health & illness exam 3 review questions

normal value of magnesium

1.8-2.6

normal value of sodium

136-145

normal value of phosphate

3.0-4.5

normal value of potassium

3.5-5.0

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright

A. Breathing ranging from very deep to very shallow with periods of apnea Rationale: This describes Cheyne-Stokes respirations, an indication that the client is approaching death.

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? A. Keeping an appointment with a client B. Allowing a new mother to hold her stillborn infant C. Confirming that a client going for surgery has signed a consent form D. Refusing to disclose information about a client to the media

A. Keeping an appointment with a client Rationale: Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.

Which variable is the most important to assess with any brain injury? A. Level of consciousness B. Body temperature C. Heart rate D. Blood pressure

A. Level of consciousness Rationale: LOC is the most important variable to assess with any brain injury. The first sign of increased intracranial pressure is a declining LOC. Heart rate, blood pressure, and body temperature can be assessed after LOC is evaluated.

A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.) A. Provide skin care with a moisture barrier cream. B. Administer artificial tears PRN. C. Obtain vital signs every 2 hr. D. Perform mouth care every hour. E. Administer oxygen 2 L/min via nasal cannula.

A. Provide skin care with a moisture barrier cream. B. Administer artificial tears PRN. D. Perform mouth care every hour. E. Administer oxygen 2 L/min via nasal cannula. Rationale: Provide skin care with a moisture barrier is correct. The nurse should apply a moisture barrier cream for a client who is incontinent to reduce the risk of skin breakdown and increase comfort. Palliative care relies on comfort measures and use of alternative therapies to help individuals become more at peace during the end of life.Administer artificial tears PRN is correct. Blinking reflexes can produce corneal dryness. Artificial tears or lubricants can reduce corneal irritation and promote comfort.Obtain vital signs every 2 hr is incorrect. Monitoring vital signs every 2 hr will not promote comfort or provide for a more peaceful death.Perform mouth care every hour is correct. Oral care reduces dry mucous membranes caused by a decrease in salivary secretions and mouth breathing. It also increases comfort.Administer oxygen 2 L/min via nasal cannula is correct. Providing low-flow oxygen via nasal cannula increases the comfort level of the client.

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure? A. Semi-fowlers B. Sims C. Trendelenburg D. Prone

A. Semi-fowlers - Position a patient with an increased ICP with his or her head elevated, as in semi-fowlers position. Sim's position is side-lying with one leg flexed, which may elevate ICP. A prone position is flat with the face down, and the Trendelenburg position is supine with the feet higher than the head. The head is not elevated in these positions, which is dangerous for someone with ICP.

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.) A. The shoulders droop. B. The facial muscles relax. C. The respiratory rate increases. D. The pulse is within the expected range. E. The client draws his legs up into a fetal position.

A. The shoulders droop. B. The facial muscles relax. D. The pulse is within the expected range. Rationale: The shoulders droop is correct. A back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. Relaxation or drooping of the shoulders is a positive response to the backrub.The facial muscles relax is correct. A back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. Relaxed facial muscles are a positive response to the backrub.The respiratory rate increases is incorrect. A back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. Relaxation decreases the respiratory rate.The pulse is within the expected range is correct. Pulse rates increase with acute pain. A pulse within the expected range indicates a positive response to the backrub. The client draws his legs up into a fetal position is incorrect. A back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. This position indicates guarding or acute pain and is not a positive response to the backrub.

Over 1.7 million people suffer TBI yearly, of which about 52,000 die. A. True B. False

A. True

A nurse is completing an admission assessment for a patient who has schizophrenia. Which of the following findings should the nurse document as negative symptoms? A. poor personal hygiene B. Delusion of persecution C. Bizarre behavior D. Lack of motivation

A. poor personal hygiene D. Lack of motivation Rationale: Negative symptoms include apathy, anhedonia, poor social functioning,, and poverty of thought. Poor personal hygiene is an example of poor social functioning and lack of motivation and lack of motivation is an example of avolition. Hallucinations, delusions, alterations in speech, and bizarre behavior are positive symptoms.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech

Answer B bradycardia and D nonreactive dilated pupils Bradycardia is 1 of the 3 findings of Cushing's triad, which is a late sign of ICP. Nonreactive dilated pupils or constricted nonreactive pupils can be the result of ICP. Confusion is an early sign of ICP, manifested as restlessness, irritability, & confusion. Severe hypertension, not hypotension is a sign of late ICP (1 of the 3 findings of Cushing's triad) Slowed speech can be an early sign of ICP. Late manifestations include; stupor, progressing to coma, & abnormal motor responses, including decorticate * decerebrate.

