Test # 7 IVs, EEG PTSD, stress adaptation, defense mechanisms.

A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose? 4 3 1 2

The nurse will give 2 tablets. It will take 2 tablets (0.5) to equal 1 mg OR ordered dose (1) over dose on hand (0.5). 1/0.5 = 2 tablets.

The nurse is administering 250 mg of a medication elixir to the patient. The medication comes in a dose of 1000 mg/5 mL. How many milliliters should the nurse administer? Record your answer using two decimal places. ____ mL

1.25

The patient is to receive amoxicillin 500 mg q8h; the medication is dispensed at 250 mg/5 mL. How many milliliters will the nurse administer for one dose? Record your answer using a whole number. ___ mL

10

A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage? 1. Resistance 2. Exhaustion 3. Alarm

3, 1, 2 The general adaptation syndrome (GAS), a three-stage reaction to stress, describes how the body responds physiologically to stressors through stages of alarm, resistance, and exhaustion.

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce intravenous (IV) fluid contamination and prevent catheter site complications. 48 72 24 96

Established standards for routine replacement of peripheral intravenous (IV) catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.

What should the nurse do upon noting bleeding around a dressing at an intravenous (IV) catheter insertion site? 1. Discontinue the IV. 2. Elevate and apply warm compresses to the extremity. 3. Assess the insertion site. 4. Leave the dressing intact, but reinforce it.

When blood appears on the dressing, verify that the system is intact, and change the dressing. The intravenous (IV) catheter should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.

While assessing the patient, the nurse recognizes that special caution should be taken with the intravenous (IV) infusion because of fluid volume excess when the nurse notes the presence of which condition? 1. Crackles in the lungs 2. Decreased blood pressure 3. Dry skin and mucous membranes 4. Poor skin turgor

ans. 1 Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for intravenous (IV) therapy. Dry skin and mucous membranes may indicate dehydration.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats/min Respiratory rate: 26 breaths/min Blood pressure: 140/106 Which hormones should the nurse consider as the most likely causes of the abnormal vital signs? 1. Epinephrine and norepinephrine 2. ADH and norepinephrine 3. ACTH and epinephrine 4. ADH and ACTH

ans. 1 During the alarm stage, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate.

A nurse is planning care for a patient that uses displacement. Which information should the nurse consider when planning interventions? 1. This protects against feelings of worthlessness and anxiety. 2. This triggers the stress control functions of the medulla oblongata. 3. This copes with stress directly. 4. This evaluates an event for its personal meaning.

ans. 1 Ego-defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and offer psychological protection from a stressful event. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with? 1. Informing the nurse if they notice anything abnormal 2. Changing empty IV solution containers 3. Confirming the correct IV drip rate 4. Assessing the patient for response to IV therapy

ans. 1 If nursing assistive personnel (NAP) notice anything they consider abnormal, they should notify the nurse. It is the nurse's responsibility to inform the NAP of specific things to look for. Changing empty intravenous (IV) solution containers cannot be delegated to NAP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurse's responsibility. Assessment is not the responsibility of NAP; it is the responsibility of the nurse.

A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? 1. Post-traumatic stress disorder 2. Alarm reaction 3. General adaptation syndrome 4. Acute stress disorder

ans. 1 Post-traumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional detachment and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Acute stress disorder is a similar diagnosis that differs from PTSD in duration of symptoms. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) 1. Cancer 2. Low blood pressure 3. Allostasis 4. Infections 5. Diabetes

ans. 1, 4, 5 Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person's susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress.

The nurse needs to specifically prevent air emboli that may result from intravenous (IV) therapy. What should the nurse make sure to do to prevent air emboli? 1. Prime the tubing completely. 2. Check for medication compatibility. 3. Use a needleless system. 4. Select a larger-gauge needle or catheter.

ans. 1 Prime the infusion tubing by filling it with intravenous (IV) solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? 1. Strengthen friendships outside the workplace. 2. Use progressive muscle relaxation. 3. Delegate complex nursing tasks to nursing assistive personnel. 4. Write for 10 minutes in a journal every day.

ans. 1 Strengthening friendships outside of the workplace, arranging for temporary social isolation for personal "recharging" of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating complex nursing tasks to nursing assistive personnel is an inappropriate.

