230 Unit 3

identify the arrhythmia

PVC (Premature Ventricular Contraction)

Identify the arrhythmia

atrial fibrillation

What motor function is affected by a C6 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

wrist extenders

A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. "The goal of AA is for members to learn controlled drinking with the support of a higher power." "An individual is supported by peers while striving for abstinence one day at a time." "You must make a commitment to permanently abstain from alcohol and other drugs." "You will be assigned a sponsor who will plan your treatment program."

"An individual is supported by peers while striving for abstinence one day at a time." (Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.)

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. "Everyone here is trying to help you. No one wants to harm you." "Feeling that people want to destroy you must be very frightening." "That is not true. People here are trying to help you if you will let them." "Staff members are health care professionals who are qualified to help you."

"Feeling that people want to destroy you must be very frightening." (Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.)

What motor function is affected by a C3 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

diaphragm

A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Synchronized cardioversion Electrophysiology studies (EPS) Anticoagulation Radiofrequency ablation therapy

Anticoagulation (The patient's rhythm has stabilized but because of the risk for thromboembolism related to AF, anticoagulation is necessary.Cardioversion is not needed at this time. EPS are indicated for recurring, symptomatic dysrhythmia. Ablation therapy is ordered for recurring and symptomatic atrial fibrillation.)

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? Clozapine (Clozaril) Olanzapine (Zyprexa) Ziprasidone (Geodon) Aripiprazole (Abilify)

Aripiprazole (Abilify) (Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine (second generation) may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone (second generation) may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine (second generation) fosters weight gain.)

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (first generation) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? Sedation and muscle stiffness Sweating, nausea, and diarrhea Mild fever, sore throat, and skin rash Headache, watery eyes, and runny nose

Sedation and muscle stiffness (Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.)

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? Perform a thorough assessment of the patient. Verify that security services are immediately available. Self-assess personal attitude, values, and beliefs about this health problem. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

Self-assess personal attitude, values, and beliefs about this health problem. (The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.)

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Sensation (The nurse uses a paper clip bilaterally on each limb of the client with back pain to assess sensation. Both extremities may be checked for sensation by using a paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side. Gait is assessed by having the client walk. Mobility is assessed by determining the client's ability to move on his/her own, turn or perform ADLs. Strength is measured by having the client perform bilateral grips.

Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Obtaining informed consent Setting the defibrillator to the synchronized mode Removing oxygen

Setting the defibrillator to the synchronized mode (Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation. Cardioversion is usually performed starting at a lower rate of 120-200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.)

Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? Simple and safe Stimulating and colorful Active and bright Confrontational and challenging

Simple and safe (Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip.")

Which precaution should the nurse follow when providing cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) to a patient? Protective Isolation Standard Precautions Surgical asepsis with defibrillator Respiratory isolation during intubation

Standard Precautions (Standard Precautions and personal protective equipment must be used when there is risk of contact with blood and body fluids. Protective isolation is designed to protect the patient from pathogens in the environment. Surgical asepsis involves ridding an item of all pathogens, such as in the operating room, with sterilization procedures. A defibrillator is a "clean," not sterile, item. Respiratory isolation is used to prevent transmission of organisms by droplets, such as chickenpox or meningitis. The nurse may choose to use protective eyewear or a face shield during intubation or suctioning of the airway to protect from spraying blood and body fluids.)

The nurse is providing care for a patient in the emergency department who reports a headache and weakness and is noted to have cardiac dysrhythmias on the electrocardiogram. The patient is talkative, restless, anxious, and asking to leave the emergency department. The nurse suspects that the patient might be taking which abuse substance? Stimulants Depressants Alcohol Opioids

Stimulants (Stimulants of abuse include amphetamines and often are related to anxiety, talkativeness, headaches, weakness, restlessness, and cardiac dysrhythmias.)

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? Substance Abuse and Mental Health Services Administration (SAMHSA) Institute of Medicine - National Research Council (IOM) National Council of State Boards of Nursing (NCSBN) American Society of Addictions Medicine

Substance Abuse and Mental Health Services Administration (SAMHSA) (The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.)

A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? Intoxication Tolerance Withdrawal Addiction

Tolerance (Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.)

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? Tolerance has developed. Antagonistic effects are evident. Metabolism of the alcohol is now delayed. Pharmacokinetics of the alcohol have changed.

Tolerance has developed. (Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.)

The nurse is caring for a patient with a history of chronic alcohol abuse. The nurse recognizes the need to closely monitor the patient for which withdrawal signs and symptoms? Select all that apply. Tremors Agitation Bradycardia Difficulty breathing Hypertension

Tremors Agitation Hypertension (Common symptoms and signs of alcohol withdrawal include increased blood pressure, pulse, tremors, and agitation. The signs and symptoms may vary depending on the patient's usage pattern, the preferred type of ethanol, and the presence of comorbidities.)

What assessment findings mark the prodromal stage of schizophrenia? Withdrawal, misinterpreting, poor concentration, and preoccupation with religion Auditory hallucinations, ideas of reference, thought insertion, and broadcasting Stereotyped behavior, echopraxia, echolalia, and waxy flexibility Loose associations, concrete thinking, and echolalia neologisms

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion (Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.)

In the emergency department, a patient's vital signs are: BP 66/40 mmHg pulse 140 beats/min respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. (The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.)

A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? Word salad Anhedonia Neologism Echolalia

Word salad (Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.)

A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a neologism. thought insertion. concrete thinking. an idea of reference.

a neologism. (A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.)

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications (A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.)

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

b. Notify the provider immediately. (If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.)

A 29-year-old male patient is admitted to the intensive care unit with the following symptoms: restlessness, hyperactive reflexes, talkativeness, confusion and periods of panic and euphoria, tachycardia, and fever. The nurse suspects that he may be experiencing the effects of taking which substance? a. Opioids b. Alcohol c. Stimulants d. Depressants

c. Stimulants (The adverse effects listed may occur with use of stimulants and are commonly an extension of their therapeutic effects. Opioids, alcohol, and depressants do not have these effects.)

