Nursing 406 Unit 1 Nclex

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults? A) Substantially reduced renal function B) Acute kidney injury C) Decreased cardiac output D) Alterations in ratio of body fluids to muscle mass

Ans: A Feedback: Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acidbase disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.

A gerontologic nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiological change that contributes to this trend? A) Heart muscle and arteries lose their elasticity. B) Systolic blood pressure decreases. C) Resting heart rate decreases with age. D) Atrial-septal defects develop with age.

Ans: A Feedback: The leading cause of death for patients over the age of 65 years is cardiovascular disease. With age, heart muscle and arteries lose their elasticity, resulting in a reduced stroke volume. As a person ages, systolic blood pressure does not decrease, resting heart rate does not decrease, and the aged are not less likely to adopt a healthy lifestyle

You are the psychiatric-mental health nurse caring for a young, recently married woman, whose sister and niece were recently killed in a motor vehicle accident. This young woman is making arrangements for the funerals, and you know that your patient has insight into her current stressors. What do you know is occurring with this young woman? A) The mediating process is occurring. B) The patient is experiencing an expected level of denial. C) The patients awareness of her stress makes it more acute. D) The patient is emotionally overwhelmed.

Ans: A Feedback: After recognizing a stressor, a person consciously or unconsciously reacts to manage the situation. This is termed the mediating process. Nothing in the scenario indicates the patient is either in denial or feeling overwhelmed. Awareness of stress does not necessarily exacerbate it.

An elderly patient has presented to the clinic with a new diagnosis of osteoarthritis. The patients daughter is accompanying him and you have explained why the incidence of chronic diseases tends to increase with age. What rationale for this phenomenon should you describe? A) With age, biologic changes reduce the efficiency of body systems. B) Older adults often have less support and care from their family, resulting in illness. C) There is an increased morbidity of peers in this age group, and this leads to the older adults desire to also assume the sick role. D) Chronic illnesses are diagnosed more often in older adults because they have more contact with the health care system.

Ans: A Feedback: Causes of the increasing number of people with chronic conditions include the following: longer lifespans because of advances in technology and pharmacology, improved nutrition, safer working conditions, and greater access (for some people) to health care. Also, biologic conditions change in the aged population. These changes reduce the efficiency of the bodys systems. Older adults usually have more support and care from their family members. Assuming the sick role can be a desire in any age group, not just the elderly.

A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, It hurts him so bad and it looks swollen, red, and infected. What can the triage nurse teach the mother? A) The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection. B) Bee stings frequently cause infection, pain, and swelling, and, with treatment, the infection should begin to subside late today. C) The infection was probably caused by the stinger, which may still be in the wound. D) The mothers assessment is accurate and the ED doctor will probably prescribe antibiotics to fix the problem.

Ans: A Feedback: Cells or tissues of the body may be injured or killed by any agent (physical, chemical, infectious). When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the injury site. Inflammation is not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. Although bee stings may cause infection, the signs and symptoms (very painful, looks swollen and red) result from the acute inflammatory response. If the stinger were still in the wound, it would only be creating inflammation, not infection. Antibiotics are not indicated.

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration

Ans: A Feedback: Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.

A 44-year-old woman will undergo a bilateral mastectomy later today and the nurse in surgical admitting has begun the process of patient education. What positive outcome of providing the patient with information should the nurse expect? A) Increased concentration B) Decreased depression levels C) Sharing of personal details D) Building interdependent relationships

Ans: A Feedback: Giving patients information also reduces the emotional response so that they can concentrate and solve problems more effectively. Educating the patient does not decrease depression levels or build interpersonal relationships. Educating the patient does not mean sharing of personal details

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide

Ans: A Feedback: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.

The nurse is caring for a 65-year-old patient who has previously been diagnosed with hypertension. Which of the following blood pressure readings represents the threshold between high-normal blood pressure and hypertension? A) 140/90 mm Hg B) 145/95 mm Hg C) 150/100 mm Hg D) 160/100 mm Hg

Ans: A Feedback: Hypertension is the diagnosis given when the blood pressure is greater than 140/90 mm Hg. This makes the other options incorrect.

A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patients fluid volume deficit is due to acute or chronic renal failure

Ans: A Feedback: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolytefree water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture

Based on a patients vague explanations for recurring injuries, the nurse suspects that a community dwelling older adult may be the victim of abuse. What is the nurses primary responsibility? A) Report the findings to adult protective services. B) Confront the suspected perpetrator. C) Gather evidence to corroborate the abuse. D) Work with the family to promote healthy conflict resolution.

Ans: A Feedback: If neglect or abuse of any kind including physical, emotional, sexual, or financial abuse is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.

A patient who is legally blind is being admitted to the hospital. The patient informs the nurse that she needs to have her guide dog present during her hospitalization. What is the nurses best response to the patient? A) Arrangements can be made for your guide dog to be at the hospital with you during your stay. B) I will need to check with the care team before that decision can be made. C) Because of infection control, your guide dog will likely not be allowed to stay in your room during your hospitalization. D) Your guide dog can stay with you during your hospitalization, but he will need to stay in a cage or crate that you will need to provide.

Ans: A Feedback: If patients usually use service animals to assist them with ADLs, it is necessary to make arrangements for the accommodation of these animals. The patient should be moved to a private room, and a cage would prevent the service dog from freely assisting the patient, so it is not necessary.

You are caring for a patient with a history of chronic angina. The patient tells you that after breakfast he usually takes a shower and shaves. It is at this time, the patient says, that he tends to experience chest pain. What might you counsel the patient to do to decrease the likelihood of angina in the morning? A) Shower in the evening and shave before breakfast. B) Skip breakfast and eat an early lunch. C) Take a nitro tab prior to breakfast. D) Shower once a week and shave prior to breakfast.

Ans: A Feedback: If the nurse determines that one of the situations most likely to precipitate angina is to shower and shave after breakfast, the nurse might counsel the patient to break these activities into different times during the day. Skipping breakfast and eating an early lunch would not decrease the likelihood of angina in the morning. Taking a nitro tablet before breakfast is inappropriate because the event requiring the medication has not yet occurred. Also, suggesting that the patient shower once a week and shave prior to breakfast is an incorrect suggestion because showering and shaving can both be done every day if they are spread out over the course of the day.

An international nurse has noted that a trend in developing countries is a decrease in mortality from some acute conditions. This has corresponded with an increase in the incidence and prevalence of chronic diseases. What has contributed to this decrease in mortality from some acute conditions? A) Improved nutrition B) Integration of alternative health practices C) Stronger international security measures D) Decrease in obesity

Ans: A Feedback: In developing countries, chronic conditions have become the major cause of health-related problems due to improved nutrition, immunizations, and prompt and aggressive management of acute conditions. The integration of alternative health practices has not contributed to a decrease in mortality. Stronger international security measures have not contributed to a decrease in mortality. Obesity has not decreased, even in developing countries.

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

Ans: A Feedback: Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication

Ans: A Feedback: Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.

For several years, a community health nurse has been working with a 78-year-old man who requires a wheelchair for mobility. The nurse is aware that the interactions between disabilities and aging are not yet clearly understood. This interaction varies, depending on what variable? A) Socioeconomics B) Ethnicity C) Education D) Pharmacotherapy

Ans: A Feedback: Large gaps exist in our understanding of the interaction between disabilities and aging, including how this interaction varies, depending on the type and degree of disability, and other factors such as socioeconomics and gender. Ethnicity, education, and pharmacotherapy are not identified as salient influences on this interaction.

The nurse is assessing a newly admitted patient who is an 84-year-old woman. The nurse learns that the patient has simultaneously experienced a hip fracture and the exacerbation of her chronic heart failure. What is an example of a bodily function that restores homeostasis by negative feedback when conditions shift out of normal range? A) Body temperature B) Pupil dilation C) Diuresis D) Blood clotting

Ans: A Feedback: Negative feedback mechanisms throughout the body monitor the internal environment and restore homeostasis when conditions shift out of normal range. Body temperature, blood pressure, and acid-base balances are examples of functions regulated by these compensatory mechanisms. Blood clotting in the body involves positive feedback mechanisms. Pupil dilation and diuresis are not modulated by negative feedback mechanisms.

A case manager is responsible for ensuring that patients meet the criteria for diagnoses of chronic conditions in order to ensure their eligibility for federal programs. Which of these definitions may not apply for legal purposes? A) A person who is temporarily disabled but later return to full functioning. B) A person who is disabled and cannot expect a return to full functioning. C) A person whose disability is the result of a developmental disorder. D) A person whose disability is the result of a traumatic injury.

Ans: A Feedback: People can be temporarily disabled because of an injury or acute exacerbation of a chronic disorder, but later return to full functioning; this definition of disability may not apply for legal purposes. Disabilities may result from developmental challenges or trauma.

You are discharging a 4-year-old boy from the emergency department. The boy was seen for an insect bite that became swollen and reddened and warm and painful to touch. The patients vital signs are all within normal range for age. While giving discharge instructions to the patients father, he asks why the child is not going to get antibiotics for the infected insect bite. What would be your best response? A) This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help. B) In children who are previously healthy, inflammation and infections usually resolve without the need for drugs. C) Ill make sure the doctor is made aware that youd like your son to have a course of antibiotics. D) Infection is not the same as inflammation. What your son has is inflammation.

Ans: A Feedback: Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration. As these changes take place, five cardinal signs of inflammation are produced: redness, heat, swelling, pain, and loss of function. Infections do not always resolve spontaneously. The nurse should teach the patients father about the reasons that antibiotics are unnecessary rather than simply deferring to the physician.

Selyes general adaptation syndrome (GAS) is a theory of adaption to biologic stress. Selye compared the GAS with the life process: childhood, adulthood, and later years. What would occur during adulthood in the GAS? A) Stressful events occur and resistance or adaption occurs. B) Successful avoidance of stressful life events leaves the body vulnerable. C) The accumulation of lifes stressors causes resistance to fall. D) Vulnerability leads to eventual death.