The nurse is admitting a patient with a diagnosis of schizophrenia. When asked about his living situation, the patient responds with "Over the hills, basic color sleep ideas class". Which term describes this speech pattern? A. Word salad B. Loose associations C. Poverty of speech D. Tangentiality

Answer: A Rationale: Word salad consists of meaningless phrases and words that are thrown together. Loose associations the individual's ideas seem unrelated to the topic at hand or take another direction altogether. They are unaware the topics are unconnected. Tangentiality is rapid, often tangential speech with an extreme sense of urgency Poverty of speech, is an absence of spontaneous speech.

A patient with a history of alcohol use disorder (AUD) is admitted to the hospital following an automobile accident. What is most important for the nurse to assess to plan care for the patient? A. When the patient last had alcohol intake B. How much alcohol has recently been used C. What type of alcohol has recently been ingested D. The patient's current blood alcohol level

Answer: A Rationale The knowledge of when the patient last had alcohol intake will help the nurse anticipate the onset of withdrawal symptoms. Symptoms can start as soon as 6-8 hours, peak in 24-48 hours. In patients with alcohol tolerance, the amount of alcohol & the blood alcohol level do not reflect impairment as consistently as in the nondrinker. The type of alcohol ingested is not important because in the body it is all alcohol.

A patient diagnosed with Schizophrenia is prescribed clozapine (Clozaril). Which patient symptoms related to the side effects of this medication should prompt the nurse to intervene immediately? A. Sore throat, fever, and fatigue B. Constipation and weight gain C. Dry mouth and urinary retention D. Sedation and hypersalivation

Answer: A Rationale: Sore throat, fever, and malaise are symptoms of infectious processes that require immediate nursing intervention. Agranulocytosis (ANC <500), a potentially fatal drop in WBCs, is a serious side effect of the atypical antipsychotic medication clozapine (Clozapine). Patients taking clozapine should receive routine (weekly to monthly) monitoring and maintain an absolute neutrophil count (ANC) >1500.

A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the nurse provide at the bedside? (Select all that apply) A. Oxygen B. Nasogastric Tube C. Suction Setup D. Padded tongue blade

Answer: A & C (Oxygen & suction) Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. Padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient's mouth because the jaw may clench down as soon as the seizure begins.

Which is a priority nonoperative treatment following a spinal cord injury? A. Stabilization B. Spinalfusion C. Cervical traction D. Pain management

Answer: A (Stabilization) Stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. Pain management is important, but it is a lower priority than stabilization.

You are called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, what do you think you should do first? A. Turn the patient to the side. B. Start oxygen by mask at 6 L/min. C. Restrain the patient's arms and legs to prevent injury. D. Record the time sequence of the patient's movements and responses as they occur.

Answer: A (Turn the patient to the side) During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.

Which assessment finding would the earliest and most sensitive indicator that there is an alteration in intracranial regulation? A. Change in level of consciousness B. Subclinical seizures C. Loss of primitive reflexes D. Unequal pupil size

Answer: A (change in LOC) A change in LOC is the earliest & most sensitive indication of a change in intracranial processing. A change in pupil size or unequal pupils or subclinical seizures may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

The nurse suspects that a patient is experiencing major alcohol withdrawal syndrome based on which clinical manifestations? Select all that apply. A. Hypertension B. Tremors C. Disorientation D. Visual hallucinations E. Increased heart rate

Answer: A, B, & E Rationale Hypertension, tremors, and increased heart rate are clinical manifestations of alcohol withdrawal syndrome. Disorientation and visual hallucinations are associated with alcohol withdrawal delirium (DTs)

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? (Select all that apply). A. Keep suction equipment readily available at the patient's bedside B. Provide sufficient stimulation of the patient to avoid comatose behaviors C. Implement seizure treatment only after confirming the seizure diagnosis D. Pad side rails and maintain an airway at the bedside per facility protocol E. Use prophylactic anti-seizure therapy during first seven days after injury

Answer: A, D, E Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Utilize prophylactic anti-seizure therapy during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate the condition; the environment should be quiet.

