exam 2
The public health nurse is providing follow-up care to a client with TB who does not regularly take his medication. Which nursing action would be most appropriate for this client? Ask the client's spouse to supervise the daily administration of the medications. Visit the clinic weekly to ask him whether he is taking his medications regularly. Remind the client that TB can be fatal if not taken properly. Notify the physician of the client's non-compliance and request a different prescription.
Ask the client's spouse to supervise the daily administration of the medications.
14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective? a. The client responds to verbal directions to eat b. The client initiates simple activities without direction c. The client walks with the nurse to her room d. The client is able to move all extremities occasionally
B. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.
23. Which of the following would nurse Ronald use as the best measure to determine a client's progress in rehabilitation? a. The way he gets along with his parents b. The number of drug-free days he has c. The kinds of friends he makes d. The amount of responsibility his job entails
B. The best measure to determine a client's progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is.
40. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate: Low self esteem Concrete thinking Effective self boundaries Weak ego
C. A person with this disorder would not have adequate self-boundaries.
17. Which statement about an individual with a personality disorder is true? a. Psychotic behavior is common during acute episodes b. Prognosis for recovery is good with therapeutic intervention c. The individual typically remains in the mainstream of society, although he has problems in social and occupational roles d. The individual usually seeks treatment willingly for symptoms that are personally distressful.
C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people's reaction to the individual's behavior.
16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others? a. Attending an activity with the nurse b. Leading a sing a long in the afternoon c. Participating solely in group activities d. Being involved with primarily one to one activities
C. Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.
36. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to? a. Isolate his gym time b. Encourage his active participation in unit programs c. Provide foods, fluids and rest d. Encourage his participation in programs
C. The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.
12. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects? a. Olanzapine (Zyprexa) b. Paroxetine (Paxil) c. Benztropine mesylate (Cogentin) d. Lorazepam (Ativan)
C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.
41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client's difficulties began in: a. Early childhood b. Late childhood c. Adolescence d. Puberty
C. The usual age of onset of schizophrenia is adolescence or early childhood.
43. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate: a. Slumped posture, pessimistic out look and flight of ideas b. Grandiosity, arrogance and distractibility c. Withdrawal, regressed behavior and lack of social skills d. Disorientation, forgetfulness and anxiety
C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
A client has active TB. Which of the following symptoms will he exhibit? Chills, fever, night sweats, and hemoptysis Headache and photophobia Fever of more than 104*F and nausea Chest and lower back pain
Chills, fever, night sweats, and hemoptysis
13. Jon a suspicious client states that "I know you nurses are spraying my food with poison as you take it out of the cart." Which of the following would be the best response of the nurse? a. Giving the client canned supplements until the delusion subsides b. Asking what kind of poison the client suspects is being used c. Serving foods that come in sealed packages d. Allowing the client to be the first to open the cart and get a tray
D. Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.
40. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client's fear of: a. Phobia b. Powerlessness c. Punishment d. Rejection
D. An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance
46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly: a. While watching TV b. During meal time c. During group activities d. After going to bed
D. Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, "Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt." The nurse interprets these statements as indicating which of the following? a. Echolalia b. Neologism c. Clang associations d. Flight of ideas
D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
41. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statement illustrate: Neologisms Echolalia Flight of ideas Loosening of association
D. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
28. Nurse Perry is aware that language development in autistic child resembles: Scanning speech Speech lag Shuttering Echolalia
D. The autistic child repeat sounds or words spoken by others.
A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has: Developed passive immunity to TB. Active TB Developed a resistance to tubercle bacilli Had contact with Mycobacterium tuberculosis
Had contact with Mycobacterium tuberculosis
A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? High-grade fever Nonproductive or productive cough Anorexia and weight loss Chills and night sweats
High-grade fever
Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? Apathy Depression Coma Irritability
Irritability
The nurse is caring for a client who has had an acute myocardial infarction. The client is taking chlorothiazide (Diuril) 500 mg and digoxin (Lanoxin) 0.25 mg daily. The nurse should plan to monitor the client for which of the following?
Muscle weakness. The client is at risk for hypokalemia due to fluid loss from chlorothiazide, which places him at greater risk for digoxin toxicity. Muscle weakness is a sign of hypokalemia. The client is at risk for hypokalemia, which would result in hypoactive reflexes.