A patient has been taking haloperidol (first generation) for 3 months for a psychotic disorder, and the nurse is concerned about the development of extrapyramidal symptoms. The nurse will monitor the patient closely for which effects? a. Increased paranoia b. Drowsiness and dizziness c. Tremors and muscle twitching d. Dry mouth and constipation

c. Tremors and muscle twitching (Extrapyramidal symptoms are manifested by tremors and muscle twitching, and the incidence of such symptoms is high during haloperidol therapy. The other options are incorrect.)

What motor function is affected by a T2-T6 injury? chest muscles abdominal muscles

chest muscles

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: codependence. role reversal. assertiveness. homeostasis.

codependence. (Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.)

The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should: provide long-term care for the patient in a residential facility. withdraw the patient from cannabis, then treat the schizophrenia. consider each diagnosis primary and provide simultaneous treatment. first treat the schizophrenia, then establish goals for substance abuse treatment.

consider each diagnosis primary and provide simultaneous treatment. (Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.)

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

d. "Tighten your abdominal muscles to stimulate urine flow." (In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.)

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

d. "What would you like to be done if you begin to have difficulty breathing?" (ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.)

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

d. Ensure that everyone is clear of contact with the client and the bed. (To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.)

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status. (The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.)

A patient has been taking naltrexone (ReVia) as part of the treatment for addiction to heroin. The nurse expects that the naltrexone will have which therapeutic effect for this patient? a. Naltrexone prevents the cravings for opioid drugs. b. Naltrexone works as a safer substitute for the heroin until the patient completes withdrawal. c. The patient will experience flushing, sweating, and severe nausea if he takes heroin while on naltrexone. d. If opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the opioid's desired effects are lost.

d. If opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the opioid's desired effects are lost. (Naltrexone works to eliminate the euphoria that occurs with opioid drug use; therefore, the reinforcing effect of the drug is lost.)

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

d. Impairment of respiratory muscles (In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.)

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone (Medrol) (Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.)

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

d. Perform hand hygiene. (To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.)

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

d. Place the client in a gown that has cloth ties instead of metal snaps. (Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.)

The nurse is administering an interferon and will implement which intervention? a. Giving the medication with meals b. Monitoring daily weights c. Limiting fluids while the patient is taking this medication d. Rotating sites if administered subcutaneously

d. Rotating sites if administered subcutaneously (Interferon is given parenterally (not orally), and injection sites need to be rotated. Fluids need to be increased during interferon therapy. The other options are incorrect.)

A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next? a. Administer the dose. b. Administer the dose, and notify the prescriber. c. Check the radial pulse for 1 full minute. d. Withhold the dose, and notify the prescriber.

d. Withhold the dose, and notify the prescriber. (Digoxin doses are held and the prescriber notified if the apical pulse is 60 beats/min or lower or is higher than 100 beats/min. The other options are incorrect.)

What motor function is affected by a C4 or C5 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

deltoids & biceps

The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: gain insight into unconscious factors that contribute to their illness. explore situations that trigger hostility and anger. learn to manage delusional thinking. demonstrate improved social skills.

demonstrate improved social skills. (Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.)

An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a schizophrenic episode. opium intoxication. hallucinogen ingestion. cocaine overdose.

hallucinogen ingestion. (The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.)

The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Defibrillate the patient at 200 joules. Check the patient for a pulse. Cardiovert the patient at 50 joules. Give the patient IV lidocaine.

Check the patient for a pulse. (The nurse needs to first assess the patient to determine stability before proceeding with further interventions. If the patient has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone.If the patient is pulseless or nonresponsive, the patient is unstable and defibrillation is used and not cardioversion. Also, if the patient is pulseless, lidocaine may be given after defibrillation.)

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? Temperature 98.2°F (36.8°C) Chest tube drainage 175 mL last hour Serum potassium 3.9 mEq/L (3.9 mmol/L) Incisional pain 6 on a scale of 0 to 10

Chest tube drainage 175 mL last hour (The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL per hour is excessive.Although hypothermia is a common problem after surgery, a temperature of 98.2°F (36.8°C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.)

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? Detachment and overconfidence Darting eyes, tilted head, mumbling to self Euphoric mood, hyperactivity, distractibility Foot tapping and repeatedly writing the same phrase

Darting eyes, tilted head, mumbling to self (Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.)

The nurse is preparing to administer digoxin (Lanoxin) 0.25mg intravenous push to a patient. Which is an expected patient outcomerelated to the administration of digoxin? Low serum potassium Reduction in urine output Increase in blood pressure Decrease in the heart rate

Decrease in the heart rate (Digoxin has a negative chronotropic effect (decreased heart rate).)

The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Cardiopulmonary resuscitation (CPR) Administration of epinephrine Administration of oxygen

Defibrillation (Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over. In asystole, there is no rhythm to interrupt. Therefore, this intervention is not used.If drug therapy fails to restore effective rhythm, CPR is initiated. Epinephrine is used to increase heart rate in asystole. Hypoxia may be a cause of cardiac arrest, so the administration of oxygen would be appropriate.)

A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? Denial Introjection Projection Rationalization

Denial (Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.)

Which assessment findings are likely for an individual who recently injected heroin? Anxiety, restlessness, paranoid delusions Muscle aching, dilated pupils, tachycardia Heightened sexuality, insomnia, euphoria Drowsiness, constricted pupils, slurred speech

Drowsiness, constricted pupils, slurred speech (Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.)

Nico, a 22-year-old patient, is diagnosed with schizophrenia. Which of the following symptoms would alert a provider to a possible diagnosis of schizophrenia in a 22-year-old male client? Excessive sleeping with disturbing dreams Hearing voices telling him to hurt his roommate Withdrawal from college because of failing grades Chaotic and dysfunctional relationships with his family and peers

Hearing voices telling him to hurt his roommate (People diagnosed with schizophrenia all have at least one psychotic symptom such as hallucinations, delusional thinking, or disorganized speech. The other options do not describe schizophrenia but could be caused by a number of problems.)

