discussing feelings. Which response is the best?

"Are you uncomfortable with what you were told?" "Are you uncomfortable?" helps the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the other group members indicates a lack of acceptance of the client. The perception of the others is not the issue; the focus should be turned back to the client.

Which statement by a nursing student demonstrates an understanding of collaboration?

"Collaboration with patients has been used by nurses throughout the history of nursing." History shows that from the time of Florence Nightingale, nurses have worked with patients to assess their needs and wants. Collaboration with fellow care providers such as physicians is not a new concept; it is becoming more prevalent. To correctly use collaboration, the team does not make decisions without including the patient.

A student nurse asks why care coordination is now a top priority for health system redesign. What is the nursing instructor's best response?

"Every patient will need coordinated care services at some time in life." Care coordination is more prominent in healthcare design today because patients will need coordination of services to promote optimal healthcare outcomes. Community services are not always lacking but may be restricted by financial resources. Care coordination should not increase confusion but should rather lessen it. Patients are usually knowledgeable about the service agencies that are available to care for them.

The nurse is teaching a class of junior high school students about infection control through effective hand washing. Which statement made by a student indicates the need for further teaching?

"Hand sanitizer works just as well as washing with soap and water." Hand sanitizer does not work as well as soap and water, because it is not effective against all pathogens or in all situations. For example, hand sanitizer should not be used when hands are visibly dirty. Repeating the song "Happy Birthday" twice takes about 20 seconds, which is how long hands should be rubbed together with soap. Hand sanitizer needs to be at least 60% alcohol to be effective. Hand washing before eating is recommended by the Centers for Disease Control.

The nurse is assessing the coping abilities of a patient recently diagnosed with a degenerative neuromuscular disease with no known cure. Which statement by the patient alerts the nurse that more intervention is needed?

"I am sleeping much better when I have two drinks and smoke before bed." Using alcohol, smoking, or drugs to enhance sleep is not a positive coping mechanism, and it is also a safety hazard; other interventions should be enlisted to help the patient cope with the devastating diagnosis. Taking art lessons and planning a family reunion are positive ways to not focus on the illness and keep the patient from becoming more isolated. Moving in with a family member is a problem-solving strategy that allows the patient to maintain more control over the illness outcome.

Which statement(s) by the nurse aim to help the patient to cope by addressing the mediators of stress? (Select all that apply.)

"I have found a support group for newly divorced persons in your neighborhood." "Perhaps a short-term loan from your father will make your layoff less stressful." "Journaling gives one more awareness of how experiences have affected them." "A divorce, while stressful, can be the beginning of a new, better phase of life." Stress mediators are factors that can help persons cope by influencing how they perceive and respond to stressors; they include personality, social support, perceptions, and culture. Suggesting that a divorce may have positive as well as negative aspects helps the patient to alter his perceptions of the stressor. Journaling increases self-awareness regarding how life experiences may have shaped how one perceives and responds to stress (or how one's personality affects how one responds to stressors). A loan could help the patient perceive a layoff differently by reducing the financial pressures that accompany it. Participation in support groups is an excellent way to expand one's support network relative to specific issues. However, neither aerobic exercise nor breath control exercises, while helpful in other ways, affect stress mediators.

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective?

"I need to drink liquids with some sodium in them." Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.

The RN is teaching a nursing sudent how to communicate with a client who is cognitively impaired. Which statement(s) made by the nursing student is (are) incorrect? (Select all that apply. One,, some, or all response may be correct.

"I should use visual cues" " I should speak in a normal tone of voice" " I should face the client so that my mouth can be seen" When communicating with a client who is cognitively impaired, the nurse would ask one question at a time and give the client time to respond. When a client cannot speak clearly, the nurse would use visual cues. When the client is visually impaired, the nurse would speak in a normal tone of voice. When the client has a hearing impairment, the nurse would ensure that the mouth is visible to the client.

Which statement indicates that further teaching is needed after the nurse completes teaching for a client with foot pain who has peripheral arterial disease?

"I will elevate my foot" Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity.

A nurse and a student nurse are talking about healthcare coordination. Which statement should the nurse make about the subject?

"Patients have needs beyond the healthcare system." Many patients do have needs that go beyond what the healthcare system can offer, such as financial or social assistance. Patients do not have the healthcare knowledge to coordinate their care. Physicians and community health nurses are not the only ones involved in the coordination of health care.

The nurse is reviewing skin care for immobilized patients with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement?

"Proper care of the skin is important because the immobilized patient is at high risk for breakdown." Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids. Body odor (smell) is embarrassing to the patient, but it does not pose a risk to the skin. Not every immobilized patient is incontinent. Having visitors does not pose a risk to the skin.

A patient has come to the health clinic for an annual checkup. He reports increased stress at work and having to work a lot of mandatory overtime. He has not been able to do his usual daily exercise for several weeks. What is the best response by the nurse?

"Regular exercise would be good because it helps the body deal with stress." Exercise is a form of emotion-based coping that increases a feeling of well-being. Cutting back on hours may not be an option in his current work climate, although it might help reduce stress. There are other nonpharmacological methods that may help with stress, such as music or meditation, which would not involve possible side effects from medications. Exercise will decrease feelings of stress when balanced with the time requirements of the stressor.