A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: Inconclusive Negative The need for repeat testing. Positive
Positive
A client has been taking isoniazid (INH) and rifampin (Rifadin) for 3 weeks after being diagnosed with active pulmonary tuberculosis (TB). The client calls the clinic to report that his urine is a reddish orange color. Which of the following is an appropriate response by the nurse?
Rifampin may turn all body fluids orange-red. This is a harmless side effect. Rifampin will turn body fluids, such as tears, sweat, saliva, and urine, an orange-red color. Advise the client that this effect does not cause harm.
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to: 1. Admin a laxative 2. Placing the client on a clear liquid diet 3. Giving the client a tap water enema 4. starting an IV infusion
Take a laxative. -client should take a laxative after an upper gastrointestinal series to stimulate a bowel movement. This examination involves the administration of barium, which must be promptly eliminated from the body because it may harden and cause an obstruction.
Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia? A maximum loss of 5 to 10 pounds of body weight The ability to perform ADL's without dyspnea Chest pain that is minimized by splinting the ribcage. A respiratory rate of 25 to 30 breaths per minute
The ability to perform ADL's without dyspnea
Which of the following symptoms is common in clients with TB? Dyspnea on exertion Increased appetite Weight loss Mental status changes
Weight Loss
A 26-year-old Air Force staff sergeant is returning for diagnostic follow-up to the cardiologist's office where you practice nursing. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart? a) All options are correct b) Elevated temperature c) Shock d) Strenuous exercise
a) All options are correct Explanation: It occurs in clients with healthy hearts as a physiologic response to strenuous exercise, anxiety and fear, pain, fever, hyperthyroidism, hemorrhage, shock, or hypoxemia. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Fever is one cause. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Shock is one cause. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Strenuous exercise is one cause. pg.694
You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client? a) Immediate defibrillation b) Electric cardioversion c) Chemical cardioversion d) IV lidocaine
a) Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present. pg.716
Which of the following nursing interventions must a nurse perform when administering prescribed vasopressors to a patient with a cardiac dysrhythmia? a) Monitor vital signs and cardiac rhythm b) Keep the patient flat for one hour after administration c) Document heart rate before and after administration d) Administer every five minutes during cardiac resuscitation
a) Monitor vital signs and cardiac rhythm Explanation: The nurse should monitor the patient's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill patient. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a patient flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.
Your patient is experiencing asymptomatic sinus tachycardia with a rate of 118. The nurse understands that the treatment of this condition includes: a) Treating the underlying cause b) Immediate defibrillation c) Administration of amiodarone d) Electrical cardioversion
a) Treating the underlying cause Explanation: Sinus tachycardia occurs in response to an underlying condition and will usually resolve once that condition is corrected. pg.699
A 65-year-old client has come to the emergency department reporting light-headedness, chest pain, and shortness of breath. As you finish your assessment, the physician enters and orders tests to ascertain what is causing the client's problems. In your client education, you explain the tests. Which test is used to identify cardiac rhythms? a) Electroencephalogram b) Electrocardiogram c) Electrocautery d) Echocardiogram
b) Electrocardiogram Explanation: An electrocardiogram is used to identify normal and abnormal cardiac rhythms. An electrocardiogram is the device used to identify normal and abnormal cardiac rhythms. pg.694
The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation? a) It uses less electrical energy than cardioversion. b) It is used to eliminate ventricular dysrhythmias. c) The client is sedated before the procedure. d) It is a scheduled procedure 1 to 10 days in advance.
b) It is used to eliminate ventricular dysrhythmias. Explanation: The only treatment for a life-threatening ventricular dysrhythmia is immediate defibrillation, which has the exact same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion. pg.715
A 26-year-old client is returning for diagnostic follow-up. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minutes. What type of dysrhythmia would you expect the cardiologist to diagnose? a) Supraventricular bradycardia b) Sinus tachycardia c) Supraventricular tachycardia d) Sinus bradycardia
b) Sinus tachycardia Explanation: Sinus tachycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a faster than usual rate (100 to 150 beats/minute). Sinus tachycardia is the dysrhythmia with a faster than usual heart rate (100 to 150 beats/minute). pg.699
A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? a) Ventricular tachycardia b) Ventricular fibrillation c) Atrial fibrillation d) Third-degree heart block
b) Ventricular fibrillation Explanation: The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. No atrial activity is seen on the ECG. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute myocardial infarction. Ventricular fibrillation is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations. pg.709
When caring for a patient with irritable bowel syndrome (IBS), it is most important for the nurse to a. recognize that IBS is a psychogenic illness that cannot be definitely diagnosed b. develop a trusting relationship with the patient to provide support and symptomatic care c. teach the patient that a diet high in fiber will relieve the symptoms of both diarrhea and constipation d. inform the patient that new medications for IBS are available and effective for treatment of IBS maintained by either diarrhea or constipation
b. develop a trusting relationship with the patient to provide support and symptomatic care
A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip" The best reply by the nurse is which of the following? a) "The QRS complex will be smaller in sinus bradycardia." b) "The P waves will be shaped differently." c) "The only difference is the rate, which will be below 60 bpm in sinus bradycardia." d) "The P-R interval will be prolonged in sinus bradycardia, and you will have to measure carefully to note the width."