A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? 1. Ask about the patient's priority needs. 2. Find support for the family and patient. 3. Allow time for the patient's friends. 4. Provide information to the patient.

ans. 1 Take time to understand a patient's meaning of the precipitating event and the ways in which stress is affecting his life. For example, in the case of a woman who has just been told that a breast mass was identified on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and finding support may be implemented after finding out what the patient wants or needs.

A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? 1. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. 2. Administer antidiarrheal medications with meals. 3. Teach the teen about the food pyramid. 4. Gently admonish the teen and her parents regarding the consistently poor diet choices.

ans. 1 Tertiary-level interventions assist the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent maturational needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill and the food pyramid is usually a primary intervention. Administering antidiarrheal medications may help but is not a tertiary-level or maturational intervention. Admonishing the teen and parents is not a tertiary-level intervention, and because this approach is nontherapeutic, it may cause communication problems.

Which patient does the nurse most closely monitor for an unintended synergistic effect? 1. The 72 year old who is seeing four different specialists 2. The 4 year old who has mistakenly taken a half bottle of vitamins 3. The 35 year old who has ingested meth mixed with several household chemicals 4. The 50 year old who is prescribed a second blood pressure medication

ans. 1 The 72 year old seeing four different providers is likely to experience polypharmacy. Polypharmacy places the patient at risk for unintended mixing of medications that potentiate each other. When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately. The child taking too much of a medication by mistake could experience overdose or toxicity. The 50 year old is prescribed two different blood pressure medications for their synergistic effect, but this is a desired, intended event. A patient taking meth and mixing chemicals can be toxic.

The nurse is teaching a patient how to measure medication dosages at home. The prescription is written for 30 mL of the medication. Which household measurement will the nurse teach the patient to use? 1. Tablespoon 2. Cup 3. Teaspoon 4. Drops

ans. 1 The equivalents of measurement are as follows: 15 drops = 1 mL, 1 teaspoon = 5 mL, 1 tablespoon = 15 mL, and 1 cup = 240 mL; therefore, a tablespoon is most appropriate, with 2 tablespoons = 30 mL.

The student nurse is preparing to administer an intravenous (IV) bolus medication through a small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question? 1. Immediately stopping the IV infusion and removing the IV catheter 2. Injecting the IV medication if no signs of infiltration 3. Checking to see if the IV is infusing without difficulty 4. Checking the IV site for redness and swelling

ans. 1 The student should stop the intravenous (IV), remove the catheter, and start a new one only if the line is not patent. In some cases, especially with a smaller-gauge IV catheter, blood return is not always aspirated, even if the IV is patent. Confirm patency. If the IV site does not show signs of infiltration and the IV fluid is infusing without difficulty, give the IV bolus medication.

Which methods will the nurse use to administer an intravenous (IV) medication that is incompatible with the patient's IV fluid? (Select all that apply.) 1. Flush with 10 mL of sterile water before and after administration. 2. Administer slowly with the IV fluid. 3. Start another IV site. 4. Do not give the medication and chart. 5. Flush with 10 mL of normal saline before and after administration.

ans. 1, 3, 5 When IV medication is incompatible with IV fluids, stop the IV fluids, clamp the IV line above the injection site, flush with 10 mL of normal saline or sterile water, give the IV bolus over the appropriate amount of time, flush with another 10 mL of normal saline or sterile water at the same rate as the medication was administered, and restart the IV fluids at the prescribed rate. Do not administer the drug slowly with the IV; this is contraindicated when incompatibility exist. Not giving the medication and charting is inappropriate; this is not a prudent or safe action by the nurse.