A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise?

"Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you." Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient.

A family is talking with a nurse because a family member is experiencing a chronic illness. The family asks the nurse how they should cope with their changing roles. What is the nurse's best response?

"The family should discuss the changing roles and what is needed for everyone." The nurse should encourage the family to discuss the changes and what everyone needs and wants with this new situation. This approach will allow every family member to recognize their own needs in addition to the changing needs of the family. Everyone may not know what to do, so answer A is incorrect. Talking to the physician is fine, but he or she will not take on the role of problem solver for the family. The nurse does not have the right to decide for the family; decisions about role changes have to be made by the family members.

A patient comes to the clinic stating, "My left arm is red and swollen. It hurts badly enough that I couldn't go to work today." The healthcare provider orders computer-assisted tomography (CT) scanning of the left upper extremity. Which statement by the patient indicates understanding of the reason for the procedure?

"This test will help to better determine where the injury actually is and how severe it is." Radiographic imaging studies such as CT scans help to determine the location and extent of inflammation within the body. The CT scan will help with diagnosis. The diagnosis is not predetermined. CT scanning does not alleviate pain. Radiography does not necessarily determine a cause of an injury.

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? (Select all that apply.)

1. Drink six to eight glasses of noncaffeinated fluids daily 2. Void when the urge is felt Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.

Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? (Select all that apply.)

1. Encourage the patient's family to participate in teaching sessions 2. Schedule a visit by another resident who is diabetic 3. Demonstrate food choices using food photographs 4. Ask the patient about past experiences with lifestyle changes Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? (Select all that apply.)

1. Hypokalemia 2. Hypocalcemia 3. Extracellular fluid volume (ECV) deficit Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.

The home health nurse is caring for a patient experiencing constipation. The patient asks the nurse how to prevent constipation. Which recommendations should the nurse include in their answer to the patient? (Select all that apply.)

1. Increase activity or exercise 2. Increase fiber in the diet 3. Defecate when the urge is felt 4. Drink at least 1500 mL of water per day Drinking at least 1500 mL of water, increased activity or exercise and fiber, and defecating when the urge is felt are measures that increase GI peristalsis and soften stool and thus help to avoid constipation. Eating fruits with seeds (raspberries, apples, strawberries, etc.) does not need to be avoided, rather many of them are high in fiber and should be encouraged.

A person of Northern heritage is at an increased risk for which of the following? (Select all that apply.)

1. Type 1 diabetes 2. Celiac disease Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.)

1. Weight loss of 6% since last month's visit 2. Hemoglobin level of 8.2 g/dL 3. Body mass index (BMI) of 17 A BMI of 18.5-24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14-18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15-36 mg/dL. A hematocrit level of 50% is within normal limits.

Which questions should the nurse ask when assessing for risk factors for metabolic acidosis? (Select all that apply.)

1. When did your kidneys stop working? 2. How long have you had diarrhea? 3. Which weight loss diet are you using? Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids. Shortness of breath might be related to a cause of respiratory acidosis.

Which factors increase the risk for the development of type 2 diabetes mellitus? (Select all that apply.)

1.Hypertension 2. Body mass index greater than 25 kg/m 3. Delivery of a 4.99-kg baby Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.

The embryonic period is critical because external and internal structures in the fetus are forming. When is it most important for the pregnant patient to avoid all teratogens?

4-8 weeks The embryonic period lasts from the beginning of the fourth week to the end of the eighth week. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infectious agents. At the end of this period, the embryo has human features. The span of gestation from 8 to 12 weeks, from 12 to 16 weeks, or from 16 to 20 weeks is not within the embryonic stage of fetal development, when teratogenicity is of greatest concern.

Which of the following patients is at higher risk for inflammatory reactions?

79-year-old man with diabetes The 79-year-old man is at highest risk for inflammatory reactions among these patients for two reasons, his age and having diabetes. The risk would be high during the first year of life, but this 2-year-old girl has gotten beyond this risk period and she also has the positive factor of a healthy diet. The 38-year-old man is not in a high-risk category because of age but is because of obesity. Although a 54-year-old woman is getting older, being in menopause does not increase the risk for inflammatory reactions.

Which patient is at greatest risk for contracting a primary bacterial infection?

A patient whose lab results reveal leukopenia The patient with a decrease in the number of white blood cells (leukopenia) is at greatest risk for contracting a primary infection because of a weakened primary defense system. A patient with a diagnosis of diabetes mellitus is at greater risk for infection than a patient who does not have the disease but does not have the greatest risk of the four patients described. The patient receiving broad-spectrum antibiotics already has an infection and is at risk for a secondary infection. The patient who has undergone a surgical procedure is at risk for a bacterial infection but does not have the greatest risk of the patients described. Laparoscopy minimizes invasion and tissue impairment.

Which patient should the nurse closely monitor for the risk factors of metabolic acidosis?

A patient with a pancreatic fistula that is draining The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss. Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion. Meningitis can stimulate hyperventilation, which causes respiratory alkalosis. Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

Which factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment?