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? ST segment Heart rate Troponin Myoglobin

Heart rate (The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.)

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

Help the client sit up. (The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.)

The nurse is planning long-term goals for a 17-year-old male client recently diagnosed with schizophrenia. Which statement should serve as the basis for the goal-setting process? If treated quickly following diagnosis, schizophrenia can be cured. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.

Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. (Unfortunately, in most cases, schizophrenia does not respond fully to available treatments; it leaves residual symptoms and causes varying degrees of dysfunction or disability. The other options are all untrue of schizophrenia.)

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? Self-esteem Physiological Psychosocial Self-actualization

Physiological (Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.)

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? Pulse 60 beats/min and regular Urinary frequency Incisional discomfort Respiratory rate 28 breaths/min

Respiratory rate 28 breaths/min (The activity should be terminated when the nurse notices the client's respiration rate of 28 breaths per minute. This indicates tachypnea and possibly tachycardia due to activity intolerance.Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.)

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy (To help prevent death for a client with spinal cord injury, collaboration with the Respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with Respiratory therapy is crucial. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.)

The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I will be able to shower again soon." "I need to take my pulse every day." "I might trigger airport security metal detectors." "I no longer need my heart pills."

"I no longer need my heart pills." (All prescribed medications, including heart medications, are still needed after the pacemaker is implanted.Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices. A card can be shown to authorities to indicate that the patient has a pacemaker.)

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. "How long has the voice been directing your behavior?" "Does what the voice tell you to do frighten you?" "Do you recognize the voice speaking to you?' "What is the voice telling you to do?"

"What is the voice telling you to do?" (Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.)

Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. Empathetic, supportive Cool, distant Skeptical, guarded Confrontational

Empathetic, supportive (Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.)

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? Psychoeducational Transactional Psychoanalytic Family

Psychoeducational (A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.)

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? PCP Barbiturates Heroin Amphetamines

Amphetamines (The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.)

Ch. 34: Care of Patients with Dysrhythmias

Ch. 34: Care of Patients with Dysrhythmias

Ch. 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord

Ch. 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord

What motor function is affected by a L5-S3 injury? leg muscles bowel & bladder sexual function

bowel & bladder

What motor function is affected by a C8 or T1 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

hands

What motor function is affected by a T12-L4 injury? leg muscles bowel & bladder sexual function

leg muscles

Before administering a dose of an antidysrhythmic drug to a patient, what is the priority nursing assessment? Measure urine output and specific gravity. Check apical pulse and blood pressure. Evaluate peripheral pulses and level of consciousness. Obtain temperature and pulse oximetry on room air.

Check apical pulse and blood pressure. (Antidysrhythmic drugs can cause both hypotension and bradycardia; therefore, it is important to assess blood pressure and apical pulse before administration.)

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

a. Medication reconciliation (The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.)

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? "This way you will not need to have a leg incision." "The surgeon prefers this approach because it is easier." "These arteries remain open longer." "The surgeon has chosen this approach because of your age."

"These arteries remain open longer." (The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.)

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. "Nothing you are saying is clear." "Your thoughts are very disconnected." "Try to organize your thoughts and then tell me again." "I am having difficulty understanding what you are saying."

"I am having difficulty understanding what you are saying." (When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.)

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. "Do you hear the voices often?" "Do you have a plan for getting away from the voices?" "I'll stay with you. Focus on what we are talking about, not the voices." "Forget the voices and ask some other patients to play cards with you."

"I'll stay with you. Focus on what we are talking about, not the voices." (Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.)

A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." Your best response would be: "You are having problems with your speech. You need to try harder to be clear." "You are confused. I will take you to your room to rest a while." "I will get you a prn medication for agitation." "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

"I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?" (The guidelines that are useful in communicating with a patient with disorganized or bizarre speech are to place the difficulty in understanding on yourself, not the patient, and look for themes that may be helpful in interpreting what the patient wants to say. Telling the patient he needs to try harder to be clearer is unrealistic since the patient would be unable do this. The other options are not useful in communicating with this patient and attempting to find common themes.)

A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? "It helps your mood so that you don't feel the need to do drugs." "It will keep you from experiencing flashbacks." "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." "It helps prevent relapse by reducing drug cravings."

"It helps prevent relapse by reducing drug cravings." (Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone.)

A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "It's important I work out in the afternoon so my muscles are warmed up." "I always keep my medications in the same place."

"It's important I work out in the afternoon so my muscles are warmed up." (More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial.If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.)

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."

"Keep straws available for drinking fluids." (The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.)

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. "Alcoholism is a lifelong disease. Relapses are expected." "Use search and destroy tactics to keep the home alcohol free." "It's important that you visit your family member on a regular basis." "Make your loved one responsible for the consequences of behavior."

"Make your loved one responsible for the consequences of behavior." (Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.)

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

"Parts of my nervous system have plaques." (The statement that demonstrates that the newly diagnosed client with MS correctly understands the pathophysiology of the disease is "parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system.The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.)

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider. I will help set that up."

"Please request a meeting with the health care provider. I will help set that up." (The nurse's best response to a family member of a client with a recent spinal cord injury is, "Please request a meeting with the primary health care provider. I will set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.)

What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "It is important to consume a diet high in green leafy vegetables." "You would take aspirin or ibuprofen for headache." "Report nosebleeds to your provider immediately." "Avoid caffeinated beverages."

"Report nosebleeds to your provider immediately." (A nosebleed could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot.Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.)

A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. "I see," and use interested silence. "I think you are drinking more than you report." "Social drinkers have one or two drinks, once or twice a week." "You describe drinking steadily throughout the day and evening." "Your comments show denial of the seriousness of your problem."

"Social drinkers have one or two drinks, once or twice a week." "You describe drinking steadily throughout the day and evening." (The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.)