Ans: A Feedback: Selye compared the general adaptation syndrome with the life process. During childhood, too few encounters with stress occur to promote the development of adaptive functioning, and children are vulnerable. During adulthood, a number of stressful events occur, and people develop resistance or adaptation. During the later years, the accumulation of lifes stressors and wear and tear on the organism again decrease peoples ability to adapt, so resistance falls, and, eventually, death occurs. Based on this comparison, options B, C, and D are incorrect.

You are the nurse caring for an 85-year-old patient who has been hospitalized for a fractured radius. The patients daughter has accompanied the patient to the hospital and asks you what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What would be your best response? A) He should likely take showers rather than baths, if possible B) Make sure that he applies sunscreen each morning. C) Dry skin is an age-related change that is largely inevitable. D) Try to help your father increase his intake of dairy products.

Ans: A Feedback: Showers are less drying than hot tub baths. Sun exposure should indeed be limited, but daily application of sunscreen is not necessary for many patients. Dry skin is an age-related change, but this does not mean that no appropriate interventions exist to address it. Dairy intake is unrelated.

You walk into your patients room and find her sobbing uncontrollably. When you ask what the problem is, your patient responds, I am so scared. I have never known anyone who goes into a hospital and comes out alive. On this patients care plan you note a pre-existing nursing diagnosis of Ineffective Coping related to stress. What is the best outcome you can expect for this patient? A) Patient will adopt coping mechanisms to reduce stress. B) Patient will be stress free for the duration of treatment. C) Patient will avoid all stressful situations. D) Patient will be treated with an antianxiety agent

Ans: A Feedback: Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the patient needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. The other options are incorrect because it is unrealistic to expect a patient to be stress free; avoiding stressful situations and starting an antianxiety agent are not the best answers as outcomes for ineffective coping.

A man with a physical disability uses a wheelchair. The individual wants to attend a support group for the parents of autistic children, which is being held in the basement of a church. When the individual arrives at the church, he realizes there are no ramps or elevators to the basement so he will not be able to attend the support group. What type of barrier did this patient encounter? A) A structural barrier B) A barrier to health care C) An institutional barrier D) A transportation barrier

Ans: A Feedback: Structural barriers make certain facilities inaccessible. Examples of structural barriers include stairs, lack of ramps, narrow doorways that do not permit entry of a wheelchair, and restroom facilities that cannot be used by people with disabilities. This individual did not experience a barrier to health care, an institutional barrier, or a transportation barrier.

A patient with a spinal cord injury is being assessed by the nurse prior to his discharge home from the rehabilitation facility. The nurse is planning care through the lens of the interface model of disability. Within this model, the nurse will plan care based on what belief? A) The patient has the potential to function effectively despite his disability. B) The patients disabling condition does not have to affect his lifestyle. C) The patient will not require care from professional caregivers in the home setting. D) The patients disability is the most salient aspect of his personal identity.

Ans: A Feedback: The interface model does not ignore the disabling condition or its disabling effects; instead, it promotes the view that people with disabilities are capable, responsible people who are able to function effectively despite having a disability. This does not mean that the patient will not require care, however, or that it will not affect his lifestyle. The persons disability is not his identity.

A nurse is caring for an 86-year-old female patient who has become increasingly frail and unsteady on her feet. During the assessment, the patient indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this patient is at a high risk for what health problem? A) A hip fracture B) A femoral fracture C) Pelvic dysplasia D) Tearing of a meniscus or bursa

Ans: A Feedback: The most common fracture resulting from a fall is a fractured hip resulting from osteoporosis and the condition or situation that produced the fall. The other listed injuries are possible, but less likely than a hip fracture.

You are assessing an older adult patient post-myocardial infarction. You attempt to identify your patients health patterns and to assess if these health patterns are achieving the patients goals. How should you best respond if it is found that the patients health patterns are not achieving their goals? A) Seek ways to promote balance in the patient. B) Refer the patient to social work. C) Identify alternative models of health care. D) Provide insight into the patients physiological failings.

Ans: A Feedback: The nurse has a significant role and responsibility in identifying the health patterns of the patient receiving care. If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote balance. The nurse is not obligated to refer to social work, identify alternative forms of care, or provide insight into the physiologic failings of the system if the patients health patterns are not achieving their goals.

The community nurse is caring for a patient who has paraplegia following a farm accident when he was an adolescent. This patient is now 64 years old and has just been diagnosed with congestive heart failure. The patient states, Im so afraid about what is going to happen to me. What would be the best nursing intervention for this patient? A) Assist the patient in making suitable plans for his care. B) Take him to visit appropriate long-term care facilities. C) Give him pamphlets about available community resources. D) Have him visit with other patients who have congestive heart failure.

Ans: A Feedback: The nurse should recognize the concerns of people with disabilities about their future and encourage them to make suitable plans, which may relieve some of their fears and concerns about what will happen to them as they age. Taking him to visit long-term care facilities may only make him more afraid, especially if he is not ready and/or willing to look at long-term care facilities. Giving him pamphlets about community resources or having him visit with other patients who have congestive heart failure may not do anything to relieve his fears.

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

Ans: A Feedback: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

A home care nurse is making an initial visit to a 68-year-old man. The nurse finds the man tearful and emotionally withdrawn. Even though the man lives alone and has no family, he has been managing well at home until now. What would be the most appropriate action for the nurse to take? A) Reassess the patients psychosocial status and make the necessary referrals B) Have the patient volunteer in the community for social contact C) Arrange for the patient to be reassessed by his social worker D) Encourage the patient to focus on the positive aspects of his life

Ans: A Feedback: The patient is exhibiting signs of depression and should be reassessed and a referral made as necessary. Patients with chronic illness are at an increased risk of depression. It would be simplistic to arrange for him to volunteer or focus on the positive. Social work may or may not be needed; assessment should precede such a referral.

An elderly patient, while being seen in an urgent care facility for a possible respiratory infection, asks the nurse if Medicare is going to cover the cost of the visit. What information can the nurse give the patient to help allay her concerns? A) Medicare has a copayment for many of the services it covers. This requires the patient to pay a part of the bill. B) Medicare pays for 100% of the cost for acute-care services, so the cost of the visit will be covered. C) Medicare will only pay the cost for acute-care services if the patient has a very low income. D) Medicare will not pay for the cost of acute-care services so the patient will be billed for the services provided.

Ans: A Feedback: The two major programs that finance health in the United States are Medicare and Medicaid, both of which are overseen by the Centers for Medicaid and Medicare Services (CMS). Both programs cover acute-care needs such as inpatient hospitalization, physician care, outpatient care, home health services, and skilled nursing care in a nursing. Medicare is a plan specifically for the elderly population, and Medicaid is a program that provides services based on income.

The nurse is providing patient teaching to a patient with early stage Alzheimers disease (AD) and her family. The patient has been prescribed donepezil hydrochloride (Aricept). What should the nurse explain to the patient and family about this drug? A) It slows the progression of AD. B) It cures AD in a small minority of patients. C) It removes the patients insight that he or she has AD. D) It limits the physical effects of AD and other dementias

Ans: A Feedback: There is no cure for AD, but several medications have been introduced to slow the progression of the disease, including donepezil hydrochloride (Aricept). These medications do not remove the patients insight or address physical symptoms of AD.

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

Ans: A Feedback: To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

The nurse is caring for a patient who was widowed 2 years prior to this current hospitalization, her fifth since the death of her husband. The woman says to the nurse, The doctor says my blood pressure is dangerously high. What is making my blood pressure so high? What does the nurse know about the probable cause of this patients hypertension? A) Prolonged or unrelenting suffering can cause physical illness. B) Physical illness is always caused by prolonged stress. C) The elderly are at increased risk for hypertension due to stress. D) Stress always exacerbates the physiologic processes of the elderly

Ans: A Feedback: When a person endures prolonged or unrelenting suffering, the outcome is frequently the development of a stress-related illness. Physical illness is not always caused by prolonged stress. The elderly population is not the only population at increased risk for hypertension due to stress. Stress does not always exacerbate the physiologic processes of the elderly. This is an absolute statement, and true absolutes are rare.

Your older adult patient has been diagnosed with urosepsis and has a temperature of 103.4F. You should be aware that the oxygen demands of the patients body would change in which direction and why? A) Increase due to an increase in metabolism B) Decrease due to a decrease in metabolism C) Increase due to a decrease in metabolism D) Decrease due to an increase in metabolism

Ans: A Feedback: When a persons temperature is elevated, hypermetabolism occurs, and the respiratory rate, heart rate, and basal metabolic rate increase. The other options are incorrect because oxygen demands would not decrease and they would not increase due to a decrease in metabolism.

A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug? A) An older patient has less subcutaneous tissue and less muscle mass than a younger patient. B) An older patient has more subcutaneous tissue and less durable skin than a younger patient. C) An older patient has more superficial and tortuous nerve distribution than a younger patient. D) An older patient has a higher risk of bleeding after an IM injection than a younger patient.

Ans: A Feedback: When administering IM injections, the nurse should remember that in an older patient, subcutaneous fat diminishes, particularly in the extremities. Muscle mass also decreases. There are no significant differences in nerve distribution or bleeding risk.

A patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a chronic condition. She asks the nurse what chronic condition means. What would be the nurses best response? A) Chronic conditions are defined as health problems that require management of several months or longer. B) Chronic conditions are diseases that come and go in a relatively predictable cycle. C) Chronic conditions are medical conditions that culminate in disabilities that require hospitalization. D) Chronic conditions are those that require short-term management in extended-care facilities.

Ans: A Feedback:Chronic conditions are often defined as medical conditions or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic diseases are usually managed in the home environment. They are not always cyclical or predictable.

You are auditing the electronic health record of a 33-year-old patient who was treated for a postpartum hemorrhage. When reviewing the patients records, you can see various demonstrations of negative feedback loops. Which of the following constitute negative feedback loops? Select all that apply. A) Serum glucose levels B) Acid-base balance C) Temperature D) Blood clotting E) Labor onset

Ans: A, B, C Feedback: These mechanisms work by sensing deviations from a predetermined set point or range of adaptability and triggering a response aimed at offsetting the deviation. Blood pressure, acidbase balance, blood glucose level, body temperature, and fluid and electrolyte balance are examples of functions regulated through such compensatory mechanisms. Coagulation and labor onset are results of positive feedback loops.