Ability to perform tasks without becoming frustrated The nurse would consider ability to perform tasks without becoming frustrated. When the client is unable to perform a task, frustration occurs and results in more disorganized behavior.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. Which action by the nurse caring for the child requires the nurse manager to intervene?

Adjusts the bed to the Trendelenburg position It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis?

Administration of intravenous insulin The Kussmaul's respiration pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1-6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.

The client can no longer recognize familiar objects such as their glasses and toothbrush. Which term describes these assessment findings?

Agnosia Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the body. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment (Individual with apraxia is unable to perform purposeful tasks such as walking or properly putting on clothing Aphasia is the term for the loss of language ability; loss is usually progressive Amnesia is the term for impairment of memory both recent and remote

Which action should the nurse teach a diabetic client who self-injects insulin to prevent local irritation at the injection site?

Allow the insulin to warm to room temperature before injecting it. Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency?

An African-American female who is breastfeeding Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

Which occurrence can delay wound healing after surgery?

An increased hospital stay An increased hospital stay increases the risk for hospital-acquired infections, which can delay wound healing. Adequate arterial blood flow improves, rather than delays, wound healing. Supplemental oxygen can increase wound healing. A healthy diet is important to wound healing.

Which data would the nurse use to determine a client's score on the Braden Scale to predict a client's risk for developing pressure injuries? (Select all that apply. One, some, or all responses may be correct)

Anorexia Hemiplegia History of diabetes Urinary incontinence Anorexia causes nutrional problems, nutrition is a category on the braden scale. Hemiplegia causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing numbness or loss of sensation in the hands in feet; sensory perception is a category on the Braden Scale.

Patients who are immobile often experience which emotions? (Select all that apply.)

Anxiety Helplessness Anger Patients who experience immobility often have psychological issues such as helplessness, anger, and anxiety.

A nursing instructor and a student nurse are talking about caregivers and their role in the caring process. What are some of the emotions and obstacles that caregivers experience that the nursing instructor should include in the discussion? (Select all that apply.)

Anxiety Social isolation Denial The caregiver experiences emotions such as anxiety and denial of the disease process and faces obstacles such as social isolation when caring for someone else. Financial prosperity is usually not occurring; quite the opposite is likely because a caregiver may be drained of his or her savings. A caregiver does not feel euphoria, because the caregiver is not happy about the situation. The caregiver may not understand the disease process and may not know what to expect as he or she assumes the caregiver role.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? (Select all that apply.)

Apply sunscreen 30 minutes prior to exposure Wear sunglasses Consume fish oil and vitamin E Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma

The nurse in the skilled nursing facility is very busy and unable to answer all the call lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply.)

Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary.

A married couple present to the preconceptual clinic with questions about how a fetus's chromosomal sex is established. What is the best response by the nurse?

At fertilization, chromosomal sex is established. Remember that the primary spermatocyte contains two sex chromosomes, one X chromosome and one Y chromosome, and the primary oocyte contains two sex chromosomes, both X chromosomes. During the first reduction division, two secondary spermatocytes are produced, one X and one Y, establishing X and Y cell lines. The X-bearing cell line is established during oogenesis. Female gametes will all be X bearing and male gametes will be either X or Y bearing. A female develops through the fertilization of the ovum by an X-bearing sperm producing an XX zygote; a male is produced through the fertilization of a Y-bearing sperm producing an XY zygote. Therefore, at fertilization, chromosomal sex is established. Chromosomal sex is not established at ovulation, ejaculation, or climax, so these choices are erroneous.

Coordination of healthcare services is complicated by which of the following? (Select all that apply.)

Authority for managing services Poorly funded social programs Involving one or more services Coordination of services is complicated because it involves more than one service, poorly funded social programs, confusing chains of authority for managing services, and a lack of healthcare systems. Too many community resources and too many nurses are not complicating the healthcare system.

A patient has begun smoking again and drinks six alcoholic beverages per day since experiencing the loss of his job. The nurse recognizes that the patient is exhibiting symptoms of which type of stress?

Behavioral Signs and symptoms of behavioral stress include smoking, overeating, and substance abuse. Substance abuse is not a symptom of psychological, emotional, or physiological stress.

Mr. Walker is caring for his ailing wife, who was diagnosed with a terminal illness. Mr. Walker is talking with a nurse, and states, "I miss my old life. I don't see any of my friends anymore. Caring for my wife is much more difficult than I thought. I want things to be the way they used to be." Which emotional strain should the nurse realize that Mr. Walker is experiencing?

Caregiver stress Mr. Walker is showing signs of caregiver stress because he expresses that he wants his situation to change. He is not remorseful about being healthy. No children are mentioned in the question. He has not lost his friends; he just does not see them any more.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which steps should the nurse include in the teaching plan? (Select all that apply.)

Cleansing the wound Managing pain Hand washing Administering pain medications will ensure that the patient is comfortable prior to a dressing change. Hands should be washed before and after performing a dressing change. The nurse should show the daughter how to cleanse the wound and then apply the sterile.

Which client is demonstrating characteristics of self-actualization based on Maslow's hierarchy of needs?