A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? "Sooner or later, alcohol will kill you. Then what will happen to your children?" "I hear a lot of defensiveness in your voice. Do you really believe this?" "If you were coping so well, why were you hospitalized again?" "Tell me what happened the last time you drank."

"Tell me what happened the last time you drank." (The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.)

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? "The importance of taking your medication correctly" "How to complete an application for employment" "How to dress when attending community events" "How to give and receive compliments" "Ways to quit smoking"

"The importance of taking your medication correctly" "Ways to quit smoking" (Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics.)

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? "The table of contents tells what a book is about." "You can't judge a book by looking at the cover." "Things are not always as they first appear." "Why are you asking me about books?"

"The table of contents tells what a book is about." (Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.)

Which hallucination necessitates the nurse to implement safety measures? The patient says, "I hear angels playing harps." "The voices say everyone is trying to kill me." "My dead father tells me I am a good person." "The voices talk only at night when I'm trying to sleep."

"The voices say everyone is trying to kill me." (The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.)

During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." "It will be important for you to structure life to avoid as much stress as you can and provide social protection." "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

"While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." (During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.)

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. "Why are you laughing?" "Please share the joke with me." "I don't think I said anything funny." "You're laughing. Tell me what's happening."

"You're laughing. Tell me what's happening." (The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.)

Which goal for treatment of alcoholism should the nurse address first? Learn about addiction and recovery. Develop a peer support system. Develop alternate coping strategies. Achieve physiologic stability.

Achieve physiologic stability. (The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.)

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (first generation). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. (Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.)

A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? Allowing the patient supervised access to food vending machines Allowing the patient to phone a local restaurant to deliver meals Offering to taste each portion on the tray for the patient Providing tube feedings or total parenteral nutrition

Allowing the patient supervised access to food vending machines (The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer.)

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? Neologism Thought broadcasting Idea of reference Associative looseness

Associative looseness (Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.)

A patient is admitted to the intensive care unit with an acute pulmonary embolism. What dysrhythmia would most likely contribute to this condition? Atrial fibrillation Sinus bradycardia Ventricular tachycardia Premature atrial contractions

Atrial fibrillation (Because the atria are not fully contracting in atrial fibrillation, there is stagnation of blood flow resulting in formation of thrombi in the atria. A thrombus can be dislodged from the right atrium and travel to the lung, causing a pulmonary embolus. There is not a risk of thrombus formation with sinus bradycardia, premature atrial contractions, or ventricular tachycardia.)

Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid talking on a cell phone. Avoid operating electrical appliances over the pacemaker. Avoid sexual activity. Do not take tub baths.

Avoid operating electrical appliances over the pacemaker. (The patient needs to avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction.It is not necessary to avoid a telephone or a cell phone, but the patient would keep cellular phones at least six inches (15 centimetres) away from the generator and with the handset on the ear opposite the side of the generator. Radio transmitter towers, arc welding, and strong electromagnetic fields may pose a hazard. No hazard exists with sexual activity. Bathing and showering are permitted.)

Which statement correctly differentiates cardioversion from defibrillation? Defibrillation is a synchronized shock delivered to depolarize the myocardium simultaneously in atrial fibrillation. Cardioversion is an asynchronous shock to the patient to convert ventricular tachycardia or ventricular fibrillation. Defibrillation delivers an electrical shock to the heart; cardioversion involves use of a temporary pacemaker to deliver the shock. Cardioversion delivers a synchronized shock for ventricular tachycardia or supraventricular tachycardia.

Cardioversion delivers a synchronized shock for ventricular tachycardia or supraventricular tachycardia. (Cardioversion involves the delivery of a synchronized electric shock to terminate unstable ventricular or supraventricular rhythms. It is not useful in ventricular fibrillation because all electrical activity is disorganized with no ability to synchronize. Defibrillation delivers an asynchronous countershock, depolarizing a critical mass of the myocardium to stop the re-entry circuit in ventricular fibrillation or pulseless ventricular tachycardia, allowing the sinus node to regain control of the heart.)

Ch. 12: Schizophrenia Spectrum Disorders

Ch. 12: Schizophrenia Spectrum Disorders

Ch. 16: Antipsychotic Drugs

Ch. 16: Antipsychotic Drugs

Ch. 22: Substance-Related and Additive Disorders

Ch. 22: Substance-Related and Additive Disorders

A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? Client will return to a predrug level of functioning within 1 week. Client will be medically stabilized while in the hospital. Client will state within 3 days that they will totally abstain from drugs and alcohol. Client will take a leave of absence from college to alleviate stress.

Client will be medically stabilized while in the hospital. (If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.)

Which statement is true regarding substance addiction and medical comorbidity? Most substance abusers do not have medical comorbidities. There has been little research done regarding substance addiction disorders and medical comorbidity. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.

Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. (The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.)

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? Force fluids. Consult the health care provider. Obtain a clean-catch urine sample. Place the patient in a vest-type restraint.

Consult the health care provider. (Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.)

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4°F (38.0°C)

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness (The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/minute is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.)

Calcium channel blockers have which pharmacodynamic effect? Positive chronotropic Shortened refractory period Positive inotropic Coronary vasodilation

Coronary vasodilation (Calcium channel blockers cause coronary vasodilation, a negative inotropic effect, a negative chronotropic effect, and a negative dromotropic effect.)

A patient in a rehabilitation center is beginning to experience opioid withdrawal symptoms. The nurse expects to administer which drug as part of the treatment? a. Diazepam (Valium) b. Methadone c. Disulfiram (Antabuse) d. Bupropion (Zyban)

b. Methadone (Opioid withdrawal can be managed with either methadone or clonidine (Catapres). Diazepam and disulfiram are used for treatment of alcoholism, and bupropion is used to assist with smoking cessation.)

A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? Disorganized Supportive Dangerous Bizarre

Dangerous (The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.)

Which risk factors are known to contribute to atrial fibrillation? Select all that apply. Use of beta-adrenergic blockers Excessive alcohol use Advancing age High blood pressure Palpitations

Excessive alcohol use Advancing age High blood pressure (Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.)