c) "The only difference is the rate, which will be below 60 bpm in sinus bradycardia." Explanation: All characterestics of sinus bradycardia are the same as those of normal sinus rhythm, except for the rate, which will be below 60 in sinus bradycardia. pg.726
The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment? a) A cell phone to call 911 b) A stethoscope c) An automatic external defibrillator d) A blood pressure cuff
c) An automatic external defibrillator Explanation: Most malls in the United States now have automatic external defibrillators in common areas. These defibrillators can easily be applied and obtain electrical confirmation of no ventricular contraction or R wave. The machine allows an electrical stimulation when the discharge button is depressed. A blood pressure cuff and stethoscope will not provide the equipment needed to save the client's life. The 911 can be called by a bystander, but the priority is to obtain the life-saving equipment. If defibrillation is performed within the first 3 minutes of cardiac arrest, the potential for survival is 74%. pg.717
The nurse caring for a patient with a dysrhythmia understands that the P wave on an electrocardiogram (ECG) represents what phase of the cardiac cycle? a) Ventricular repolarization b) Ventricular depolarization c) Atrial depolarization d) Early ventricular repolarization
c) Atrial depolarization Explanation: The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. The T wave represents ventricular repolarization. The ST segment represents early ventricular repolarization, and lasts from the end of the QRS complex to the beginning of the T wave. pg.696
After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have? a) Decreased blood pressure with reflex tachycardia b) Decreased peripheral vascular resistance c) Decreased cardiac output and decreased systolic and diastolic blood pressure d) Increased cardiac output and increased systolic and diastolic blood pressur
c) Decreased cardiac output and decreased systolic and diastolic blood pressure Explanation: As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia. pg.701
While assessing a client, the nurse finds a heart rate of 120 beats per minute. The nurse recalls that causes of sinus tachycardia include which of the following? a) Hypothyroidism and athletic training b) Vagal stimulation and sleep c) Hypovolemia and fever d) Digoxin and vagal stimulation
c) Hypovolemia and fever Explanation: Causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, sleep, hypothyroidism, athletic training, and Digoxin all will cause a slow heart rate. pg.698
A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal? a) Heart block b) Atrial bradycardia c) Sinus bradycardia d) None
c) Sinus bradycardia Explanation: Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower than usual (≤60 beats/minute) heart rate. pg.698
The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated? a) The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute b) The registered nurse stating to administer Lanoxin (digoxin) c) The registered nurse administering atropine sulfate intravenously d) The registered nurse stating to administer all medications accept those which are cardiotonics
c) The registered nurse administering atropine sulfate intravenously Explanation: The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed. pg.699
Your client has just been diagnosed with a dysrhythmia. The client asks you to explain normal sinus rhythm. What would you explain are the characteristics of normal sinus rhythm? a) Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 seconds. b) Heart rate between 60 and 150 beats per minute. c) The sinoatrial (SA) node initiates the impulse. d) The ventricles depolarize in 0.5 seconds or les
c) The sinoatrial (SA) node initiates the impulse. Explanation: The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats per minute; the SA node initiates the impulse; the impulse travels to the AV node in 0.12 to 0.2 seconds; the ventricles depolarize in 0.12 seconds or less; and each impulse occurs regularly. pg.698
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? a) Sustained asystole b) Supraventricular tachycardia c) Ventricular fibrillation d) Atrial fibrillation
c) Ventricular fibrillation Explanation: Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation is monitored and reported to the physician but is not addressed first. pg.709
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi? a) Adenosine (Adenocard) b) Atropine c) Warfarin (Coumadin) d) Amiodarone (Pacerone)
c) Warfarin (Coumadin) Explanation: Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone (Cordarone), flecainide (Tambocor), ibutilide (Corvert), propafenone (Rythmol), or sotalol (Betapace) prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation (Fuster, Rydén et al., 2011). pg.704
The nurse teaches the patient with a hiatal hernia of GERD to control symptoms by a. drink 10-12 oz of water with each meal b. spacing six small meals a day between breakfast and bedtime c. sleeping with the head of the bed elevated on 4 to 6 inch blocks d. performing daily exercises of toe-touching, sit-ups and weight lifting