Client has an accurate perception of reality and is accepting of self and others According to Maslow, a self-actualized person has an accurate perception of reality and is accepting of self and others. This person is fair-minded, independent, spontaneous, and creative; they take pleasure in being alone but is also socially active. Accomplishing work goals is meeting self-esteem needs. Being in a stable, loving relationship is evidence of having love and belonging needs met.

A nurse is talking with a woman who is caring for her elderly father. The woman states that she has very little time for herself or any of the activities she used to enjoy. What process is the nurse using to assess this situation?

Cognitive ability of appraisal The cognitive ability of appraisal allows the nurse to assess the woman's feelings and her ability to care for her father. Understanding the woman's or the father's wishes is good, but it is not a process of appraisal of the situation. Diagnosing the father's health is outside of the nursing realm.

The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient. What information does this test provide?

Confirms the nonspecific presence of inflammation An elevated ESR is indicative of the presence of inflammation in the body. Proteins produced during the inflammatory process adhere to red blood cells, causing them to be heavier and settle out of blood samples at a faster rate than normal. The ESR does not identify specific causes of inflammation and does not determine a specific location of inflammation. The ESR is a nonspecific indicator of inflammation.

A patient with hypothermia is brought to the emergency department. What treatment should the nurse anticipate?

Core rewarming with warm fluids Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

Which term is the conglomerate of morals, values, beliefs, norms, and meanings that a group of people share and communicate from one generation to the next?

Culture Culture is a blend of everything an individual experiences throughout the lifespan. Norms, values, beliefs, meanings, and morals are shared and taught to young persons. As an individual grows, he or she reflects on the teachings and molds them to fit his or her personal development.

When planning care for a diabetic patient with microalbuminuria, which goal to reduce the progression to renal failure should be included in the plan?

Decrease the total percentage of calories from proteins Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure.

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What is the best response by the nurse?

Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.

A nurse mentor is explaining the benefits of collaborative practice to a nurse new to a facility. Which research-based benefits should the nurse identify as likely positive outcomes of collaboration? (Select all that apply.)

Decreased staff resignations Decreased length of stay for patients Increased job satisfaction of the staff Documented positive outcomes from collaboration include a shortened length of stay, increased job retention and decreased staff turnover, increased job satisfaction for registered nurses, and improved problem-solving skills. Identified research has not demonstrated less use of pain medication, increased reimbursement, or better follow-up by patients after discharge.

After performing a screening assessment on a patient, which finding should be documented as a physiological stressor?

Dementia Physiological stressors have physical causes. Dementia is an example of a physiological stressor. Caregiving, divorce, and death of a friend are examples of psychological or emotional stressors

A client reports to the nurse, I've been using St. John's wort to try and feel more like myself again. I'm not sure whether it's going to work. Which symptom would the nurse further assess?

Depression St John's wort is an herb marketed as a natural way to improve mood and ease feelings of depression. Because of St. John's wort is considered a dietary supplement, it is not regulated by the Food and Drug Administration as medications are. It has not been shown to exert positive effects in people with sleep disturbances, diminished cognitive abilities, or sensory-perceptual disturbances.

Which expected sensory loss associated with aging would a nurse recall when designing a plan of care for an 85-year-old client admitted to nursing home. (Select all that apply. One, some, or all response may be correct)

Diminished sensation of pain Impaired hearing of high frequency sounds Because of aging of the nervous system, an older adult has diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure.

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete?

Gait and balance When the patient is walking, the nurse is assessing for gait and balance (mobility). Speech, hearing, mental alertness, and the ability to follow directions do not have a bearing on mobility.

What matters can palliative care be used to promote? (Select all that apply.)

Discussion on advance directives Physical functioning Reduction in disease exacerbations Improved quality of life If optimally delivered, palliative care can provide patients with aggressive symptom management while helping to restore and promote physical functioning. Management of symptoms helps to reduce the exacerbations that are common to chronic disease. Palliative care provides an opportunity to engage patients and families with earlier and supportive discussions about advance care planning. Palliative care supports an improved quality of life, whether the treatment plan is through surgical or medical intervention.

The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient?

Drink six to eight glasses of noncaffeinated fluids daily. Drinking six to eight glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.

A female patient comes to the clinic at 8 weeks' gestation. She lives in a house beneath electrical power lines, which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient's plan of care?

Drinking alcohol should be avoided during pregnancy because of its teratogenic effects. Stages of development include the ovum, the embryo, and the fetus. The embryonic period lasts from the beginning of the fourth week to the end of the eighth week of gestation. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. During pregnancy, a woman should avoid exposure to all potential toxins, especially alcohol, tobacco, radiation, and infectious agents. Living beneath power line or near an oil field is not teratogenic in itself. Stopping sweets can be addressed after the alcohol cessation is addressed.

The nurse is caring for a patient with severe metabolic alkalosis. Which intervention is the highest priority?