In your role as a school nurse, you are presenting at a high school health fair and are promoting the benefits of maintaining a healthy body weight. You should refer to reductions in the risks of what diseases? Select all that apply. A) Heart disease B) Stroke C) Cancer D) Diabetes E) Hypertension

Ans: A, B, D, E Feedback: The increasing prevalence of obesity has increased the incidence of heart disease, strokes, diabetes, and hypertension. Obesity is not usually cited as a major risk factor for most types of cancer.

Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? Select all that apply. A) Medication effects B) Overdependence on assistive devices C) Poor lighting D) Sensory impairment E) Ineffective use of coping strategies

Ans: A, C, D Feedback: Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply. A) Milk B) Beef C) Poultry D) Green vegetables E) Liver

Ans: A, C, E Feedback: If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.

The nurse is admitting a 51-year-old patient to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply. A) Severity of the injury B) Social relationships C) Condition of the host D) Familial support E) Nature of the injury

Ans: A, C, E Feedback: The condition of the host, the environment, and the nature and severity of the injury affect the processes of inflammation, repair, and replacement. The patients social relationships and familial support do not directly affect the processes of inflammation, repair, and replacement.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium

Ans: A, D, E Feedback: Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

A patient presents to the health center and the nurse practitioners assessment reveals an enlarged thyroid. The nurse practitioner believes the thyroid cells may be undergoing hyperplasia. How would the nurse practitioner explain this condition to the patient? A) Hyperplasia is the abnormal decrease in cell and organ size and is a precursor to cancer. B) Hyperplasia is an abnormal increase in new cells and is reversible with the stimulus for cell growth removed. C) Hyperplasia is the change in appearance of the thyroid due to a chronic irritation and will reverse with the stimulus removed. D) Hyperplasia is a cancerous growth and will be removed surgically

Ans: B Feedback: Hyperplasia is an increase in the number of new cells in an organ or tissue. This is due to increased mitotic stimulation from the additional cell division, and this, in turn, enlarges the tissue. Hyperplasia is reversible when the stimulus for cell growth is removed. Hyperplasia is the increase in the number of new cells, not a change in size or appearance. Hyperplasia is the increase in the number of new cells, which may or may not be cancerous growth.

A patient tells the nurse that she does not like to go to the doctor and is feeling anxious about being in this place. When the nurse checks her blood pressure, it is elevated along with her heart rate. The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurses response? A) She should not worry; it was stress related and her regular blood pressure is good. B) The first blood pressure was part of a simple stress response; our long-term blood pressure is controlled by negative feedback systems. C) Blood pressure is only one measure of hypertension; she should review this with the doctor and plan to recheck it on a regular basis. D) The respiratory infection is the probably the cause of the elevated blood pressure, and, with treatment, her blood pressure should remain normal.

Ans: B Feedback: A simple stress response will temporarily elevate a blood pressure and heart rate. Long-term blood pressure response is controlled by negative feedback systems. For a science teacher, this would be an appropriate level of teaching/learning and would serve to promote health. The nurse would be incorrect in assuming the patients blood pressure is good based on only two blood pressure readings. The stress of a respiratory infection could account for the elevated blood pressure, but assuring the patient that, with treatment, her blood pressure will return to normal may not be true.

A patient is experiencing intense stress during his current hospital admission for the exacerbation of chronic obstructive pulmonary disease (COPD). Which of the patients actions best demonstrates adaptively coping? A) Becoming controlling B) Reprioritizing needs and roles C) Using benzodiazepines as ordered D) Withdrawing

Ans: B Feedback: Adaptive ways of coping included seeking information, reprioritizing needs and roles, lowering expectations, making compromises, comparing oneself to others, planning activities to conserve energy, taking things one step at a time, listening to ones body, and using self-talk for encouragement. Becoming controlling or withdrawing are not ways to cope adaptively. Benzodiazepines are sometimes indicated, but these are not considered to be an adaptive coping behavior.

An occupational health nurse overhears an employee talking to his manager about a 65-year-old coworker. What phenomenon would the nurse identify when hearing the employee state, He should just retire and make way for some new blood.? A) Intolerance B) Ageism C) Dependence D) Nonspecific prejudice

Ans: B Feedback: Ageism refers to prejudice against the aged. Intolerance is implied by the employees statement, but the intolerance is aimed at the coworkers age. The employees statement does not raise concern about dependence. The prejudice exhibited in the statement is very specific.

The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient? A) Advance directives are not legal documents, so you have nothing to worry about. B) Advance directives are limited only to health care instructions and directives. C) Your finances cannot be managed without an advance directive. D) Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money.

Ans: B Feedback: An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney for health care) and covers only issues related specifically to health care, not financial issues. They do not address financial issues. Advance directives are implemented when a patient becomes incapacitated, but financial issues are addressed with a durable power of attorney for finances, or financial power of attorney.

The nurse is assessing a patient and finds two enlarged supraclavicular lymph nodes. The nurse asks the patient how long these nodes have noticeably enlarged. The patient states, I cant remember. A long time I think. Do I have cancer? Which of the following is an immediate physiologic response to stress the nurse would expect this patient to experience? A) Vasodilation of peripheral blood vessels B) Increased blood pressure C) Decrease in blood glucose levels D) Pupil constriction

Ans: B Feedback: An initial response to stress, as seen by the fight-or-flight response, is an increase in the patients heart rate and blood pressure. Vasoconstriction leads to the increase in blood pressure. Blood glucose levels increase, supplying more readily available energy, and pupils dilate.

A 19-year-old patient with a diagnosis of Down syndrome is being admitted to your unit for the treatment of community-acquired pneumonia. When planning this patients care, the nurse recognizes that this patients disability is categorized as what? A) A sensory disability B) A developmental disability C) An acquired disability D) An age-associated disability

Ans: B Feedback: Developmental disabilities are those that occur any time from birth to 22 years of age and result in impairment of physical or mental health, cognition, speech, language, or self-care. Examples of developmental disabilities are spina bifida, cerebral palsy, Down syndrome, and muscular dystrophy. Acquired disabilities may occur as a result of an acute and sudden injury, acute nontraumatic disorders, or progression of a chronic disorder. Age-related disabilities are those that occur in the elderly population and are thought to be due to the aging process. A sensory disability is a type of a disability and not a category.

A patient who has a 40 pack-year history of smoking may have dysplasia of the epithelial cells in her bronchi. What would the nurse tell the patient about dysplastic cells in the bronchi? A) This is a benign process that occurs as lung tissue regenerates. B) Dysplastic cells have a high potential to become malignant. C) This process involves a rapid increase in number of cells. D) Dysplasia may cause uncontrolled growth of scar tissue

Ans: B Feedback: Dysplasia is bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type. Dysplastic cells have a tendency to become malignant; dysplasia is seen commonly in epithelial cells in the bronchi of people who smoke. This may not be a harmless condition and dysplasia does not cause scar tissue. Hyperplasia is an increase in the number of new cells.

A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist among health care providers. The nurse has made the point that most people aged 75 years remains functionally independent. The nurse should attribute this trend to what factor? A) Early detection of disease and increased advocacy by older adults B) Application of health-promotion and disease-prevention activities C) Changes in the medical treatment of hypertension and hyperlipidemia D) Genetic changes that have resulted in increased resiliency to acute infection

Ans: B Feedback: Even among people 75 years of age and over, most remain functionally independent, and the proportion of older Americans with limitations in activities is declining. These declines in limitations reflect recent trends in health-promotion and disease-prevention activities, such as improved nutrition, decreased smoking, increased exercise, and early detection and treatment of risk factors such as hypertension and elevated serum cholesterol levels. This phenomenon is not attributed to genetics, medical treatment, or increased advocacy.

A 47-year-old patient who has come to the physicians office for his annual physical is being assessed by the office nurse. The nurse who is performing routine health screening for this patient should be aware that one of the first physical signs of aging is what? A) Having more frequent aches and pains B) Failing eyesight, especially close vision C) Increasing loss of muscle tone D) Accepting limitations while developing assets

Ans: B Feedback: Failing eyesight, especially close vision, is one of the first signs of aging in middle life. More frequent aches and pains begin in the early late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood.

You are caring for a patient with late-stage Alzheimers disease. The patients wife tells you that the patient has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop to assist the patients wife? A) The caregiver learns to explain to the patient why she needs time for herself. B) The caregiver distinguishes essential obligations from those that can be controlled or limited. C) The caregiver leaves the patient at home alone for short periods of time to encourage independence. D) The caregiver prioritizes her own health over that of the patient.

Ans: B Feedback: For prolonged periods, it is not uncommon for caregivers to neglect their own emotional and health needs. The caregiver must learn to distinguish obligations that she must fulfill and limit those that are not completely necessary. The caregiver can tell the patient when she leaves, but she should not expect that the patient will remember or will not become angry with her for leaving. The caregiver should not leave the patient home alone for any length of time because it may compromise the patients safety. Being thoughtful and selective with her time and energy is not synonymous with prioritizing her own health over than of the patient; it is more indicative of balance and sustainability.

Gerontologic nursing is a specialty area of nursing that provides care for the elderly in our population. What goal of care should a gerontologic nurse prioritize when working with this population? A) Helping older adults determine how to reduce their use of external resources B) Helping older adults use their strengths to optimize independence C) Helping older adults promote social integration D) Helping older adults identify the weaknesses that most limit them

Ans: B Feedback: Gerontologic nursing is provided in acute care, skilled and assisted living, community, and home settings. The goals of care include promoting and maintaining functional status and helping older adults identify and use their strengths to achieve optimal independence. Goals of gerontologic nursing do not include helping older adults promote social integration or identify their weaknesses. Optimal independence does not necessarily involve reducing the use of available resources.

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the patients mobility when selecting a site. C) Have the patient briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes.