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin Atropine Dobutamine Magnesium sulfate

Heparin (The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin [Lovenox], warfarin [Coumadin], and novel oral anticoagualants, when nonvalvular, such as dabigatran [Pradaxa], rivaroxaban [Xarelto], apixaban [Eliquis], or edoxaban [Savaysa]) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.)

When caring for a patient with premature ventricular contractions (PVCs), which electrolyte imbalances will contribute to this dysrhythmia and should therefore be monitored? Select all that apply. Hypokalemia Hyponatremia Hypocalcemia Hypomagnesemia Hypophosphatemia

Hypokalemia Hypomagnesemia (Low serum levels of potassium and magnesium predispose the patient to PVCs. The other electrolyte imbalances may cause ECG changes but do not increase the risk for PVCs.)

The nurse is educating a group of college students about substance abuse. When discussing the potential use and abuse of stimulants, the nurse is aware these drugs are commonly abused and cause what signs and symptoms? Select all that apply. Constipation Increased alertness Weight loss Elevated mood Decreased aggressiveness

Increased alertness Weight loss Elevated mood (The abuse of stimulants is related to their ability to cause elevation of mood, reduction of fatigue, a sense of increased alertness, and invigorating aggressiveness. Other signs and symptoms include diarrhea and abdominal cramps, not constipation.)

What training does an Advanced Cardiac Life Support (ACLS) certification offer? Neonatal and pediatric resuscitation Validation of core emergency nursing knowledge base Noninvasive assessment skills for airway maintenance Invasive airway management skills and electrical therapies

Invasive airway management skills and electrical therapies (An ACLS certification provides training in invasive airway management skills, pharmacology, special therapies, and electrical therapies. A Basic Life Support (BLS) certification provides training in noninvasive assessment skills for airway maintenance and cardiopulmonary resuscitation. A Pediatric Advanced Life Support certification (PALS) provides training in neonatal and pediatric resuscitation. A Certified Emergency Nurse (CEN) certification validates the core emergency nursing knowledge base.)

Khan Academy: www.youtube.com/watch?v=xW1UeIxEzoM&list=PLmZFuei9zpbaRg01MY9G-MN0iBLv-Y8Rp

Khan Academy: www.youtube.com/watch?v=xW1UeIxEzoM&list=PLmZFuei9zpbaRg01MY9G-MN0iBLv-Y8Rp

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway

Patent airway (The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.)

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? Visual hallucinations Idea of reference Magical thinking Thought insertion

Magical thinking (Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters.)

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? Assess coping skills. Assess for postoperative pain at the client's incision site. Monitor the heart rate for dysrhythmias. Monitor mental status.

Monitor the heart rate for dysrhythmias. (The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.)

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. Monitor vital signs. Observe for depression. Awaken the patient every 15 minutes. Use warmers to maintain body temperature.

Monitor vital signs. (Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.)

The nurse is monitoring a patient taking a first generation antipsychotic medication for extrapyramidal symptoms. Which clinical finding indicates an adverse effect of this drug? Presence of myoglobin in the blood Muscle cramps of the head and neck Dry mouth and constipation Blood pressure of 80/50 mm Hg

Muscle cramps of the head and neck (Dystonia, or sudden and painful muscle spasms, is the only extrapyramidal adverse effect listed. The other adverse effects also occur but are not extrapyramidal effects.)

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? Bromocriptine (Parlodel) Disulfiram (Antabuse) Methadone (Dolophine) Naltrexone (ReVia)

Naltrexone (ReVia) (Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.)

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? Haloperidol (Haldol) Chlorpromazine (Thorazine) Olanzapine (Zyprexa) Diphenhydramine (Benadryl)

Olanzapine (Zyprexa) (Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are first generation antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.)

A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? Check the patient every 15 minutes Keep the room dimly lit One-on-one supervision Force fluids

One-on-one supervision (One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.)

While obtaining a medication history from a patient, the nurse notes that the patient is currently prescribed naltrexone (ReVia). The nurse should question the patient about a previous history of which substance abuse? Amphetamine Barbiturate Alcohol Opioid

Opioid (Naltrexone (ReVia), an opioid antagonist, is used to treat opioid abuse or dependence. Naltrexone works by blocking the opioid receptors so that use of opioid drugs does not produce euphoria. When euphoria is eliminated, the reinforcing effect of the drug is lost.)

A patient reports severe back pain and asks the nurse for medication "to take the pain away." Nursing assessment findings on the physical examination include mydriasis (dilated pupils), rhinorrhea (runny nose), diaphoresis, lacrimation (crying), blood pressure of 160/84 mmHg, heart rate of 116 beats/min, and respiratory rate of 24 breaths/min. Which condition would the nurse suspect? Amphetamine overdose Barbiturate overdose Opioid withdrawal Ethanol intoxication

Opioid withdrawal (Signs and symptoms associated with opioid withdrawal include drug seeking, mydriasis, piloerection (goose bumps), diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, and elevated blood pressure and pulse rate. Nurses must be alert for this behavior in patients seeking medication for subjective pain complaints, especially when accompanied by withdrawal symptoms.)

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? Poverty of content Neologisms Concrete thinking Paranoia

Paranoia (The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.)

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? Auditory hallucinations Poor personal hygiene Delusions of grandeur Psychomotor agitation

Poor personal hygiene (Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia.)

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential (The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.)

Which are therapeutic effects of digoxin (Lanoxin)? Positive inotropic, negative chronotropic, and negative dromotropic Negative inotropic, negative chronotropic, and negative dromotropic Positive inotropic, positive chronotropic, and negative dromotropic Positive inotropic, negative chronotropic, and positive dromotropic

Positive inotropic, negative chronotropic, and negative dromotropic (Digoxin increases cardiac contractility (positive inotropic effect), decreases heart rate (negative chronotropic effect), and decreases conductivity (negative dromotropic effect).)