Ensure the upper side rails of the patient's bed are up. Severe metabolic alkalosis causes a decreased level of consciousness; raising the side rails is a safety intervention in that situation. Safety interventions are a higher priority than teaching. An order to administer intravenous NaHCO3 to a patient with metabolic alkalosis should be questioned because it would make the alkalosis worse. Urine output and skin turgor are part of the assessment for extracellular fluid volume (ECV) deficit, but this is not a high priority in this situation.

Which physiological change that occurs with aging causes stress incontinence? (Select all that apply. One, some, or all response may be correct)

Estrogen deficiency Weakening of the urinary sphincter Estrogen deficiency causes stress incontience, overactive bladder, and dysuria. Weakening of the urinary sphincter causes stress incontinence. Prostatic enlargement may result in hesitancy, frequency, urgency, nocturia, straining, retention, and dribbling.

A 15-year-old female patient has come to the office for her annual physical and first pelvic examination. In this situation, which nursing action is most important?

Excuse the parent. Although all of these actions are important, in this situation the parent should be excused in order to allow the teen to discuss her sexual concerns without fear of repercussions. Adolescents may be concerned about their altered appearance and impulse control. This is the ideal time to encourage the patient to ask questions and reassure her that she does not appear ignorant. All patients should be screened for possible abuse, and this is the most appropriate time to do so. If the parent remains present, the patient may be reluctant to answer a question honestly about any history of childhood sexual abuse. The nurse must pose all questions to the patient in a nonjudgmental manner and ensure her that all answers will be kept strictly confidential.

When developing a teaching plan for the parent of a child with attention deficit, the nurse would remember which concepts?

Experience perceptual difficulties that make learning problematic This disorder interferes with the ability to perceive and respond to sensory stimuli, which in turn results in a deficit in interpreting new sensory data and makes learning difficult. That a child will probably not be a self-sufficient adult or will perform two grade levels below the age norm is not necessarily true. It is not an intellectual deficit that prevents lt is not an intellectual deficit that prevents learning but rather a perceptual difficulty; these children may have superior intelligence.

The nurse is auscultating a patient's bowel sounds and notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. What is the best explanation for the scar's appearance?

Fibrous tissue replacing damaged tissue when injury is extensive Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.

A client with which conditon or situation would the nurse classify as having intermediate priority needs? (Select all that apply. One, some, or all responses may be correct)

Healing wound being monitored for infection Diabetes requiring education for newly prescribed insulin Deep vein thrombosis being monitored for impairment of peripheral tissue perfusion 8 Hours postoperative thyroidectomy being monitored for possible complications Cancer in need of education concerning prescribed home chemotherapy regimen

A patient is on contact isolation for a bacterial infection. Which interventions should the nurse implement for this patient?

Help to ensure adequate social interaction and support. Frequently, patients on contact isolation do experience a decrease in social interaction because of the isolation. The nurse must help provide adequate social stimulation for the patient. Frequently, this is done by educating the family and friends regarding isolation practices. Isolation does not mean that the patient cannot have visitors. Visitors must be educated on how to maintain the contact isolation while with the patient, especially hygiene guidelines. Personal protective equipment must be used when entering the room of a patient on contact isolation. Nurses and visitors do not always know when they will come into contact with a pathogen, especially if it is highly virulent. The patient on contact isolation should have regular face-to-face contact with the nurse. The nurse should not use the call light system to communicate with a patient in isolation any more than for any other patient.

The nurse is caring for a patient newly diagnosed with hyperparathyroidism. What findings should the nurse expect?

Hypercalcemia, lethargy, and constipation Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.

Which statements made by the nurse indicate accurate awareness about the condition associated with hypothermia. (Select all that apply. One, some, or all responses may be correct)

Hypothermia can often be misdiagnosed because it mimics other disorders Near-drowning increases evaporative heat loss to 25 times greater than normal Hypothemia mimics cerebral or metabolic disturbances causing ataxia, confusion, and withdrawal, so the client may be misdiagnosed. Immersion in cold water, such as near-drowning, increases evaporative heat loss to 25 times greater than normal.

A 20-year-old woman comes for preconceptual counseling. She wants to get pregnant soon. Which health-promoting habit would have the highest priority at this time?

Immediate tobacco cessation Psychosocial factors affecting pregnancy include smoking, excessive use of caffeine, alcohol and drug abuse, psychological status including impaired mental health, an addictive lifestyle, spouse abuse, and noncompliance with cultural norms. Immediate tobacco cessation would be the highest priority because continued smoking could be teratogenic if the woman should become pregnant. Smoking causes vasoconstriction which restricts the amount of oxygen and nutrients to the rapidly growing fetus. Daily exercise promotes health but would not be the highest priority among these factors. Stopping caffeine and avoiding sweets are important and can be addressed after tobacco cessation.

Which external barriers can prevent a nursing professional from making morally correct actions? (Select all that apply. One, some, or all responses may be correct)

Inadequate staffing Lack organizational support Poor relationships with colleagues When faced with dilemmas, external and internal barriers may prevent a professional from acting in a morally correct way. This may cause moral distress. External barriers include inadequate staffing, lack of organizational, support, and poor relationships with colleagues. These factors are present in the organizational environment and can lead a person to act in particular manner. Internal barriers are factors within a person that prevent one from acting in a morally correct way. These include lack of assertiveness and perception of powerlessness.