Ans: B Feedback: Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response? A) I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup. B) Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids. C) It is normal to be a little confused following surgery, and it is safe not to urinate at night. D) If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Ans: B Feedback: In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

You are the nurse caring for an adult patient who has just received a diagnosis of prostate cancer. The patient states that he will never be able to cope with this situation. How should you best understand the concept of coping when attempting to meet this patients needs? A) Coping is a physiologic measure used to deal with change, and he will physically adapt. B) Coping is composed of the physiologic and psychological processes that people use to adapt to change. C) Coping is the human need for faith and hope, both of which create change. D) Coping is a social strategy that is used to deal with change and loss.

Ans: B Feedback: Indicators of stress and the stress response include both subjective and objective measures. They are psychological, physiologic, or behavioral and reflect social behaviors and thought processes. The physiologic and psychological processes that people use to adapt to stress are the essence of the coping process. Coping is both a physiologic and psychological process used to adapt to change. Coping is a personal process used to adapt to change.

A 35-year-old woman comes to the local health center with a large mass in her right breast. She has felt the lump for about a year, but was afraid to come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient? A) Self-esteem disturbance related to late diagnosis B) Ineffective individual coping related to reluctance to seek care C) Altered family process related to inability to obtain treatment D) Ineffective denial related to reluctance to seek care

Ans: B Feedback: Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case, the patient was unable to access health care even when she was aware the disorder could be life-threatening. Self-esteem Disturbance, Altered Family Process, and Ineffective Denial are all nursing diagnoses that are often associated with breast cancer, but the patients ineffective individual coping has created a significant safety risk and is, therefore, the most appropriate nursing diagnosis.

Research has corroborated an experienced nurses observation that the incidence and prevalence of chronic conditions is increasing in the United States. What health promotion initiative most directly addresses the factor that has been shown to contribute to this increase? A) A program to link residents with primary care providers B) A community-based weight-loss program C) A stress management workshop D) A cancer screening campaign

Ans: B Feedback: Lifestyle factors, such as smoking, chronic stress, and sedentary lifestyle, that increase the risk of chronic health problems such as respiratory disease, hypertension, cardiovascular disease, and obesity are all thought to be factors for the increasing incidence of chronic conditions. Obesity is paramount among these, exceeding the significance of lack of access to primary care, inadequate cancer screening, and inadequate stress management.

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? A) Diarrhea B) Dilute urine C) Increased muscle tone D) Joint pain

Ans: B Feedback: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.

A nurse knows that patients with invisible disabilities like chronic pain often feel that their chronic conditions are more challenging to deal with than more visible disabilities. Why would they feel this way? A) Invisible disabilities create negative attitudes in the health care community. B) Despite appearances, invisible disabilities can be as disabling as visible disabilities. C) Disabilities, such as chronic pain, are apparent to the general population. D) Disabilities. Such as chronic pain, may not be curable, unlike visible disabilities.

Ans: B Feedback: Many disabilities are visible, but invisible disabilities are often as disabling as those that can be seen. Invisible disabilities are not noted to create negative attitudes among health care workers, though this is a possibility. Disabilities, such as chronic pain, are considered invisible and are not apparent to the general population.

A group of nursing students are applying the concept of steady state to the nursing care plan of a patient who is undergoing chemotherapy and radiotherapy for the treatment of lung cancer. What would be the most complete statement by the students about the concept of steady state? A) The concept of steady state preserves life. B) The mechanisms of steady state work to maintain balance in the body. C) This concept compensates for biologic and environmental attacks on the body. D) Steady state is the same as adaptation

Ans: B Feedback: Mechanisms for adjusting internal conditions promote the normal steady state of the organism and its survival. These mechanisms are compensatory in nature and work to restore balance in the body. Adaptation is a part of the concept of steady state; it is not the concept itself.

You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan? A) A decrease in cognition, judgment, and memory B) A decrease in muscle mass and bone density C) The disappearance of sexual desire for both men and women D) An increase in sebaceous and sweat gland function in both men and women

Ans: B Feedback: Normal signs of aging include a decrease in the sense of smell, a decrease in muscle mass, a decline but not disappearance of sexual desire, and decreased sebaceous and sweat glands for both men and women. Cognitive changes are usually attributable to pathologic processes, not healthy aging.

You are the nurse caring for an elderly patient with cardiovascular disease. The patient comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. As the nurse, what do you know about the altered responses of older adults? A) Treatments for older adults need to be more holistic than treatments used in the younger population. B) The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. C) The altered responses of older adults define the nursing interactions with the patient. D) Older adults become hypersensitive to antibiotic treatments for infectious disease states.

Ans: B Feedback: Older people may be unable to respond effectively to an acute illness, or, if a chronic health condition is present, they may be unable to sustain appropriate responses over a long period. Furthermore, their ability to respond to definitive treatment is impaired. The altered responses of older adults reinforce the need for nurses to monitor all body system functions closely, being alert to signs of impending systemic complication. Holism should be integrated into all patients care. Altered responses in the older adult do not define the interactions between the nurse and the patient. Older adults do not become hypersensitive to antibiotic treatments for infectious disease states.

A patient with end-stage lung cancer has been admitted to hospice care. The hospice team is meeting with the patient and her family to establish goals for care. What is likely to be a first priority in goal setting for the patient? A) Maintenance of activities of daily living B) Pain control C) Social interaction D) Promotion of spirituality

Ans: B Feedback: Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological problems, the nurse helps prioritize problems and establish the goals of care. Identification of goals must be a collaborative effort, with the patient, family, and nurse working together, and the goals must be consistent with the abilities, desires, motivations, and resources of those involved. Pain control is essential for patients who have a terminal illness. If pain control is not achieved, all activities of daily living are unattainable. This is thus a priority in planning care over the other listed goals.

A medical-surgical nurse is teaching a patient about the health implications of her recently diagnosed type 2 diabetes. The nurse should teach the patient to be proactive with her glycemic control in order to reduce her risk of what health problem? A) Arthritis B) Renal failure C) Pancreatic cancer D) Asthma

Ans: B Feedback: One chronic disease can lead to the development of other chronic conditions. Diabetes, for example, can eventually lead to neurologic and vascular changes that may result in visual, cardiac, and kidney disease and erectile dysfunction. Diabetes is not often linked to cancer, arthritis, or asthma.

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

Ans: B Feedback: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

A 39-year-old patient with paraplegia has been admitted to the hospital for the treatment of a sacral ulcer. The nurse is aware that the patient normally lives alone in an apartment and manages his ADLs independently. Before creating the patients plan of care, how should the nurse best identify the level of assistance that the patient will require in the hospital? A) Make referrals for assessment to occupational therapy and physical therapy. B) Talk with the patient about the type and level of assistance that he desires. C) Obtain the patients previous medical record and note what was done during his most recent admission. D) Apply a standardized care plan that addresses the needs of a patient with paraplegia

Ans: B Feedback: Patients should be asked preferences about approaches to carrying out their ADLs, and assistive devices they require should be readily available. The other listed actions may be necessary in some cases, but the ultimate resource should be the patient himself.

Older people have many altered reactions to disease that are based on age-related physiological changes. When the nurse observes physical indicators of illness in the older population, that nurse must remember which of the following principles? A) Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged population. B) Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. C) The same physiological processes that indicate serious health care problems in a younger population indicate mild disease states in the elderly. D) Middle-aged people do not react to disease states the same as a younger population does.

Ans: B Feedback: Physical indicators of illness that are useful and reliable in young and middle-aged people cannot be relied on for the diagnosis of potential life-threatening problems in older adults. Option A is incorrect because a potentially life-threatening problem in an older person is more serious than it would be in a middle-aged person because the older adult does not have the physical resources of the middle-aged person. Physical indicators of serious health care problems in a young or middle-aged population do not indicate disease states that are considered mild in the elderly population. It is true that middle-aged people do not react to disease states the same as a younger population, but this option does not answer the question.

Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses? A) Risk for infection related to polypharmacy and hypotension B) Risk for falls related to polypharmacy and impaired balance C) Adult failure to thrive related to chronic disease and circulatory disturbance D) Disturbed thought processes related to adverse drug effects and hypotension

Ans: B Feedback: Polypharmacy and loss of balance are major contributors to falls in the elderly. This patient does not exhibit failure to thrive or disturbed thought processes. There is no evidence of a heightened risk of infection.

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

Ans: B Feedback: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

During the care conference for a patient who has multiple chronic conditions, the case manager has alluded to the principles of the interface model of disability. What statement is most characteristic of this model? A) This patient should be free to plan his care without our interference. B) This patient can be empowered and doesnt have to be dependent. C) This patient was a very different person before the emergence of these health problems. D) This patients physiological problems are the priority over his psychosocial status.

Ans: B Feedback: The interface model focuses on care that is empowering rather than care that promotes dependency. The other listed statements are inconsistent with the principles of the interface model.

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

Ans: B Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days).

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

Ans: B Feedback: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2 . CNS disturbances are found in extreme hyponatremia and fluid overload.

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Ans: B Feedback: The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

The nurse is with a patient who has learned that he has glioblastoma multiforme, a brain tumor associated with an exceptionally poor prognosis. His heart rate increases, his eyes dilate, and his blood pressure increases. The nurse recognizes these changes as being attributable to what response? A) Part of the limbic system response B) Sympathetic nervous response C) Hypothalamic-pituitary response D) Local adaptation syndrome

Ans: B Feedback: The sympathetic nervous system responds rapidly to stress; norepinephrine is released at nerve ending causing the organs to respond (i.e., heart rate increases, eyes dilate, and blood pressure increases). The limbic system is a mediator of emotions and behavior that are critical to survival during times of stress. The hypothalamic-pituitary response regulates the cortisol-induced metabolic effect that results in elevated blood sugars during stressful situations. Local adaptation syndrome is a tissue-specific inflammatory reaction.

You are providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patients life most significantly? A) Neurologic deficits B) Loss of independence C) Age-related changes D) Tremors and decreased mobility

Ans: B Feedback: This patients statement places a priority on his loss of independence. This is undoubtedly a result of the neurologic changes associated with his disease, but this is not the focus of his statement. This is a disease process, not an age-related physiological change.