Which finding constitutes a negative symptom associated with schizophrenia? Hostility Poverty of thought Bizarre behavior Auditory hallucinations

Poverty of thought (Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia.)

A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Establish IV access. Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR).

Prepare for defibrillation. (Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols.After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.)

A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? 1-week detoxification program 12-step self-help program Long-term outpatient therapy Residential program

Residential program (Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.)

A patient diagnosed with schizophrenia has taken fluphenazine (first generation) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? Neuroleptic malignant syndrome Pseudoparkinsonism Hepatocellular effects Akathisia

Pseudoparkinsonism (Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.)

The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. Respiratory rate QT interval Heart rate Heart rhythm Urine output

QT interval Heart rate Heart rhythm (Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.)

The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? Readiness to change and support system Current college performance Financial ability Availability of immediate family to come to meetings

Readiness to change and support system (The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient's perceived need for change and having others who can lend support outside the hospital.)

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning (Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.)

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? Cardiovascular Neurologic Respiratory Hepatic

Respiratory (Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.)

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? Disturbed sensory perception Ineffective denial Ineffective coping Risk for injury

Risk for injury (The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.)

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. Risk for other-directed violence Disturbed thought processes Risk for loneliness Spiritual distress Social isolation

Risk for other-directed violence Disturbed thought processes (Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.)

What atypical antipsychotic medication should the nurse anticipate the health care provider prescribing for treatment of acute schizophrenia? Prazodone (Desyrel) Phenelzine (Nardil) Amoxapine (Asendin) Risperidone (Risperdal)

Risperidone (Risperdal) (Risperidone (second generation) is effective for schizophrenia, including negative symptoms. The other medications listed are antidepressants.)

A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone (second generation). The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her son faces for extrapyramidal side effects (EPSs)? All antipsychotic medications have an equal chance of producing EPSs. Newer antipsychotic medications have a higher risk for EPSs. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. Advise the mother to ask the provider to change the medication to clozapine instead of risperidone.

Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. (Risperidone is a newer, atypical antipsychotic. All newer antipsychotic medications have a lower incidence of EPSs than older, traditional antipsychotics. The other responses are untrue. There is no reason to advise a medication change at this time.)

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years old and Tara at 31 years old. Based on your knowledge of early and late onset of schizophrenia, which of the following is true? Tara and Aaron have the same expectation of a poor long-term prognosis. Tara will experience more positive signs of schizophrenia such as hallucinations. Aaron will be more likely to hold a job and live a productive life. Tara has a better chance for positive outcomes because of later onset.

Tara has a better chance for positive outcomes because of later onset. (Female patients diagnosed with schizophrenia between the ages of 25 and 35 years have better outcomes than do their male counterparts diagnosed earlier. These two patients do not have the same expectation of a poor prognosis. There is no evidence suggesting that Tara will have more positive signs of schizophrenia. It is actually more unlikely that Aaron will be able to live a productive life because of his earlier onset, which has a poorer prognosis.)

A patient has been taking an antipsychotic drug daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? Agranulocytosis Tourette's syndrome Tardive dyskinesia Anticholinergic effects

Tardive dyskinesia (Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.)

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." Tell the client, "You are in a safe place where you will be helped." Administer a prn dose of an antipsychotic medication. Tell the client, "You don't need to worry about that."

Tell the client, "You are in a safe place where you will be helped." (The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.)

The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. The client's chest moves very little with each respiration. The client demonstrates flaccid paralysis below the level of injury.

The client's chest moves very little with each respiration. (The most rapid action is needed for a spinal cord injury client injured one hour prior to arrival whose chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.Bradycardia and hypotension are indications neurogenic shock due to disruption of autonomic pathways. This will need to be addressed rapidly however airway and breathing are always the top priority. Flaccid paralysis below the level of the injury is to be expected.)

The nurse is reading a patient's substance abuse history on admission to inpatient rehabilitation. The patient states to the nurse, "I have been increasing my drug dosage to get the same effect." What is the patient experiencing? Habituation Tolerance Physiological dependence Addiction

Tolerance (Tolerance is defined as requiring an increased amount of drugs in the system to have the same desired effect)

A patient is receiving lidocaine (Xylocaine) by continuous intravenous (IV) infusion. The nurse understands this medication is prescribed for what condition? Ventricular dysrhythmias Sinus bradycardia Atrial fibrillation First-degree heart block

Ventricular dysrhythmias (Lidocaine is a sodium channel blocker drug used specifically to treat ventricular dysrhythmias.)

identify the arrhythmia

Ventricular tachycardia (V-tach)

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. (Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.)

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? Echolalia Depersonalization Waxy flexibility Thought withdrawal

Waxy flexibility (Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.)

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (second generation). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? How to recognize tardive dyskinesia Ways to manage constipation Weight management strategies Sleep hygiene measures

Weight management strategies (Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.)

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mmHg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness (Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.)

Which patient-teaching instructions are appropriate for a patient taking an antidysrhythmic drug? (Select all that apply.) a. "Do not chew or crush extended-release forms of medication." b. "Take the medication with food if gastrointestinal distress occurs." c. "If a dose is missed, the missed dose should be taken along with the next dose that is due to be taken." d. "Take the medications with an antacid if gastrointestinal distress occurs." e. "Limit or avoid the use of caffeine." f. "The presence of a capsule in the stool should be reported to the physician immediately."

a. "Do not chew or crush extended-release forms of medication." b. "Take the medication with food if gastrointestinal distress occurs." e. "Limit or avoid the use of caffeine." (Appropriate teaching instructions for a patient taking an antidysrhythmic drug include: do not chew or crush extended-release forms; if gastrointestinal distress occurs, take the drug with food; and limit or avoid the use of caffeine. Do not double medication doses or take medications with an antacid. The presence of a portion of a capsule or tablet in the stool is actually the wax matrix that carried the medication, which has been absorbed. The physician does not need to be notified.)

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

a. "High glucose is common in shock and needs to be treated." (High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.)

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

a. "I'll use my incentive spirometer every 2 hours while I'm awake." (Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.)