When arterial blood gas finding would be expected in a child with an acute asthma exacerbation?

Increased carbon dioxide level Gas exchange is limited because of narrowing and swelling of the bronchi; the carbon dioxide level increases. The oxygen level will be decreased, not increased. The pH will decrease; the child is in respiratory acidosis, not alkalosis. The bicarbonate level will be increased to compensate for acidosis.

What clinical indicator will the nurse likely identify when assessing a patient with pyrexia?

Increased pulse rate The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is a loss of taste perception from the anterior two-thirds region of the tongue. Which origin of the brain is associated with the involved nerve?

Inferior pons Loss of taste perception from the anterior two-thirds of the tongue indicates injury to the facial nerve, which originates from the inferior pons. The medulla is the site of origin for the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The optic nerve and oculomotor nerve originate from the midbrain. The site of origin for the olfactory nerve is the olfactory bulb in the anterior ventral cerebrum

Lack of mobility in a child may interfere with which developmental milestone?

Intellectual and psychomotor function A child must experience mobility so he or she can explore and learn about the world. Immobility can cause intellectual and psychomotor deficits because children need to experience mobility to explore the world. Immobility does not have a direct effect on growth, speech, hearing, or play.

A nurse working in a free clinic has recognized the need for health promotion for pregnant teenagers. The nurse works to develop a consortium of healthcare experts from several disciplines across the region to work toward improving the nutrition of pregnant teenagers. This is an example of what type of collaboration?

Interorganizational collaboration Interorganizational collaboration occurs between regional, national, or international organizations to achieve a common goal. Nurse-patient collaboration occurs when a nurse is working directly with a patient. Nurse-nurse collaboration occurs between nurses and among professionals in nursing management projects. Intraprofessional collaboration occurs among members of a professional discipline.

Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time?

Ketone bodies in the urine Ketones in the urine indicate that the body is breaking down fatty acids for energy instead of glucose as a result of a lack of insulin. In this situation, the patient's blood sugar would be elevated. Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake

Which explanation would the nurse provide a parent regarding their toddler's higher risk of falling from heights?

Lack of motor coordination A lack of motor coordination places a toddler at risk of falling from heights. The toddler's cognitive and sensory perception are not the primary factors that place the toddler at risk of falling from heights.

The nurse is assessing a patient diagnosed with diabetic ketoacidosis. The assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation?

Lubricate the patient's lips and allow continued hyperventilation Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

The nurse is caring for preterm infants with respiratory distress in the neonatal intense care unit. Which is the priority nursing action?

Maintaining a high-humidity environment to promote gas exchange The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible. Caloric intake is increased; the amount, number. and type of feedings are related to the metabolic rate

A diabetic patient who is hospitalized asks the nurse what factors are associated with increased blood glucose while in the hospital. Which response(s) by the nurse are appropriate? (Select all that apply.)

Medications such as steroids may increase glucose levels. Stressors such as illness cause the release of hormones that increase blood sugar. Blood sugar may be higher in the hospital due to decreased activity or rest. The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. Activity decreases blood glucose; therefore, increase in blood glucose while in the hospital could be related to inactivity. Steroids cause increases in blood glucose levels. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose

Which behavior by a nurse indicates the effective strategy for collaboration with other professionals?

Negotiates with others Conflicts may arise during collaboration, requiring the skill of negotiation. Strongly defending the professional role does not allow for input from other disciplines. Avoiding conflict does not allow proper representation of the nursing role. Collaboration should not be based on personal views.

A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. The action by the nursing assistant indicates understanding of the instructions? (Select all that apply.)

Offers nutritional supplements and frequent snacks Turns the patient at least every 2 hours The patient should be turned at least every 2 hours because permanent damage to the tissues can occur at pressure points in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin.

The nurse is working with a college student who is planning to become sexually active. She is requesting a reliable method of birth control that could be easily discontinued if necessary. Which is the best option for this college student?

Oral contraceptive pills Oral contraceptive pills prevent ovulation, are easy to stop, and are 99% effective in pregnancy prevention. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation; they should not be recommended for this college student who desires a reliable method of birth control that can be easily discontinued.

The nurse should explain to a patient that which are effective treatments for atopic pruritus? (Select all that apply.)

Oral steroids Topical steroids Oral and topical steroids may be given for acute cases of atopic pruritus.

What are the most important reasons for considering the use of palliative care in patient care management? (Select all that apply.)

Patients live with multiple chronic diseases several years before dying. Patients live with debilitating symptoms that interfere with the quality of life. Palliative care is used to reduce the symptoms associated with chronic disease. Because of the aging population in the United States, the older patient often lives with multiple diseases for several years before dying. These diseases produce symptoms that interfere with the activities of daily living and quality of life. Palliative care is symptom management and should be integrated into the management of chronic disease and not reserved only for terminal illness. Palliative care is utilized to help patients live as comfortably as possible (quality of life) for an unspecified amount of time, not just until cures are discovered.

The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form?

Position the client face down or in a side-lying position Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice.

While assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. Which physical finding would confirm the nurse's suspicion? (Select all that apply. One, some, or all responses may be correct)

Presence of burns from cigarettes Presence of bedsores Presence of unexplained bruises on the wrist(s) A physical finding of abuse in older adult can be the presence of burns from cigarettes. The physical presence of bedsores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults.

Which nutrients are critical for the musculoskeletal development during infancy, childhood, and adolescence?

Protein and calcium Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly. Without the proper vitamins, minerals, and protein, the bones would not develop as they should.

Which action would be beneficial when after an assessment, the nurse observes a feeling of an altered perception of body appearance in an adolescent? (Select all that apply. One, some or all responses may be correct)

Providing a therapeutic discussion of personal attributes perceived as positive Encouraging a discussion of maladaptive behaviors surrounding food and fluid intake Involving the adolescent in actives designed to promote a positive image of self-worth and accomplished Providing a therapeutic discussion of positive personal attributes would be beneficial for an adolescent who has a feeling of an altered perception of body appearance. Encouraging a discussion on a maladaptive behaviors surrounding food and fluid intake would provide consistency in therapy and allow for mutual discussion.

Which assesment item needs to be documented on a client with restraints? (Select all that apply. One, some, or all responses may be correct)

Pulse near the restrained area Temperature of the restrained area Skin integrity surrounding the restraint Behavior leading to the need for restraint Restraint use requires assessment of the body area restrained, such as a pulse quality and temperature for perfusion and the integrity of the skin. Behavior necessitating restraint should be assessed and documented. Restraints are used for safety only, not for connivence in care.

Which is the priority nursing invention for a patient with hyperthermia?

Removing excess clothing The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, so decreasing heat absorption through clothing is the highest priority. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

Human sexuality is interrelated with a variety of other nursing concepts that may affect sexuality or be affected by healthy sexual functioning. Prompt diagnosis and treatment of potential concerns related to concept overlap is an important nursing function. Which other concept is most likely to overlap with sexuality?

Reproduction The most obvious overlap between concepts is that of sexuality and reproduction. An example may be the use of contraceptives in order to avoid pregnancy. Women who are unable to conceive a child may experience emotional distress. A sexual relationship is likely to change as pregnancy advances. If a patient is feeling stress because of other life issues, this is likely to have a negative impact on his or her sexual relationships. The patient who has poor gas exchange may encounter challenges with sexual activity related to hypoxia. One physiological barrier to healthy sexual functioning is pain. Both chronic pain and pain during intercourse can negatively affect a patient's sexual relationship.

A nurse has begun working on a new unit with high-acuity patients. She also has care responsibilities for her children and her aging parents. The nurse is experiencing signs of being overwhelmed. What counsel by the nurse manager would help the nurse cope with her work stress?

Request that another nurse help her focus on essential aspects of care rather than optional aspects of care. Learning to prioritize care to what is essential to perform versus what would be nice to perform but could be eliminated on stressful days will help the nurse manage her physical and emotional resources at work. Taking time off does not address the underlying issue of how to handle work stress. Periodic breaks in a work day, such as a meal break, allow the staff to refocus and maintain energy to complete their work. Support from family may help address stressors at home but does not help manage stress at work.

The nurse should recommend the pen-injector insulin delivery system for the client with which clinical presentation?

Requirements for intensive therapy with small, frequent insulin doses The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.

The nurse is completing a care plan for a patient who is exhibiting poor coping after receiving a serious medical diagnosis. Which interventions should the nurse consider? (Select all that apply.)

Review pamphlets about treatment options with the patient. Compile a list of activities that are of interest to the patient. Identify positive aspects of the illness, such as the chance to spend more time with family. Interventions that develop an action plan (activities that the patient is still able to do), education about the illness (review of treatment options), and changing how the patient views some aspect of the illness (have more time with family members) are all interventions that help coping skills. Recommending the use of alcohol is not good, because the drinking may get out of control or the alcohol may interact with prescribed medications. Having the medical team make all decisions reinforces the lack of control the patient feels and encourages negative coping mechanisms of denial and avoidance.

A patient injured in an earthquake today when a wall fell on his legs and was hemorrhaging received 9 units of blood an hour ago. Which laboratory value is priority for the nurse to check?

Serum potassium The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.

A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem?

Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.

In order to fully understand the concept of sexuality, it is necessary to become familiar with the terms used when discussing this topic. Which term best describes how one views oneself as masculine or feminine?

Sexual identity Gender identity is socially derived from experiences with family, friends, and society. Sexual identity is defined as whether one is male or female based on biological sexual characteristics. Sexual orientation is how one views oneself in terms of being emotionally, romantically, or sexually attracted to an individual of a particular gender. Sexual behavior is how one responds to sexual impulses and desires.

The nurse is admitting a patient to the emergency room on a cold winter night. Which assessment finding would cause the nurse to suspect hypothermia?

Slow capillary refill With hypothermia, there is slow capillary refill. The skin is usually pale or cyanotic with hypothermia.

The nurse is caring for a patient with a colostomy of the ascending colon. What would the nurse expect of the stool in the colostomy device?