An initiative has been launched in a large hospital to promote the use of people-first language in formal and informal communication. What is the significance to the patient when the nurse uses people-first language? A) The nurse knows more clearly who the patient is. B) The person is of more importance to the nurse than the disability. C) The patients disability is the defining characteristic of the patients life. D) The nurse knows that the patients disability is a curable condition.

Ans: B Feedback: This simple use of language conveys the message that the person, rather than the illness or disability, is of greater importance to the nurse. The other answers are incorrect because no matter what language the nurse uses, the nurse knows who the patient is, that the patients disability is not most important in the patients life, and that the patients disability most likely will never be cured.

The staff development nurse is presenting a class on the importance of incorporating people-first language into daily practice as well as documentation. What is an example of the use of people-first language when giving a verbal report? A) The schizophrenic B) The patient with schizophrenia C) The schizophrenic patient D) The schizophrenic client

Ans: B Feedback: Using people-first language means referring to the person first: the patient with diabetes rather than the diabetic, the diabetic patient, or the diabetic client.

A gerontologic nurse has been working hard to change the perceptions of the elderly, many of which are negative, by other segments of the population. What negative perceptions of older people have been identified in the literature? Select all that apply. A) As being the cause of social problems B) As not contributing to society C) As draining economic resources D) As competing with children for resources E) As dominating health care research

Ans: B, C, D Feedback: Retirement and perceived nonproductivity are responsible for negative feelings because a younger working person may falsely see older people as not contributing to society and as draining economic resources. Younger working people may actually feel that older people are in competition with children for resources. However, the older population is generally not seen as dominating health care research or causing social problems.

The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that benefit coping in this age group? Select all that apply. A) Decreased risk taking B) Effective adaptation skills C) Avoiding participation in untested roles D) Increased life experience E) Resiliency during change

Ans: B, D, E Feedback: Because changes in life patterns are inevitable over a lifetime, older people need resiliency and coping skills when confronting stresses and change. It is beneficial if older adults continue to participate in risk taking and participation in new, untested roles.

A nurse is planning the care of a patient who has been diagnosed with renal failure, which the nurse recognizes as being a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply. A) Diseases that resolve slowly B) Diseases where complete cures are rare C) Diseases that have a short, unpredictable course D) Diseases that do not resolve spontaneously E) Diseases that have a prolonged course

Ans: B, D, E Feedback: Chronic conditions can also be defined as illnesses or diseases that have a prolonged course, that do not resolve spontaneously, and for which complete cures are unlikely or rare.

A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the nurse observes that the patient has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do? A) Increase the frequency of the patients home care. B) Have a family member check in on the patient in the evening. C) Arrange for the patient to see his primary care physician. D) Refer the patient to an adult day program.

Ans: C Feedback: In more than half of the cases, sudden confusion and hallucinations are evident in multi-infarct dementia. This condition is also associated with cardiovascular disease. Having the patients home care increased does not address the problem, neither does having a family member check on the patient in the evening. Referring the patient to an adult day program may be beneficial to the patient, but it does not address the acute problem the patient is having, the nurse should arrange for the patient to see his primary care physician.

The presence of a gerontologic advanced practice nurse in a long-term care facility has proved beneficial to both the patients and the larger community in which they live. Nurses in this advanced practice role have been shown to cause what outcome? A) Greater interaction between younger adults and older adults occurs. B) The elderly recover more quickly from acute illnesses. C) Less deterioration takes place in the overall health of patients. D) The elderly are happier in long-term care facilities than at home.

Ans: C Feedback: The use of advanced practice nurses who have been educated in geriatric nursing concepts has proved to be very effective when dealing with the complex care needs of an older patient. When best practices are used and current scientific knowledge applied to clinical problems, significantly less deterioration occurs in the overall health of aging patients. This does not necessarily mean that patients are happier in longterm care than at home, that they recover more quickly from acute illnesses, or greater interaction occurs between younger and older adults.

The nurse at the student health center is seeing a group of students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What will be included in the nurses intervention? A) The use of progressive tensing and relaxing of muscles to release tension in each muscle group B) Using a positive self-image to increase and intensify physical exercise, which decreases stress C) The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations D) The use of music and humor to create a calm and relaxed demeanor, which allows escape from stressful situations

Ans: C Feedback: Guided imagery is the mindful use of a word, phrase, or visual image to distract oneself from distressing situations or consciously taking time to relax or reenergize. Guided imagery does not involve muscle relaxation, positive self-image, or humor.

You are the nurse caring for a 91-year-old patient admitted to the hospital for a fall. The patient complains of urge incontinence and tells you he most often falls when he tries to get to the bathroom in his home. You identify the nursing diagnosis of risk for falls related to impaired mobility and urinary incontinence. The older adults risk for falls is considered to be which of the following? A) The result of impaired cognitive functioning B) The accumulation of environmental hazards C) A geriatric syndrome D) An age-related health deficit

Ans: C Feedback: A number of problems commonly experienced by the elderly are becoming recognized as geriatric syndromes. These conditions do not fit into discrete disease categories. Examples include frailty, delirium, falls, urinary incontinence, and pressure ulcers. Impaired cognitive functioning, environmental hazards in the home, and an age-related health deficit may all play a part in the episodes in this patients life that led to falls, but they are not diagnoses and are, therefore, incorrect.

You are the nurse caring for patients in the urology clinic. A new patient, 78 years old, presents with complaints of urinary incontinence. An anticholinergic is prescribed. Why might this type of medication be an inappropriate choice in the elderly population? A) Gastrointestinal hypermotility can be an adverse effect of this medication. B) Detrusor instability can be an adverse effect of this medication. C) Confusion can be an adverse effect of this medication. D) Increased symptoms of urge incontinence can be an adverse effect of this medication

Ans: C Feedback: Although medications such as anticholinergics may decrease some of the symptoms of urge incontinence (detrusor instability), the adverse effects of these medications (dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate choices for the elderly.

As the population of the United States ages, research has shown that this aging will occur across all racial and ethnic groups. A community health nurse is planning an initiative that will focus on the group in which the aging population is expected to rise the fastest. What group should the nurse identify? A) Asian-Americans B) White non-Hispanics C) Hispanics D) African-Americans

Ans: C Feedback: Although the older population will increase in number for all racial and ethnic groups, the rate of growth is projected to be fastest in the Hispanic population that is expected to increase from 6 million in 2004 to an estimated 17.5 million by 2050.

A gerontologic nurse is aware of the demographic changes that are occurring in the United States, and this affects the way that the nurse plans and provides care. Which of the following phenomena is currently undergoing the most rapid and profound change? A) More families are having to provide care for their aging members. B) Adult children find themselves participating in chronic disease management. C) A growing number of people live to a very old age. D) Elderly people are having more accidents, increasing the costs of health care.

Ans: C Feedback: As the older population increases, the number of people who live to a very old age is dramatically increasing. The other options are all correct, but none is a factor that is most dramatically increasing in this age group.

After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this mans risk of future infarcts, what action should the nurse most strongly encourage? A) Activity limitation and falls reduction efforts B) Adequate nutrition and fluid intake C) Rigorous control of the patients blood pressure and serum lipid levels D) Use of mobility aids to promote independence

Ans: C Feedback: Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site.

Ans: C Feedback: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.

You are caring for a 65-year-old widower whose wife died 4 months ago. He tells you that he is not doing well and that his friends and family seem hesitant to talk with him about his wife. What could the nurse do to help the patient? A) Refer him to a consciousness-raising group. B) Refer him to a psychiatrist. C) Refer him to a support group. D) Refer him to a church or temple.

Ans: C Feedback: Being a member of a group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas. Psychiatry may or may not be necessary. Spiritual assessment would necessarily precede any referral to a specific religious setting. Consciousness-raising groups are not known to be a common source of social support.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A) Leave the hair intact. B) Shave the area. C) Clip the hair in the area. D) Remove the hair with a depilatory

Ans: C Feedback: Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following? A) Help distinguish hyponatremia from hypernatremia B) Help evaluate pituitary gland function C) Help distinguish reduced renal blood flow from decreased renal function D) Help provide an effective treatment for hypertension-induced oliguria

Ans: C Feedback: If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

A group of nurses are planning the care of an older adult who is being rehabilitated following a stroke. A nurse notes that hypertension and cardiovascular disease could have occurred over time if the patient previously experienced a state of chronic arousal. In a state of chronic arousal, what can happen within the body? A) Blood pressure decreases. B) Serum glucose levels drop. C) Arteriosclerosis may develop. D) Tissue necrosis may occur.

Ans: C Feedback: If the sympathetic-adrenal-medullary response is prolonged or excessive, a state of chronic arousal develops that may lead to high (not low) blood pressure, arteriosclerotic changes, and cardiovascular disease. If the production of ACTH is prolonged or excessive, behavior patterns of withdrawal and depression are seen. In addition, the immune response is decreased, and infections and tumors may develop.

You are the nurse caring for a young mother who has a longstanding diagnosis of multiple sclerosis (MS). She was admitted to your unit with a postpartum infection 3 days ago. You are planning to discharge her home when she has finished 5 days of IV antibiotic therapy. With what information would it be most important for you to provide this patient? A) A succinct overview of postpartum infections B) How the response to infection differs in patients with multiple sclerosis C) The same information you would provide to a patient without a chronic condition D) Information on effective management of multiple sclerosis in the home setting

Ans: C Feedback: In general, patients with disabilities are in need of the same information as other patients. Information on home management of MS has likely been already provided to the patient. The immune response does not greatly differ in this patient.

Your patient tells you that he has just been told that his computed tomography results were abnormal. You can expect that his sympathetic nervous system has stimulated his adrenal gland to release what? A) Endorphins B) Dopamine C) Epinephrine D) Testosterone

Ans: C Feedback: In the sympathetic-adrenal-medullary response to stress, the sympathetic nervous system stimulates the adrenal gland to release epinephrine and norepinephrine.

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70.

Ans: C Feedback: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

Ans: C Feedback: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.