c. sleeping with the head of the bed elevated on 4-6 inch blocks
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following? a) "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." b) "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." c) "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers." d) "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
d) "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." Explanation: The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers. pg.696
Which PR interval presents a first-degree heart block? a) 0.14 seconds b) 0.18 seconds c) 0.16 seconds d) 0.24 seconds
d) 0.24 seconds Explanation: In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block. pg.711
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? a) Potassium supplement b) Diuretic c) Antihypertensive d) Anticoagulant
d) Anticoagulant Explanation: Clients with persistent atrial fibrillation are prescribed anticoagulation therapy to reduce the risk of emboli formation associated with ineffective circulation. The other options may be prescribed but not expected in most situations. pg.704
Which medication is the drug of choice for sinus bradycardia? a) Pronestyl b) Cardizem c) Lidocaine d) Atropine
d) Atropine Explanation: Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias. pg.699
Treatment of symptomatic bradycardia includes which of the following? a) Cardioversion b) Adenocard c) Lidocaine d) Atropine
d) Atropine Explanation: Treatment of symptomatic bradycardia includes transcutaneous pacing and atropine. Lidocaine may be used in the treatment of ventricular fibrillation. Cardioversion and Adenocard may be used in patients diagnosed with atrial flutter. pg.699
The nurse is working on a telemetry unit, caring for a client who has been in a sinus rhythm for the past 2 days with a heart rate of 88 to 96 beats per minute. The client puts on the call light in the bathroom and reports severe dizziness. The telemetry shows a heart rate of 46 beats per minute. What should the nurse be prepared to do? a) Assist with a temporary pacemaker. b) Prepare the client for maze surgery. c) Send the client to the cardiac catheterization laboratory. d) Give an IV bolus of atropine.
d) Give an IV bolus of atropine. Explanation: Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. pg.699
What nursing interventions could you institute with a client who has a suspected dysrhythmia that would help detect life-threatening dysrhythmias and would manage and minimize any that occur? a) Palpate the client's pulse and observe the client's response. b) Provide supplemental oxygen. c) Monitor blood pressure continuously. d) Monitor cardiac rhythm continuously.
d) Monitor cardiac rhythm continuously. Explanation: The nurse should monitor cardiac rhythm continuously. Cardiac monitors display real-time heart rate and rhythm and alert the nurse to potentially life-threatening dysrhythmias. Monitoring blood pressure continuously and palpating the client's pulse do not help detect life-threatening dysrhythmias. Providing supplemental oxygen helps maintain adequate cardiac output and does not help detect life-threatening dysrhythmias. pg.692
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? 1. lean beef 2. air-popped popcorn 3. hot chocolate 4. raw veggies
hot chocolate -Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD
protein released after MI injury
tropnin
The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. "I can use regular plate and utensils whenever I eat." "I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them properly." "I will need to dispose of my old clothing when I return home." "It is important that I isolate myself from family when possible."
"I can use regular plate and utensils whenever I eat." "I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them properly."
Cardiac Dysrhythmias: Atrial: Sinus Bradycardia
- a dose of 0.5-1.0 mg of atripine sulfate may be given every 1-2 hours to increase the HR - max of 2.0 mg is given IV - isoproterenol (isuprel), a beta adrenergic blocker,vis also used to treat severe bradycardiac - when either drug is administered, closely monitor the pulse rate for drug response
1. A 60 y/o male client comes into the emergency department with complaints of crushing substernal chest pain that radiates to his sshoulder and left arm. The admitting diagnosis is acute MI. Immedciate admission orders include oxygen by nasal cannula at 4 L/min, blood work, a chest radiograph, a 12 lead ECG, and 2 mg of morphine given IM. The nurse should first... 1. admin the morphine 2. obtain a 12-lead ECG 3. obtain blood work 4. order the chest radiograph
1. Although obtaining the ECG, chest radio-graph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods? 1. Fats 2. High-Sodium foods 3. Carbohydrates 4. High-Calcium Foods
1. Fats
25. A 68 y/o female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness. The first nursing action should be to .. 1. Inquire about the onset, duration, severity, and precipitating factors to the heaviness 2. admin oxygen via nasal cannula 3. offer pain meds 4. inform dr of the chest heaviness
1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.