A patient admitted to the hospital with pneumonia has IV antibiotics ordered. He receives the first dose with no problem, but during the second dose, he begins to complain of shortness of breath and difficulty breathing. The nurse notes wheezes throughout the lung fields. The nurse documents these symptoms as which of the following? 1. Idiosyncratic reaction 2. Anaphylactic reaction 3. Side effect of the medication 4. Toxic effect of the antibiotic

ans. 2 An allergic reaction ranges from mild to severe, depending on the patient and the medication. Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. However, the symptoms displayed by this patient are classic anaphylactic symptoms. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Two doses of a medication usually are not enough to develop toxic effects. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Anaphylaxis is usually unpredictable initially and is avoided after the first reaction by listing the cause of the anaphylaxis in the allergy alert section of the patient record.

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, "No way, I'm not crazy." What is the nurse's best response? 1. "Don't worry now. The psychiatrists are well trained to help." 2. "Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique." 3. "This will help your family communicate better." 4. "Many times disasters can create mental health problems, so you really should participate with your family."

ans. 2 Crisis intervention is a type of brief therapy that is more directive than traditional psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The other options do not properly reassure the patient and build trust. Giving advice in the form of "you really should participate" is inappropriate. "Don't worry now" is false reassurance. While crisis intervention may help families communicate better, the goal is to return to precrisis level of functioning; family therapy will focus on helping families communicate better.

A patient in a motor vehicle accident states, "I did not run the red light," despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? 1. Conversion 2. Denial 3. Dissociation 4. Compensation

ans. 2 Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into nonorganic symptoms. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

A nurse is caring for a patient with stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? 1. Select nursing interventions and promote patient's adaptation to stress. 2. Reassess patient's stress-related symptoms and compare with expected outcomes. 3. Identify stress management interventions and achieve expected outcomes. 4. Establish short- and long-term goals with the patient experiencing stress.

ans. 2 During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

The nurse is aware that a patient with liver disease and a decreased albumin level may develop which of the following effects? 1. Accelerated biotransformation of the medication 2. Toxicity on normal doses of medication 3. Reduction in therapeutic effect 4. Less active medication available in the body

ans. 2 Most medications bind to albumin to some extent. When medications bind to albumin, they are unable to exert pharmacological activity. Only the unbound or "free" medication is active. Older adults and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity. With less albumin to bind with the medication, more "free" or active medication is present in the body. This would result in an increase in therapeutic effect and possibly in toxicity. Most biotransformation occurs in the liver, although the lungs, kidneys, blood, and intestines also play a role. Patients (e.g., elderly, those with chronic disease) are at risk for medication toxicity if their organs that metabolize medications do not function correctly.

What should be the next action by the nurse once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein? 1. Loosen the stylet for removal. 2. Check for blood return in the flashback chamber. 3. Stabilize the catheter and release the tourniquet. 4. Advance the catheter until the hub rests at the insertion site.

ans. 2 Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula, indicating that the bevel of the needle has entered the vein. Lower the needle until almost flush with the skin. Advance the catheter another 1/8 to 1/4 inch into the vein, and then loosen the stylet site on the over-the-needle catheter (ONC). Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released. Only after the blood and the needle are observed to advance another 1/8 to 1/4 inch into the vein is the stylet loosened. At that point, continue to hold the skin taut, and advance the catheter into the vein until the hub rests at the venipuncture site.

A trauma survivor is requesting sleep medication because of "bad dreams." The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? 1. "Can you describe your phobias?" 2. "Are you reliving your trauma?" 3. "Can you tell me when you wake up?" 4. "Are you having chest pain?"

ans. 2 People who have PTSD often have flashbacks, recurrent and intrusive recollections of the event. The other answers involve assessment of problems not specific to PTSD.

The nurse is preparing to give a medication by intravenous (IV) bolus. When assessing the patient's IV insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first? 1. Slow the infusion rate and slowly inject the medication. 2. Discontinue the IV infusion. 3. Inject a local anesthetic to relieve the tenderness. 4. Apply warm compresses over the insertion site.

ans. 2 Swelling, warmth, redness, and tenderness indicate infiltration or phlebitis. Stop the IV infusion, remove the IV catheter, treat the IV site as indicated by institutional policy, and insert a new IV catheter if therapy continues.