You are admitting a patient who presents with inflammation of his right ankle. When planning this patients care, which of the following statements regarding acute inflammation should you recognize? A) Inflammation is essentially synonymous with infection. B) Inflammation may impair the healing process. C) Inflammation is a defensive reaction intended to remove an offending agent. D) Inflammation inhibits the release of histamines in the tissues.

Ans: C Feedback: Inflammation is a defensive reaction intended to remove an offending agent and prepare the site for repair. Inflammation is not the same as infection, it does not impair the healing process, and it does not inhibit the release of histamines in the tissues

A man and woman are in their early eighties and have provided constant care for their 44-year-old son who has Down syndrome. When planning this familys care, the nurse should be aware that the parents most likely have what concerns around what question? A) What could we have done better for our son? B) Why was our son born with Down syndrome while our other children are healthy? C) Who will care for our son once were unable? D) Will we experience the effects of developmental disabilities late in life?

Ans: C Feedback: Parents of adult children with developmental disabilities often fear what will happen when they are no longer available and able to care for their children. Developmental delays do not have a late onset. Concerns about the causes of their sons disease likely predominated when he was younger.

The nurse is caring for a young adult male with a traumatic brain injury and severe disabilities caused by a motor vehicle accident when he was an adolescent. Where does the nurse often provide care for patients like this young adult? A) Adult day-care facilities B) Step-down units C) Medical-surgical units D) Pediatric units

Ans: C Feedback: Patients with preexisting disabilities due to conditions that have been present from birth or due to illnesses or injuries experienced as an adolescent or young adult often require health care and nursing care in medical-surgical settings. Step-down units provide care between the ICU setting and the regular units. Pediatric units provide care for patients aged 19 and younger. Adult day care may or may not be appropriate.

As an occupational health nurse at a large industrial plant, you are planning the return to work of an employee who was exposed to a chemical spill. To what type of stressor has this patient been exposed? A) Physiologic B) Psychosocial C) Physical D) Psychiatric

Ans: C Feedback: Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. A chemical spill is neither a psychiatric nor a psychosocial phenomenon.

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

Ans: C Feedback: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status.

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barr syndrome D) Overdose of amphetamines

Ans: C Feedback: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barr syndrome. The other listed diagnoses are not associated with respiratory acidosis.

You are the nurse caring for a 51-year-old man who has just been told in a family meeting that he has stage IV colon cancer. You expect that the patient now has an increase in blood pressure, heart rate and respiratory rate. You spend time talking with this patient and his vital signs become closer to normal range. To what would you attribute this phenomenon? A) Cortisol levels are decreasing. B) Endocrine activity has increased. C) The patient is adapting to noxious stressors. D) The sympathetic response has been activated.

Ans: C Feedback: Selye developed a theory of adaptation to biologic stress that he named the general adaptation syndrome (GAS), which has three phases: alarm, resistance, and exhaustion. During the alarm phase, the sympathetic fight-or-flight response is activated with release of catecholamines and the onset of the adrenocorticotropic hormone (ACTH) adrenal cortical response. The alarm reaction is defensive and anti-inflammatory but self-limited. Because living in a continuous state of alarm would result in death, people move into the second stage, resistance. During the resistance stage, adaptation to the noxious stressor occurs, and cortisol activity is still increased. If exposure to the stressor is prolonged, the third stage, exhaustion, occurs. During the exhaustion stage, endocrine activity increases, and this has negative effects on the body systems (especially the circulatory, digestive, and immune systems) that can lead to death.

The nurse is reviewing the importance of preventative health care with a patient who has a disability. The patient states that she will not have the money to pay for her annual gynecologic exams or mammograms due to the cost of this hospitalization. What information would be appropriate for the nurse to share with the patient? A) Limited finances are a common problem for patients with a disability. Since you were hospitalized this year, you can likely forego the gynecologic exam and mammogram. B) These are very important health preventative measures, so you will need to borrow the money to pay for the exam and mammogram. C) Ill look into federal assistance programs that provide financial assistance for health-related expenses for people with disabling conditions. D) These preventative measures should likely be tax deductible, so you should consult with your accountant and then make your appointments.

Ans: C Feedback: Several federal assistance programs provide financial assistance for health-related expenses for people with some chronic illnesses, acquired disabling acute and chronic diseases, and diseases from childhood. Lack of financial resources, including health insurance, is an important barrier to health care for people with disabilities. Each of the other responses is inappropriate and inaccurate.

A patient who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with her chronic condition. Her ability to meet this goal will primarily depend on her ability to do which of the following? A) Lower her expectations for quality of life and level of function. B) Access community services to eventually cure her disease. C) Adapt her lifestyle to accommodate her symptoms. D) Establish good rapport with her primary care provider.

Ans: C Feedback: Successful management of chronic conditions depends largely on the patients ability to adapt in order to accommodate symptoms. However, telling the patient to lower her expectations is a simplistic and negative interpretation of this reality. Rapport is beneficial, but not paramount. A cure is not normally an option.

An 84-year-old patient has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The patient is oriented to name only. The patients family is very upset because, before having surgery, the patient had no cognitive deficits. The patient is subsequently diagnosed with postoperative delirium. What should the nurse explain to the patients family? A) This problem is self-limiting and there is nothing to worry about. B) Delirium involves a progressive decline in memory loss and overall cognitive function. C) Delirium of this type is treatable and her cognition will return to previous levels. D) This problem can be resolved by administering antidotes to the anesthetic that was used in surgery

Ans: C Feedback: Surgery is a common cause of delirium in older adults. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It has symptoms that are reversible with treatment, and, with treatment, is short term in nature. It is patronizing and inaccurate to reassure the family that there is nothing to worry about. The problem is not treated by the administration of antidotes to anesthetic.

A nursing student has presented a concept map of a medical patients health that demonstrates the maintenance of a steady state. The student has elaborated on the relationship of individual cells to compensatory mechanisms. When do compensatory mechanisms occur in the human body? A) According to a diurnal cycle B) When needed C) Continuously D) Sporadically

Ans: C Feedback: The concept of the cell as existing on a continuum of function and structure includes the relationship of the cell to compensatory mechanisms, which occur continuously in the body to maintain the steady state.

You are the case manager who oversees the multidisciplinary care of several patients living with chronic conditions. Two of your patients are living with spina bifida. You recognize that the center of care for these two patients typically exists where? A) In the hospital B) In the physicians office C) In the home D) In the rehabilitation facility

Ans: C Feedback: The day-to-day management of illness is largely the responsibility of people with chronic disorders and their families. As a result, the home, rather than the hospital, is the center of care in chronic conditions. Hospitals, rehabilitation facilities, clinics, physicians offices, nursing homes, nursing centers, and community agencies are considered adjuncts or back-up services to daily home management.

The nurse is caring for a patient diagnosed with cancer of the liver who has chosen to remain in his home as long as he is able. The nurse reviews the care plan for the patient and notes that it focuses on palliative measures. The nurse also notes that over the last 3 weeks, the patients condition has continued to deteriorate. What is the nurses best response to this clinical information? A) Recognize that death will most likely occur in the next week. B) Recognize that the patient is in the trajectory phase of chronic illness and should be kept pain-free. C) Recognize that the patient is in the downward phase of chronic illness and should be reassessed. D) Recognize that the patient should immediately be admitted into the hospita

Ans: C Feedback: The downward phase occurs when symptoms of chronic illness worsen despite attempts to control the course through proper regimen management. A downward turn does not necessarily lead to death. A downward trend can be arrested and the trajectory reestablished at any point, depending on the condition and the treatment. A patient who is palliative may not desire hospitalization and aggressive treatment.

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Ans: C Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

A teenage boy who was the victim of a near drowning has been admitted to the emergency department. The patient was submerged for several minutes and remains unconscious. What pathophysiological process has occurred as a result of the submersion? A) Atrophy of brain cells B) Cellular lysis C) Hypoxia to the brain D) Necrosis to the brain

Ans: C Feedback: The length of time different tissues can survive without oxygen varies. The brain will become hypoxic in 3 to 6 minutes. The other options are incorrect because submersion injuries do not cause atrophy to brain cells right away; submersion injuries also do not cause cellular lysis or necrosis to the brain.

You are presenting patient teaching to a 48-year-old man who was just diagnosed with type 2 diabetes. The patient has a BMI of 35 and leads a sedentary lifestyle. You give the patient information on the risk factors for his diagnosis and begin talking with him about changing behaviors around diet and exercise. You know that further patient teaching is necessary when your patient tells you what? A) I need to start slow on an exercise program approved by my doctor. B) I know theres a chance I could have avoided this if Id always eaten better and exercised more. C) There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented. D) I want to have a plan in place before I start making a lot of changes to my lifestyle.

Ans: C Feedback: The major causes of chronic diseases are known, and if these risk factors were eliminated, at least over 80% of heart disease, stroke, and type 2 diabetes would be prevented. In addition, over 40% of cancers would be prevented. The other listed options are accurate statements.

A patient who is recovering from a stroke expresses frustration about his care to the nurse, stating, It seems like everyone sees me as just a problem that needs fixing. This patients statement is suggestive of what model of disability? A) Biopsychosocial model B) Social model C) Rehabilitation model D) Interface model

Ans: C Feedback: The rehabilitation model regards disability as a deficiency that requires a rehabilitation specialist or other helping professional to fix the problem. This is not characteristic of the biopsychosocial, social, or interface models.

You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms? A) Hypocalcemia B) Hyponatremia C) Hyperchloremia D) Hypophosphatemia

Ans: C Feedback: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. With hypocalcemia, you would expect tetany. There would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.

The nurse is performing discharge planning for a patient who has numerous chronic health problems. The nurse recognizes that lifestyle changes would likely benefit the patients health status. Which factor would the nurse identify as most important in determining health status? A) Gender B) Ethnicity C) Social class D) Interfamilial relationships

Ans: C Feedback: The single most important factor for determining health status is social class and, within a social class, the research suggests that the major factor influencing health is level of education. This factor supersedes the importance of ethnicity, gender, or interfamilial relationships.

An 83-year-old woman was diagnosed with Alzheimers disease 2 years ago and the disease has progressed at an increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patients plan of care? A) Offer the patient rewards for finishing all the food on her tray. B) Offer the patient bland, low-salt foods to limit offensiveness. C) Offer the patient only one food item at a time to promote focused eating. D) Arrange for insertion of a gastrostomy tube and initiate enteral feeding.