Stool would be loose. The correct answer loose because stool in the ascending colon is loose or watery because it has not passed through much of the colon for water to have been reabsorbed. Stool should not be dark or have flecks of blood. These would be abnormal findings. Stool would not be formed, because the colon has not reabsorbed the water yet.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestation would the nurse expect?

Stupor Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

The nurse in the diabetes clinic is caring for a patient diagnosed with decreased renal function. Which clinical manifestation would the nurse expect?

Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.

Two nurses are discussing the important attributes of care coordination. Which attribute of care coordination should be included in the discussion?

Team based Care coordination should be team based, or interdisciplinary. This allows the care to extend over several disciplines for a broader approach. Care that is community based, hospital based, or health insurance based would be too broad and might not serve the patient well.

Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted?

The Glasgow Coma Scale is unchanged from 3 hours ago. Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement.

The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement?

The patient needs to be toileted to maintain a regular toileting schedule. The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs.

The nurse is assessing a patient's coping abilities related to expected placement in a long-term care facility. Which risk factor is of most concern to the nurse?

The patient was recently diagnosed with Alzheimer disease. Poor cognition is a key risk factor for poor coping because the patient has difficulty assessing a situation and making decisions that allow a sense of control. Limited support is a risk factor, but decreased cognition adds to the patient's inability to understand changes. A retired police officer would typically have experienced stress and have some strengths in managing stress. Needing assistance to move is a short-term need; the inability to understand the need for the move or a new situation because of poor cognitive function is the greater concern.

A 5-year-old boy with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After touching the blocks, she rubs her nose with her hand. Which represents the most likely mode of transmission?

The unwashed math blocks The boy has the flu and sneezes into his hand while at school. When he works with the math blocks, he leaves the flu virus on the toys. The teacher's helper picks up the virus with the blocks. When the teacher's helper touches her nose with her hand, the virus enters the susceptible host. The blocks act as the mode of transmission. The boy carries the pathogen, and his sneeze is the portal of exit. The teacher's helper is the susceptible host. The hand-to-nose contact is the portal of entry.

During a new nurse' orientation to the unit, a nurse explains why collaboration is valued. Which outcome is a key patient care outcome that occurs when collaboration is correctly used?

There are fewer errors that occur in patient care. Collaboration results in fewer errors in patient care due to the interactions between health providers of all disciplines and patient involvement in planning. A positive accreditation review benefits the agency directly and the patient only indirectly. Collaboration is not the same as cross-training, and ongoing education is an expectation of all professions.

The coordination and continuity of health care transferred between different locations or different levels of care within the same location is known as which type of care coordination?

Transitional care Transitional care transfers between different locations, as described in the chapter. Healthcare doctrine, transactional care, and multilevel care do not fit the definition of coordination and continuity of care.

Although sexual activity is considered a normative process, some individuals place themselves at increased risk for negative consequences related to this process. Which nonsexual behavior is likely to increase risk-taking activities?

Using alcohol, marijuana, or illicit substances The influence of nonsexual high-risk behavior such as the use of alcohol, marijuana, and illicit substances increases sexual risk-taking behavior. The abuse of alcohol or drugs results in impaired judgment and less thoughtfulness related to the sexual act, particularly when substances are ingested close to the time of sexual activity. More varied sexual experiences and intercourse with multiple partners are significant individual sexual risk-taking behaviors. Gay, lesbian, and bisexual youth; men who have sex with men; and women who primarily have sex with women have been found to engage in more high-risk sexual practices. Youth in particular are less likely to engage in safer sex practices such as condom use. This is a sexual behavior that significantly increases the risk for contracting sexually transmitted infections, including human immunodeficiency virus (HIV) infection, and for unintended pregnancy.

A patient with a history of cardiac problems talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagas nerve and cause bradycardia. Which physiological function is the nurse explaining?

Valsalva maneuver The Valsalva maneuver happens when the cardiac patient strains to have a bowel movement. First-degree heart block is not brought on by straining. Eupnea means normal respirations and tachypnea means fast respirations; neither has any connection to straining during a bowel movement.

A nurse in the acute care setting is caring for a patient who has rubor of an area of injury on the left lower extremity. What is the cause for this finding?

Vasodilation The inflammatory process results in rubor, or redness, of an area of insult. The body responds to injury by increasing the blood flow to an area through vasodilation. This allows increased oxygen and more nutrients and appropriate white blood cells to reach the area, isolating the area and beginning the immune response. Extravasation is the movement of fluid from its confined space into the surrounding tissue. Neutrophils are one of the most common types of white blood cells. Exudate is the fluid filled with proteins and white blood cells that moves out of the vascular spaces through extravasation.

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which supplement may be prescribed to prevent deficiency?

Vitamin B12 Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

A patient is experiencing their first severe, acute asthma episode. The episode began 2 hours ago. What blood gas values should the nurse expect?

pH low, PaCO2 high, HCO3− normal A severe acute asthma episode impairs the excretion of carbonic acid, causing respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3− normal. A high pH occurs with alkalosis, not acidosis. ANSs that include abnormal levels of HCO3− are not correct for the 2-hour time frame.