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? 1. Ego defense model 2. Neuman Systems Model 3. Pender's Health Promotion Model 4. Immunity model

ans. 2 The Neuman Systems Model uses a systems approach, and it helps you understand your patients' individual responses to stressors and also families' and communities' responses. Every person develops a set of responses to stress that constitute the "normal line of defense." This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body's natural protection mechanism. Pender's Health Promotion Model focuses on promoting health and managing stress.

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? 1. Increased liver mass 2. Reduced glomerular filtration 3. Reduced esophageal stricture 4. Increased gastric motility

ans. 2 The reduced glomerular filtration rate delays excretion, increasing chance for toxicity. In older adults, gastric motility and liver mass decrease. Esophageal stricture is not a physiological change associated with normal aging.

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? 1. Hospital 2. Nurse 3. Pharmacist 4. Health care provider

ans. 2 Ultimately, the person administering the medication is responsible for ensuring that it is correct. The nurse administered the medication, so in this case it is the nurse. Accept full accountability and responsibility for all actions surrounding the administration of medications. Do not assume that a medication that is ordered for a patient is the correct medication or the correct dose. This is the importance of verifying the six rights of medication administration. The ultimate responsibility and accountability are with the nurse, not the health care provider, pharmacist, or hospital.

A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? 1. "Let's call 911 because this freshman student is suicidal." 2. "I recommend that you help the freshman student start packing bags to go home." 3. "Give the freshman student this list of university and community resources." 4. "You must make an appointment for the freshman student to obtain medications."

ans. 3 A nurse can help reduce situational stress factors for individuals. Inform the patient about potential resources. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college.

A patient is taking a medication that has the potential to cause orthostatic hypotension. Which of the following nursing interventions is appropriate for this patient? 1. Obtain a walker or a cane for patient use. 2. Refer the patient to physical therapy. 3. Have the patient sit slowly and dangle. 4. Keep the side rails up at all times.

ans. 3 Dangling allows adjustment to orthostatic hypotension, permitting blood pressure to stabilize before ambulating. Have the patient dangle his or her feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak. The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise. Check agency policies regarding side rail use. Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely. Keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with the bed in low position and wheels locked, when you are not administering patient care. This allows the patient to maneuver and get out of bed safely. Do not assume that the patient requires a walker or a cane. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive devices may provide greater stability and may help the patient to assume a more active role.

A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? 1. Singing 2. Listening to music 3. Using sensory peaceful words 4. Massaging back

ans. 3 Guided imagery is used as a means to create a relaxed state through the person's imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

What should the nurse do when discontinuing a peripheral intravenous (IV) catheter? 1. Keep the hub perpendicular to the skin. 2. Apply pressure to the site for 1 minute. 3. Inspect the catheter for intactness after removal. 4. Withdraw the catheter quickly.

ans. 3 Inspect the catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above the site, and withdraw the catheter, using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift the catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants.

An 80-year-old patient who complains of feeling "anxious" is given lorazepam. The patient becomes agitated and delirious. The nurse documents this reaction to Ativan as which of the following? 1. Side effect 2. Toxicity 3. Idiosyncratic reaction 4. Allergic reaction

ans. 3 Medications often cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have an idiosyncratic response is impossible. For example, Ativan, an antianxiety medication, when given to an older adult, may cause agitation and delirium. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Allergic reactions are unpredictable responses to a medication. The medication acts as an antigen, and this causes antibodies to be produced. With repeated administration, the patient develops an allergic response. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal.

What should the nurse do once she recognizes that the patient has phlebitis at his intravenous (IV) catheter site? 1. Elevate the affected extremity. 2. Adjust the additive in the current IV. 3. Place a moist warm compress over the site. 4. Reduce the IV flow rate.

ans. 3 Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein. Stop the infusion and discontinue the intravenous (IV) catheter. Start a new IV if continued therapy is necessary. Place a moist warm compress over the area of phlebitis. Document the degree of phlebitis and nursing interventions per agency policy and procedure. The extremity is elevated for an infiltration to reduce edema.

A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? 1. Physical appearance 2. Identity issues 3. Self-esteem issues 4. Major changing life events

ans. 3 Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances.