Ans: C Feedback: To avoid any playing with food, one dish should be offered at a time. Foods should be familiar and appealing, not bland. Tube feeding is not likely necessary at this time and a reward system is unlikely to be beneficial.

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

Ans: C Feedback: You can induce Chvosteks sign by tapping the patients facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvosteks sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvosteks sign.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

Ans: D Feedback: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status

Ans: D Feedback: A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

You are the nurse caring for an elderly patient who is being treated for community-acquired pneumonia. Since the time of admission, the patient has been disoriented and agitated to varying degrees. Appropriate referrals were made and the patient was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this patients care? A) Social isolation related to dementia B) Hopelessness related to dementia C) Risk for infection related to dementia D) Acute confusion related to dementia

Ans: D Feedback: Acute confusion is a priority problem in patients with dementia, and it is an immediate threat to their health and safety. Hopelessness and social isolation are plausible problems, but the patients cognition is a priority. The patients risk for infection is not directly influenced by dementia.

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

Ans: D Feedback: An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas

Ans: D Feedback: Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.

You have admitted a new patient to your unit with a diagnosis of stage IV breast cancer. This woman has a comorbidity of myasthenia gravis. While you are doing the initial assessment, the patient tells you that she felt the lump in her breast about 9 months ago. You ask the patient why she did not see her health care provider when she first found the lump in her breast. What would be a factor that is known to influence the patient in seeking health care services? A) Lack of insight due to the success of self-managing a chronic condition B) Lack of knowledge about treatment options C) Overly sensitive patient reactions to health care services D) Unfavorable interactions with health care providers

Ans: D Feedback: Because of unfavorable interactions with health care providers, including negative attitudes, insensitivity, and lack of knowledge, people with disabilities may avoid seeking medical intervention. The population of people who are disabled is not overly sensitive to the reactions of those providing health care services. This is more likely than lack of insight or knowledge on the part of the patient.

You are caring for an older female patient who is being treated for acute anxiety. She has a nursing diagnosis of Ineffective Coping related to a feeling of helplessness. What would be the most appropriate nursing intervention? A) Put the primary onus for planning care on the patient herself. B) Assess and provide constructive outlets for anger and hostility. C) Assess the patients sources of social support. D) Encourage an attitude of realistic hope to help her deal with helpless feelings

Ans: D Feedback: By encouraging an attitude of realistic hope, the patient will be empowered. This allows the patient to explore her feelings and bring about more effective coping patterns. The onus for care planning should not lie with the patient. The nursing diagnosis is related to feeling of helplessness, not anger and hostility. Social support is necessary, but does not directly address the feeling of helplessness.

A major cause of health-related problems is the increase in the incidence of chronic conditions. This is the case not only in developed countries like the United States but also in developing countries. What factor has contributed to the increased incidence of chronic diseases in developing countries? A) Developing countries are experiencing an increase in average life span. B) Increasing amounts of health research are taking place in developing countries. C) Developing countries lack the health infrastructure to manage illness. D) Developing countries are simultaneously coping with emerging infectious diseases.

Ans: D Feedback: Chronic conditions have become the major cause of health-related problems in developed countries as well as in the developing countries, which are also trying to cope with new and emerging infectious diseases. There is indeed a lack of health infrastructure in many countries, but this is not cited as the cause of the increased incidence of chronic diseases. In many countries, increased life span and health research are not occurring.

An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest? A) Reduce the amount of stress she currently experiences. B) Increase carbohydrate intake and reduce protein intake. C) Take herbal laxatives, such as senna, each night at bedtime. D) Increase daily intake of water.

Ans: D Feedback: Constipation is a common problem in older adults and increasing fluid intake is an appropriate early intervention. This should likely be attempted prior to recommending senna or other laxatives. Stress reduction is unlikely to wholly resolve the problem and there is no need to increase carbohydrate intake and reduce protein intake.

A group of nurses are attending an educational inservice on adaptive and maladaptive responses to stress. When talking about the assessment of coping strategies in patients, the nurses discuss the use of drugs and alcohol to reduce stress. What is most important for the nurses to know about these coping behaviors? A) They are effective, but alternative, coping behaviors. B) They do not directly influence stress in the body. C) They are adaptive behaviors. D) They increase the risk of illness.

Ans: D Feedback: Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness. The use of drugs and alcohol as a means to reduce stress are not effective coping behaviors. They are maladaptive behaviors, even though they have a short-term effect on stress.

You are the nurse caring for a 72-year-old woman who is recovering from a hemicolectomy on the postsurgical unit. The surgery was very stressful and prolonged, and you note on the chart that her blood sugars are elevated, yet diabetes does not appear in her previous medical history. To what do you attribute this elevation in blood sugars? A) It is a temporary result of increased secretion of antidiuretic hormone. B) She must have had diabetes prior to surgery that was undiagnosed. C) She has suffered pancreatic trauma during her abdominal surgery. D) The blood sugars are probably a result of the fight-or-flight reaction.

Ans: D Feedback: During stressful situations, ACTH stimulates the release of cortisol from the adrenal gland, which creates protein catabolism releasing amino acids and stimulating the liver to convert amino acids to glucose; the result is elevated blood sugars. Antidiuretic hormone is released during stressful situations and stimulates reabsorption of water in the distal and collecting tubules of the kidney. Assuming the patient had diabetes prior to surgery demonstrates a lack of understanding of stress-induced hyperglycemia. No evidence presented in the question other than elevated blood sugars would support a diagnosis of diabetes.

You are caring for an 82-year-old man who was recently admitted to the geriatric medical unit in which you work. Since admission, he has spoken frequently of becoming a burden to his children and staying afloat financially. When planning this patients care, you should recognize his heightened risk of what nursing diagnosis? A) Disturbed thought processes B) Impaired social interaction C) Decisional conflict D) Anxiety

Ans: D Feedback: Economic concerns and fear of becoming a burden to families often lead to high anxiety in older people. There is no clear indication that the patient has disturbed thought processes, impaired social interaction, or decisional conflict.

During their prime employable years between ages 21 and 64, 77% of those with a nonsevere disability are employed. What has research shown about this employed population? A) Their salaries are commensurate with their experience. B) They enjoy their jobs more than people who do not have disabilities. C) Employment rates are higher among people with a disability than those without. D) People with disabilities earn less money than people without disabilities.

Ans: D Feedback: Employed people with a disability earn less money than people without disabilities. Of those without a disability, 85% are employed as compared to 77% of those with a nonsevere disability. Job satisfaction is not noted to differ.

A nurse is meeting with a young woman who has recently lost her job after moving with her husband to a new city. She describes herself as being anxious and pretty depressed. What principle of stress and adaptation should be integrated into the nurses plan of care for this patient? A) Adaptation often fails during stressful events and results in homeostasis. B) Stress is a part of all lives, and, eventually, this young woman will adapt. C) Acute anxiety and depression can be adaptations that alleviate stress in some individuals. D) An accumulation of stressors can disrupt homeostasis and result in disease.

Ans: D Feedback: Four conceptsconstancy, homeostasis, stress, and adaptationare key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis, and, if adaptation fails, the result is disease. If a person is overwhelmed by stress, he or she may never adapt. Acute anxiety and depression are frequently associated with stress.

A community health nurse has drafted a program that will address the health promotion needs of members of the community who live with one or more disabilities. Which of the following areas of health promotion education is known to be neglected among adults with disabilities? A) Blood pressure screening B) Diabetes testing C) Nutrition D) Sexual health

Ans: D Feedback: Health promotion interventions addressing sexual health in disabled individuals are necessary but rare. Blood pressure testing, diabetes testing, and nutrition are not known to constitute such a gap in health promotion teaching.

The home health nurse is making an initial home visit to a 76-year-old widower. The patient takes multiple medications for the treatment of varied chronic health problems. The patient states that he has also begun taking some herbal remedies. What should the nurse be sure to include in the patients teaching? A) Herbal remedies are consistent with holistic health care. B) Herbal remedies are often cheaper than prescribed medication. C) It is safest to avoid the use of herbal remedies. D) There is a need to inform his physician and pharmacist about the herbal remedies.

Ans: D Feedback: Herbal remedies combined with prescribed medications can lead to interactions that may be toxic. Patients should notify the physician and pharmacist of any herbal remedies they are using. Even though herbal remedies are considered holistic, this is not something that is necessary to include in the patients teaching. Herbal remedies may be cheaper than prescribed medicine, but this is still not something that is necessary to include in the patients teaching. For most people, it is not necessary to wholly avoid herbal remedies.

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations

Ans: D Feedback: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.

Nurses and members of other health disciplines at a states public health division are planning programs for the next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in their contributions to the overall death rate in the state. This team should plan health promotion and disease prevention activities to address what health problem? A) Stroke B) Cancer C) Respiratory infections D) Alzheimers disease

Ans: D Feedback: In the past 60 years, overall deaths, and specifically, deaths from heart disease, have declined. Recently, deaths from cancer and cerebrovascular disease have declined. However, deaths from Alzheimers disease have risen more than 50% between 1999 and 2007.

You are caring for a young woman who has Down syndrome and who has just been diagnosed with type 2 diabetes. What consideration should you prioritize when planning this patients nursing care? A) How her new diagnosis affects her health attitudes B) How her diabetes affects the course of her Down syndrome C) How her chromosomal disorder affects her glucose metabolism D) How her developmental disability influences her health management

Ans: D Feedback: It is important to consider the interaction between existing disabilities and new diagnoses. Cognitive and motor deficits would greatly affect diabetes management. Diabetes would not likely affect her attitude or the course of her Down syndrome. Chromosomal disorders such as Down syndrome do not affect glucose metabolism.