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks." (The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.)

The nurse is monitoring a patient who is experiencing severe ethanol withdrawal. Which are signs and symptoms of severe ethanol withdrawal? (Select all that apply.) a. Agitation b. Drowsiness c. Tremors d. Systolic blood pressure higher than 200 mm Hg e. Temperature over 100° F (37.7° C) f. Pulse rate 110 beats/min

a. Agitation c. Tremors d. Systolic blood pressure higher than 200 mm Hg (Signs and symptoms of severe ethanol withdrawal (delirium tremens) include systolic blood pressure higher than 200 mm Hg, diastolic blood pressure higher than 140 mm Hg, pulse rate higher than 140 beats/min, temperature above 101° F (38.3° C), tremors, insomnia, and agitation.)

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a. Assist the client to the chair for meals and to the bathroom. c. Ensure the client wears TED hose or sequential compression devices. e. Take and record a full set of vital signs per hospital protocol. (The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.)

A patient is in the emergency department with a new onset of rapid-rate atrial fibrillation, and the nurse is preparing a continuous infusion. Which drug is most appropriate for this dysrhythmia? a. Diltiazem (Cardizem) b. Atenolol (Tenormin) c. Lidocaine d. Adenosine (Adenocard)

a. Diltiazem (Cardizem) (Diltiazem (Cardizem) is indicated for the temporary control of a rapid ventricular response in a patient with atrial fibrillation or flutter and paroxysmal supraventricular tachycardia. It is given by continuous infusion after a loading dose given by IV bolus. The other options are incorrect.)

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

a. Spiritual beliefs c. Family support d. Level of independence f. Previous coping strategies (Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.)

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown

a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. e. Assess the chest and back for skin breakdown (A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.)

What motor function is affected by a T7-T11 injury? chest muscles abdominal muscles

abdominal muscles

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: echolalia. a delusion of infidelity. an idea of reference. an auditory hallucination.

an idea of reference. (Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.)

identify the arrhythmia

atrial flutter

A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) avoid aged cheeses. avoid alcohol-based skin products. read labels of all liquid medications. wear sunscreen and avoid bright sunlight. maintain an adequate dietary intake of sodium. avoid breathing fumes of paints, stains, and stripping compounds.

avoid alcohol-based skin products. read labels of all liquid medications. avoid breathing fumes of paints, stains, and stripping compounds. (The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.)

Withdrawn patients diagnosed with schizophrenia: are usually violent toward caregivers. universally fear sexual involvement with therapists. exhibit a high degree of hostility as evidenced by rejecting behavior. avoid relationships because they become anxious with emotional closeness.

avoid relationships because they become anxious with emotional closeness. (When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.)

A nurse is teaching a client with multiple sclerosis who is prescribed methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."

b. "Avoid crowds and people with colds." (The client should be taught to avoid people with any type of upper respiratory illness because this medication is immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.)

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

b. Methylprednisolone (Medrol) (Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.)

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

b. "I hope I can get my water turned back on when I get home." (All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.)

A 38-year-old male patient stopped smoking 6 months ago. He tells the nurse that he still feels strong cigarette cravings and wonders if he is ever going to feel "normal" again. Which statement by the nurse is correct? a. "It's possible that these cravings will never stop." b. "These cravings may persist for several months." c. "The cravings tell us that you are still using nicotine." d. "The cravings show that you are about to experience nicotine withdrawal."

b. "These cravings may persist for several months." (Cigarette cravings may persist for months after nicotine withdrawal. The other statements are false.)

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

b. A 50-year-old who is post coronary artery bypass graft surgery (Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.)

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

b. Assess vital signs and level of consciousness. (In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.)

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

b. Assist the client into a position of comfort in bed. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing. (Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.)

When a patient is receiving a second-generation antipsychotic drug, such as risperidone (Risperdal), the nurse will monitor for which therapeutic effect? a. Fewer panic attacks b. Decreased paranoia and delusions c. Decreased feeling of hopelessness d. Improved tardive dyskinesia

b. Decreased paranoia and delusions (The therapeutic effects of the antipsychotic drugs include improvement in mood and affect, and alleviation or decrease in psychotic symptoms (decrease in hallucinations, paranoia, delusions, garbled speech). Tardive dyskinesia is a potential adverse effect of these drugs. The other options are incorrect.)

When monitoring a patient's response to interferon therapy, the nurse notes that the major dose-limiting factor for interferon therapy is which condition? a. Diarrhea b. Fatigue c. Anxiety d. Nausea and vomiting

b. Fatigue (Patients who receive interferon therapy may experience flu-like symptoms: fever, chills, headache, malaise, myalgia, and fatigue. Fatigue is the major dose-limiting factor for interferon therapy. Patients taking high dosages become so exhausted that they are commonly confined to bed.)

A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)

b. Glatiramer (Copaxone) (Glatiramer and fingolimod are the only immunosuppressants currently indicated for reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis.)

A patient is being treated for ethanol alcohol abuse in a rehabilitation center. The nurse will include which information when teaching him about disulfiram (Antabuse) therapy? a. He should not smoke cigarettes while on this drug. b. He needs to know about the common over-the-counter substances that contain alcohol. c. This drug will cause the same effects as the alcohol did, without the euphoric effects. d. Mouthwashes and cough medicines that contain alcohol are safe because they are used in small amounts.

b. He needs to know about the common over-the-counter substances that contain alcohol. (The use of disulfiram (Antabuse) with alcohol-containing over-the-counter products will elicit severe adverse reactions. As little as 7 mL of alcohol may cause symptoms in a sensitive person. Cigarette smoking does not cause problems when taking disulfiram. Disulfiram does not have the same effects as alcohol.)

A patient has a digoxin level of 1.1 ng/mL. Which interpretation by the nurse is correct? a. It is below the therapeutic level. b. It is within the therapeutic range. c. It is above the therapeutic level. d. It is at a toxic level.

b. It is within the therapeutic range. (The normal therapeutic drug level of digoxin is between 0.5 and 2 ng/mL. The other options are incorrect.)