A nurse is helping parents who have a child with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments? 1. Routine preventative health visits 2. Assertiveness training for the family 3. Time-management skills 4. Speech articulation skills

ans. 3 Time-management skills are most related to homework assignment completion. Time-management techniques include developing lists of prioritized tasks. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress. Assertiveness includes skills for helping individuals communicate effectively regarding their needs and desires, but it does not help with homework assignments.

The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events? 1. Thrombophlebitis 2. Phlebitis 3. Extravasation 4. Occlusion

ans. 3 When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of intravenous (IV) fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein. Thrombophlebitis occurs when trauma occurs within a vein due to a thrombus.

A patient has medication ordered to be given by intravenous (IV) bolus. The nurse recognizes which advantage of this type of administration? 1. Medications are given over a longer time frame. 2. Medications given by IV bolus are less irritating to the veins. 3. There is a slower onset of medication effects. 4. Small volumes are used, so fluid overload can be avoided.

ans. 4 An intravenous (IV) bolus usually requires small volumes of fluid, which is an advantage for patients who are at risk for fluid overload. With IV bolus medications, rapid onset of medication effects occurs, which is useful for patients who are experiencing critical or emergent health problems. Medications can be prepared quickly and given over a shorter time frame rather than by IV piggyback. Medications given by IV bolus may cause direct irritation to the lining of the blood vessel.

Which of the following steps is necessary when a patient is prepared for intravenous (IV) catheter insertion? 1. Vigorously taping and massaging the selected vein 2. Shaving the hair from the site 3. Selecting a proximal site in an extremity 4. Applying a tourniquet 4 to 6 inches above the selected site

ans. 4 Apply a flat tourniquet around the arm, above the antecubital fossa or 10 to 15 cm (4 to 6 inches) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older adults, may cause hematoma and/or venous constriction.

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? 1. Family relocation 2. Loss of stamina 3. Childhood obesity 4. Prolonged poverty

ans. 4 Environmental and social stressors often lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

The patient is an elderly gentleman who is admitted for a medical problem. While doing his admission assessment, the nurse learns that the patient gets up 2 to 3 times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down? 1. Falls rarely happen in the inpatient setting. 2. Patient falls rarely result in physical injury. 3. Side rails have no bearing on whether or not a patient falls. 4. Having all side rails raised increases the occurrence of falling.

ans. 4 Having all four side rails raised often increases the occurrence of falling, because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result. Leaving three side rails up (two upper and one lower) on a bed with four side rails is safer for the patient. Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls.

The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse's first action should be to: 1. notify the charge nurse. 2. assess the patient. 3. notify the primary care provider. 4. reduce the infusion rate.

ans. 4 If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the infusion rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment.

In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? 1. Immaturity and intelligence factors 2. Restorative care factors 3. Strong financial resource factors 4. Maturational and situational factors

ans. 4 Maturational factors and situational factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

A patient with chronic back pain has been taking oral morphine sulfate for the past 2 years. Upon admission to the hospital, the patient receives morphine sulfate for back pain but reports no pain relief. The nurse notifies the health care provider, recognizing that the reason for the lack of pain relief is which of the following? 1. Drug dependence 2. Idiosyncratic response to the morphine 3. Side effect of the morphine 4. Medication tolerance

ans. 4 Medication tolerance is a decreased physiological response that occurs after repeated administration of a medication. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Drug dependence can be physical or psychological. In psychological dependence, patients have an emotional desire for a drug to maintain an effect. A person believes that a desirable effect will result when taking the medication. Physical dependence is a physiological adaptation to a medication that manifests itself by intense physical disturbance when the medication is withdrawn. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal.

The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? 1. Quad 2. Secondary 3. Primary 4. Tertiary

ans. 4 Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. At the primary level of prevention, you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Quad level does not exist.

An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? 1. Suggest acupuncture. 2. Confront the patient on malingering. 3. Recommend a regular exercise program. 4. Obtain history of any recent life stressors.

ans. 4 Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite) describes conversion. The nurse must assess the patient fully for emotional conflict and stress before implementing any nursing interventions (acupuncture or exercise program). Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.