The physician prescribes metoclopramide hydrochloride (Reglan) for the client with hiatal hernia. The nurse plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the following objectives? 1. Increase the resting tone of the esophageal sphincter 2. Neutralize gastric secretions 3. Delay gastric emptying 4. Reduce secretion of digestive juices
1. Increase the resting tone of the esophageal sphincter
A 69-year-old female has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should the nurse assess first? 1. Blood pressure. 2. Skin breakdown. 3. Serum potassium level. 4. Urine output
1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.
A nurse is preparing to administer a morphine sulfate IV to a client for pain. The nurse should expect the onset of pain relief for the client to take place in:
10-15min. The IV route is considered to be the fastest and onset of pain relief usually begins in 10-15 min
Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects? 1. Constipation 2. Urinary Urgency 3. Hypertension 4. dry oral mucosa
2 . Urinary Urgency
The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate? 1. "Surgery is usually required, although medical treatment is attempted first" 2. "Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." 3. "Surgery is not performed for this type of hernia" 4. "A minor surgical procedure to reduce the size of the opening will be planned"
2. "Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes."
Which of the following factors would most likely contribute to the development of a client's hiatal hernia? 1. Having a sedentary desk job 2. Being 5 feet, 3 inches tall and weighing 190 # 3. using laxatives frequently 4 being 40 y/o
2. Being 5 feet, 3 inches tall and weighing 190 #
The client has been taking magnesium hydroxide (milk of magnesia) at home in an attempt to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium-based antacids? 1. Anorexia 2. Weight gain 3. Diarrhea 4. Constipation
3, Diarrhea
The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackels are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss 2. Flat neck and hand veins 3. An increase in blood pressure 4. A decreased central venous pressure (CVP
3. An increase in blood pressure
Cimetidine (Tagamet) may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following? 1. Esophageal reflux 2. Dysphagia 3. Esophagitis 4. Ulcer Formation
3. Esophagitis. -Cimetidine (Tagamet) is a histamine receptor antagonist that decreases the quantity of gastric secretions.
The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Raglan)? 1. Antacids 2. Antihypertensives 3. Anticoagulants 4. Alcohol
4. Alcohol
9. When teaching the client MI, the nurse explains that the pain associated with MI is caused by ... 1. left ventricular overload 2. impending circulatory collapse 3. extracellular electrolyte imbalances 4. Insufficient oxygen reaching the heart muscle
4. An MI interferes with or blocks blood circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina.
12. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? The client.. 1. has severe chest pain 2. can identify risk factors for MI. 3. agrees to participate in a cardiac rehab program 4. can perform personal self-care activities with-out pain
4. By day 2 of hospitalization after an MI, cli-ents are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitaliza-tion may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculossis is suspected. A sputum culture is obtained and idetifies Mycobacterium tuberculosis. The nurse provides instructions to the client regarding therapeutic management of the tuberculosis and the nurse tells the client that: 1. Therapeutic abortion is required 2. She will have to stay home until treatment is completed 3. Medication will not be started until after delivery of the fetus 4. Isoniazid (INH) plus rifampin (Ridafin) will be required for 9 months
4. Isoniazid (INH) plus rifampin (Ridafin) will be required for 9 months
Which of the following family members exposed to TB would be at highest risk for contracting the disease? 17-year-old daughter 45-year-old mother 76-year-old grandmother 8-year-old son
76-year-old grandmother
22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following? a. Respiratory depression b. Epilepsy c. Kidney failure d. Cerebral edema
A. After administering naloxone (Narcan) the nurse should monitor the client's respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.
8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation? Paranoid thoughts Emotional affect Independence need Aggressive behavior
A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, "My heart has stopped and my veins have turned to glass!" Nurse Ron is aware that this is an example of: a. Somatic delusions b. Depersonalization c. Hypochondriasis d. Echolalia
A. Somatic delusion is a fixed false belief about one's body.
38. A nursing care plan for a male client with bipolar I disorder should include: Providing a structured environment Designing activities that will require the client to maintain contact with reality Engaging the client in conversing about current affairs Touching the client provide assurance
A. Structure tends to decrease agitation and anxiety and to increase the client's feeling of security.
14. A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis? 1. The client will name own body parts as separate from others by day five. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day four. 4. The client will not harm self or others by discharge.