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination. f. Perform manual disimpaction. (For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.)

A patient has been taking disulfiram (Antabuse) as part of his rehabilitation therapy. However, this evening, he attended a party and drank half a beer. As a result, he became ill and his friends took him to the emergency department. The nurse will look for which adverse effects associated with acetaldehyde syndrome? (Select all that apply.) a. Euphoria b. Severe vomiting c. Diarrhea d. Pulsating headache e. Difficulty breathing f. Sweating

b. Severe vomiting d. Pulsating headache e. Difficulty breathing f. Sweating (Acetaldehyde syndrome results when alcohol is taken while on disulfiram (Antabuse) therapy. Adverse effects include CNS effects (pulsating headache, sweating, marked uneasiness, weakness, vertigo, others); GI effects (nausea, copious vomiting, thirst); and difficulty breathing. Cardiovascular effects also occur.)

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Time: 0800 Vital Signs: Temperature: 98°F Heart rate: 68 beats/min Blood pressure: 135/60 mmHg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2L nasal cannula Time: 1000 Vital Signs: Temperature: 98.2°F Heart rate: 50 beats/min Blood pressure: 132/57 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2L nasal cannula Time: 0800 Nursing Assessment: Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Nursing Assessment: Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

b. Slow the amiodarone infusion rate. (IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.)

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations (Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.)

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

b. Turn off oxygen therapy. (For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.)

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin) (Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.)

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

c. "Clients who use cocaine are at risk for fatal dysrhythmias." (Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.)

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." (Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.)

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." (Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.)

A patient is in the intensive care unit and receiving an infusion of milrinone (Primacor) for severe heart failure. The prescriber has written an order for an intravenous dose of furosemide (Lasix). How will the nurse give this drug? a. Infuse the drug into the same intravenous line as the milrinone. b. Stop the milrinone, flush the line, and then administer the furosemide. c. Administer the furosemide in a separate intravenous line. d. Notify the prescriber that the furosemide cannot be given at this time.

c. Administer the furosemide in a separate intravenous line. (Furosemide must not be injected into an intravenous line with milrinone because it will precipitate immediately. The infusion must not be stopped because of the patient's condition. A separate line will be needed. The other options are incorrect.)

A patient is in the intensive care unit because of an acute myocardial infarction. He is experiencing severe ventricular dysrhythmias. The nurse will prepare to give which drug of choice for this dysrhythmia? a. Diltiazem (Cardizem) b. Verapamil (Calan) c. Amiodarone (Cordarone) d. Adenosine (Adenocard)

c. Amiodarone (Cordarone) (Amiodarone (Cordarone) is the drug of choice for ventricular dysrhythmias according to the Advanced Cardiac Life Support guidelines. The other drugs are not used for acute ventricular dysrhythmias.)

The nurse administering the phosphodiesterase inhibitor milrinone (Primacor) recognizes that this drug will have a positive inotropic effect. Which result reflects this effect? a. Increased heart rate b. Increased blood vessel dilation c. Increased force of cardiac contractions d. Increased conduction of electrical impulses across the heart

c. Increased force of cardiac contractions (Positive inotropic drugs increase myocardial contractility, thus increasing the force of cardiac conduction. Positive chronotropic drugs increase the heart rate. Positive dromotropic drugs increase the conduction of electrical impulses across the heart. Blood vessel dilation is not affected.)

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus (involuntary eye movement) d. Heat intolerance

c. Nystagmus (involuntary eye movement) (Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.)

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

c. Occupational therapist (The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.)

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention. (The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.)

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure. (Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.)

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

c. Schedule periods of exercise and rest during the day. (Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.)

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: is attempting to obtain attention by manipulating staff. may have sustained a head injury before admission. has symptoms of alcohol-withdrawal delirium. is having an acute psychosis.

has symptoms of alcohol-withdrawal delirium. (Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.)

What motor function is affected by a C1 or C2 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

head & neck

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: sit close to the patient. place an arm protectively around the patient's shoulders. place a hand on the patient's arm and exert light pressure. maintain a normal social interaction distance from the patient.

maintain a normal social interaction distance from the patient. (The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.)

Symptoms of withdrawal from opioids for which the nurse should assess include: dilated pupils, tachycardia, elevated blood pressure, and elation. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. mood lability, incoordination, fever, and drowsiness. excessive eating, constipation, and headache.

nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. (The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.)

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: demonstrate increased interest in the environment by the end of week 1. perform self-care activities with coaching by the end of day 3. gradually take the initiative for self-care by the end of week 2. accept tube feeding without objection by day 2.

perform self-care activities with coaching by the end of day 3. (Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.)

The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply) rehearsing techniques to handle anticipated stressful situations. advising the patient to accept residential treatment if relapse occurs. assisting the patient to identify life skills needed for effective coping. advising isolating self from significant others until sobriety is established. informing the patient of physical changes to expect as the body adapts to functioning without substances.

rehearsing techniques to handle anticipated stressful situations. assisting the patient to identify life skills needed for effective coping. informing the patient of physical changes to expect as the body adapts to functioning without substances. (Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.)

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: the need for psychoeducation. chronic deterioration. medication noncompliance. relapse.

relapse. (Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.)

A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: form of group therapy led by a psychiatrist." self-help group for which the goal is sobriety." group that learns about drinking from a group leader." network that advocates strong punishment for drunk drivers."

self-help group for which the goal is sobriety." (Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.)

What motor function is affected by a S4 or S5 injury? leg muscles bowel & bladder sexual function

sexual function

Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will: state, "I know I need long-term treatment." use denial and rationalization in healthy ways. identify constructive outlets for expression of anger. develop a trusting relationship with one staff member.

state, "I know I need long-term treatment." (The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.)

A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: cross-tolerance. substance addiction. substance abuse. substance intoxication.

substance addiction. (Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.)

What motor function is affected by a C7 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

triceps