A patient who undergoes hemodialysis three times weekly is on a fluid restriction of 1000 mL/day. The nurse sees the patient drinking a 355-mL (12 ounce) soft drink after the patient has already reached the maximum intake of fluid for the day. What action should the nurse take? A) Take the soft drink away from the patient and inform the dialysis nurse to remove extra fluid from the patient during the next dialysis treatment B) Document the patients behavior as noncompliant and notify the physician C) Further restrict the patients fluid for the following day and communicate this information to the charge nurse D) Reinforce the importance of the fluid restriction and document the teaching and the intake of extra fluid

Ans: D Feedback: Management of chronic conditions includes learning to live with symptoms or disabilities and coming to terms with identity changes resulting from having a chronic condition. It also consists of carrying out the lifestyle changes and regimens designed to control symptoms and to prevent complications. Although it may be difficult for nurses and other health care providers to stand by while patients make unwise decisions about their health, they must accept the fact that the patient has the right to make his or her own choices and decisions about lifestyle and health care

Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis? A) Metastases B) Excessive potassium intake C) Water intoxication D) Excessive administration of chloride

Ans: D Feedback: Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect.

A patient has recently been diagnosed with type 2 diabetes. The patient is clinically obese and has a sedentary lifestyle. How can the nurse best begin to help the patient increase his activity level? A) Set up appointment times at a local fitness center for the patient to attend. B) Have a family member ensure the patient follows a suggested exercise plan. C) Construct an exercise program and have the patient follow it. D) Identify barriers with the patient that inhibit his lifestyle change.

Ans: D Feedback: Nurses cannot expect that sedentary patients are going to develop a sudden passion for exercise and that they will easily rearrange their day to accommodate time-consuming exercise plans. The patient may not be ready or willing to accept this lifestyle change. This is why it is important that the nurse and patient identify barriers to change.

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acidbase disorder

Ans: D Feedback: Patients can simultaneously experience two or more independent acidbase disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3 concentration immediately suggests a mixed disorder, making the other options incorrect.

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. D) The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Ans: D Feedback: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.

An elderly man tells you that his wife died 14 months ago and that he cannot stop grieving over his loss. What should you encourage the patient to consider? A) Improve his nutritional intake. B) Make an appointment at a wellness clinic. C) Walk on a daily basis. D) Increase his interaction with his social network.

Ans: D Feedback: Social networks can reduce stress by providing the individual with a positive social identity, emotional support, material aide, information, and new social contacts. Changes to diet and activity may be beneficial, but social interaction is known to be of particular benefit. Attendance at a wellness clinic may or may not be beneficial, and does not involve social interaction.

The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A) Decrease in the release of aldosterone B) Increase of filtration in the Loop of Henle C) Decrease in the reabsorption of sodium D) Decrease in glomerular filtration

Ans: D Feedback: Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.

A gerontologic nurse is basing the therapeutic programs at a long-term care facility on Millers Functional Consequences Theory. To actualize this theory of aging, the nurse should prioritize what task? A) Attempting to control age-related physiological changes B) Lowering expectations for recovery from acute and chronic illnesses C) Helping older adults accept the inevitability of death D) Differentiating between age-related changes and modifiable risk factors

Ans: D Feedback: The Functional Consequences Theory requires the nurse to differentiate between normal, irreversible age-related changes and modifiable risk factors. This theory does not emphasize lowering expectations, controlling age-related changes, or helping adults accept the inevitability of death.

While talking with the parents of conjoined twins who are medically unstable, you note that the father of the babies has an aggressive stance, is speaking in a loud voice, and makes several hostile statements such as, Id sure like to have words with that doctor who told us our babies would be okay. You know that this fathers cognitive appraisal has led to what? A) Harm/loss feelings B) Feelings of challenge C) A positive adjustment to the possible loss of his children D) The development of negative emotions

Ans: D Feedback: The appraisal process contributes to the development of an emotion. Negative emotions, such as fear and anger, accompany harm/loss appraisals, and positive emotions accompany challenge. Harm and challenge are not feelings, so the corresponding options are incorrect. There is nothing in the scenario that indicates that the father is making a positive adjustment to the possible loss of his children.

You are caring for a patient in the urgent care center who presented with complaints of lethargy, malaise, aching, weakness, and loss of appetite. During the assessment, you note an area on the patients right posterior calf that is warm to touch, edematous, and tender to touch. You know the most probable cause of this patients symptoms is what? A) Local inflammatory response B) Systemic shock response C) Local infectious response D) Systemic inflammatory response

Ans: D Feedback: The inflammatory response is often confined to the site, causing only local signs and symptoms. However, systemic responses can also occur. During this process, general, nonspecific symptoms develop, including malaise, loss of appetite, aching, and weakness. The fact that the patient is experiencing systemic effects such as lethargy, malaise, aching, weakness, and loss of appetite suggests that inflammation is not limited to one specific site.

A gerontologic nurse is overseeing the care that is provided in a large, long-term care facility. The nurse is educating staff about the significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the incidence and prevalence of influenza in the facility A) Teach staff how to administer prophylactic antiviral medications effectively. B) Ensure that residents receive a high-calorie, high-protein diet during the winter. C) Make arrangements for residents to limit social interaction during winter months. D) Ensure that residents receive influenza vaccinations in the fall of each year

Ans: D Feedback: The influenza and the pneumococcal vaccinations lower the risks of hospitalization and death in elderly people. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be administered annually in autumn. Prophylactic antiviral medications are not used. Limiting social interaction is not required in most instances. Nutrition enhances immune response, but this is not specific to influenza prevention.

The interface model of disability is being used to plan the care of a patient who is living with the effects of a stroke. Why should the nurse prioritize this model? A) It fosters dependency and rapport between the caregiver and the patient. B) It encourages the provision of care that is based specifically on the disability. C) It promotes interactions with patients focused on the root cause of the disability. D) It promotes the idea that patients are capable and responsible

Ans: D Feedback: The interface model promotes the view that people with disabilities are capable, responsible people who are able to function effectively despite having a disability. It does not foster dependency, does not encourage giving care based on the patients disability, and does not encourage or promote interactions with patients that are focused on the cause of the disability.

A nurse is planning the care of a woman who has been admitted to the medical unit following an ischemic cerebrovascular accident. What would the nurse recognize as the longest-acting phase of the womans physiologic response to stress and its cause? A) Sympathetic-adrenal-medullary response caused by persistent stress B) Hypothalamic-pituitary response caused by acute stress C) Sympathetic-adrenal-medullary response caused by acute stress D) Hypothalamic-pituitary response caused by persistent stress

Ans: D Feedback: The longest-acting phase of the physiologic response, which is more likely to occur in persistent stress, involves the hypothalamic-pituitary pathway, not the sympathetic-adrenal-medullary pathway.

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

Ans: D Feedback: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patients presentation is inconsistent with hypophosphatemia

A 37-year-old woman with multiple sclerosis is married and has three children. The nurse has worked extensively with the woman and her family to plan appropriate care. What is the nurses most important role with this patient? A) Ensure the patient adheres to all treatments B) Provide the patient with advice on alternative treatment options C) Provide a detailed plan of activities of daily living (ADLs) for the patient D) Help the patient develop strategies to implement treatment regimens

Ans: D Feedback: The most important role of the nurse working with patients with chronic illness is to help patients develop the strategies needed to implement their treatment regimens and carry out activities of daily living. The nurse cannot ensure the patient adheres to all treatments. Providing information of treatment options is not the nurses most important role. The nurse does not provide the patient with a detailed plan of ADLs, though promotion of ADLs is a priority.

A nurse is aware that the number of people in the United States who are living with disabilities is expected to continue increasing. What is considered to be one of the factors contributing to this increase? A) The decrease in the number of people with early-onset disabilities B) The increased inability to cure chronic disorders C) Changes in infection patterns resulting from antibiotic resistance D) Increased survival rates among people who experience trauma

Ans: D Feedback: The number of people with disabilities is expected to increase over time as people with early-onset disabilities, chronic disorders, and severe trauma survive and have normal or near-normal lifespans. There has not been a decrease in the number of people with early-onset disabilities. Acquired chronic disorders still cannot be cured.

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

Ans: D Feedback: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

A nurse is planning discharge teaching for an 80-year-old patient with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. When planning the necessary health education for this patient, what should the nurse plan to do? A) Set long-term goals with the patient. B) Provide a list of useful Web sites to supplement learning. C) Keep visual cues to a minimum to enhance the patients focus. D) Keep teaching periods short

Ans: D Feedback: To assist the elderly patient with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the patient. The patient may or may not be open to the use of online resources.

The nurse is assessing a patient and learns that the patient and his wife were married just 3 weeks earlier. Which of the following statements should underlie the nurses care planning for this patient? A) The patient and spouse should seek counseling to ease their transition. B) The patient will have better coping skills being in a stable relationship. C) Happy events do not normally cause stress. D) Marriage causes transition, which has the potential to cause stress.

Ans: D Feedback: Transition can contribute to stress, even if the transition is a positive change. The third group of stressors has been studied most extensively and concerns relatively infrequent situations that directly affect people. This category includes the influence of life events such as death, birth, marriage, divorce, and retirement. Counseling is not necessarily indicated.

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response? A) The patients calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patients intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia

Ans: D Feedback: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

End: Chapter 06: Individual and Family Homeostasis, Stress, and Adaptation

End: Chapter 06: Individual and Family Homeostasis, Stress, and Adaptation

End: Chapter 09: Chronic Illness and Disability

End: Chapter 09: Chronic Illness and Disability

End: Chapter 11: Health Care of the Older Adult

End: Chapter 11: Health Care of the Older Adult

End: Chapter 13: Fluid and Electrolytes: Balance and Disturbance

End: Chapter 13: Fluid and Electrolytes: Balance and Disturbance

Start: Chapter 06: Individual and Family Homeostasis, Stress, and Adaptation

Start: Chapter 06: Individual and Family Homeostasis, Stress, and Adaptation

Start: Chapter 09: Chronic Illness and Disability

Start: Chapter 09: Chronic Illness and Disability

Start: Chapter 11: Health Care of the Older Adult

Start: Chapter 11: Health Care of the Older Adult

Start: Chapter 13: Fluid and Electrolytes: Balance and Disturbance

Start: Chapter 13: Fluid and Electrolytes: Balance and Disturbance