ANS: 1 Rationale: An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities, such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.
A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.
ANS: 1 Rationale: The nurse should determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.
After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.
ANS: 1 Rationale: The pharmacological action of Ritalin causes a decrease in appetite, which often leads to weight loss. Methylphenidate is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability.
. A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? 1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"
ANS: 2 Rationale: The most appropriate response by the nurse is to explain to the parent that autistic spectrum disorder is believed to be caused by abnormalities in brain structure or function, not poor parenting. Autism occurs in approximately 11.3 per 1,000 children and is about 4.5 times more likely to occur in boys than girls.
17. A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? 1. If one dose of Ritalin is missed, double the next dose. 2. Administer Ritalin to the child after breakfast. 3. Administer Ritalin to the child just prior to bedtime. 4. A side effect of Ritalin is decreased ability to learn.
ANS: 2 Rationale: The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and developmen
10. A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.
ANS: 2 Rationale: The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.
11. A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with neuroleptic medications. 3. Hold client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.
ANS: 3 Rationale: The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.
4. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.
ANS: 3 Rationale: The most realistic client outcome for a child diagnosed with autistic spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.
The major goal of therapy for a client with heart failure and pulmonary edema would be to: a. Increase cardiac output b. Improve respiratory edema c. Decrease peripheral edema d. Enhance comfort
Ans: A - increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
1. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. d. Is an angiotensin-converting enzyme (ACE) inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.
Ans: A - propranolol is -adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.
A client experiences some initial signs of excitation after having an intravenous infusion of lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical adverse reaction to lidocaine hydrochloride when the client complains of: a. Palpitations b. Tinnitus c. Urinary frequency d. Lethargy
Ans: B - Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride.
A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to: a. Call for the doctor b. Start an intravenous line c. Obtain a portable chest radiograph d. Draw blood for laboratory studies
Ans: B - advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the intravenous line.
10. Aspirin is administered to the client experiencing an MI because of its.. 1. antipyretic action 2. antithrombotic action 3. antiplatelet action 4. analgesic action
Ans: B - aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI.
Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to: a. Dilate coronary arteries b. Increase myocardial contractility c. Decrease cardiac dysrhythmias d. Decrease electrical conductivity in the heart
Ans: B - digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its use in clients with heart failure and pulmonary edema.
13. When teaching a client about the expected outcomes after IV admin of furosemide the nurse would include which outcome? 1. Increase blood pressure 2. Increased urine output 3. decreased pain 4. decreased PVCs
Ans: B - furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease dysrhythmias.
The nurse's discharge teaching plan for the client with congestive heart failure would stress the significance of which of the following? a. Maintaining a high-fiber diet b. Walking 2 miles every day c. Obtaining daily weights at the same time each day d. Remaining sedentary for most of the day
Ans: C - Congestive heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is not relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on his history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended.
Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? a. Risk for infection related to line placements b. Impaired skin integrity related to pressure c. Activity intolerance related to imbalance between oxygen supply and demand d. Constipation related to immobility
Ans: C - activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to immobility.
6. During the past few months, a 56-year old woman has felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? a. Visit her friend b. Rest for at least an hour before climbing the stairs c. Take a nitroglycerin tablet before climbing the stairs. d. Lie down once she reaches the friend's apartment.
Ans: C - nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.
In which of the following should the nurse place a client with suspected heart failure? a. Semi-sitting (Low Fowler's position) b. Lying on the right side (Sims' position) c. Sitting almost upright (High Fowler's position) d. Lying on the back with the head lowered (Trendelenburg position)
Ans: C - sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg position.
Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heart failure because it acts as a: a. Vasopressor b. Volume expander c. Vasodilator d. Potassium-sparing diuretic
Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.
The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels indicate that the client has a: a. Low sodium level b. High glucose level c. High calcium level d. Low potassium level
Ans: D - a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability.
The nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary reason for this is to help: a. Prevent electrolyte imbalances b. Retard rapid drug absorption c. Excrete excessive fluids accumulated during the night d. Prevent sleep disturbances during the night
Ans: D - when diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.