While caring for a patient who is experiencing alcohol withdrawal, the nurse should (select all that apply). A. Monitor neurological status on a routine basis B. Provide a quiet, non-stimulating, dimly lit environment C. Pad the side rails & place suction equipment at the bedside D. Orient the patient to environment & person with each encounter E. Give anti-seizure drugs & sedatives to relieve withdrawal symptoms.

Answer: A,C,D,&E Rationale For patients in withdrawal, nursing management includes monitoring neurologic status and vital signs and giving drugs to prevent the progression of symptoms and increase patient comfort. To prevent injury associated with seizure activity, nurses should keep suction equipment, an Ambu bag, and an oral or nasopharyngeal airway at the patient's bedside and use padded side rails. Maintaining a well lit environment that reduces sharp contrasts and shadows is important to reduce external stimuli.

The hospice nurse notices that a patient with terminal bone cancer occasionally experiences involuntary jerking of the lower extremities. Which rational explains this clinical manifestation? A. Opioids B. Anxiety C. Severe pain D. Restlessness

Answer: A. Opioids Rationale: Administration of large amounts of opioids may cause jerking of the extremities. Patients with cancer experience severe pain, and opioids are given to relieve this type of pain. Severe pain, restlessness, and anxiety do not cause jerking of the extremities. Restlessness and anxiety are psychosocial behaviors seen in patients with terminal diseases.

Two health care providers certified a patient's prognosis as terminal, with less than six months to live, secondary to colon cancer. Which rationale did the manager base the decision to report the patient as not eligible to receive hospice care? A. The patient does not agree to enrollment and receiving hospice care. B. The patient is not covered under Medicare or Medicaid for hospice care. C. Hospice nurses did not receive training to provide terminal-stage cancer care. D. The hospice care center does not provide service 24 hours a day, seven days a week.

Answer: A. The patient does not agree to enrollment & receiving hospice care. Rationale: The first criterion for entering a hospice care program is that the patient agree to accept hospice care. The patient should be willing to improve the quality of life during the last days of life. Because 2 health care providers have certified that the patient's prognosis is terminal with less than 6 months to live, the patient can be provided insurance by Medicare or Medicaid for hospice care. Hospice care centers provide care 24 hours a day, 7 days a week. Hospice nurses are an integral part of the hospice care team; they are well educated and trained to provide care in terminal stages of cancer.

Which drug is prescribed to stabilize vital signs and prevent seizures and delirium in a patient withdrawing from alcohol? A. Thiamine B. Lorazepam C. Folic acid D. Magnesium sulfate

Answer: B Rationale Patients withdrawing from alcohol experience tremors, seizures, and delirium. Benzodiazepines (e.g., lorazepam, diazepam) reduce the signs and symptoms of alcohol withdrawal and the incidence of delirium and seizures. Thiamine is given to prevent Wernicke encephalopathy.Folic acid is a supplement for vitamin deficiencies.Magnesium sulfate is given if serum levels of magnesium are low.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury A. Hypertension B. Bradycardia C. Neurogenic spasticity D. Bounding pedal pulses

Answer: B (Bradycardia) Neurogenic shock is caused by the loss of vasomotor tone caused by injury and is characterized by and . Loss of sympathetic innervations causes , venous pooling, and a decreased cardiac output. Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

A patient with a spinal cord injury at C5-C6 becomes flushed and reports a sudden severe headache. Vital signs show a blood pressure of 190/100 mm Hg and heart rate of 50 beats/min. What is the appropriate first nursing intervention? A. Notify the health care provider. B. Place the client in a sitting position. C. Check the client for fecal impaction. D. Check the urinary catheter for obstruction.

Answer: B (Place the client in a sitting position) Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in clients with spinal cord injury T6 and above. Manifestations are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Triggered by noxious stimuli - most often a distended bladder or constipation. The 1st priority of care is to place the client in a sitting position. Then contact the health care provider to treat the increased BP. Rapid treatment is essential to prevent a stroke. All other actions can be taken after placing the client in the sitting position.

A patient with a head injury has an arterial BP of 92/50 mm Hg and ICP of 18 mm Hg. Calculate the cerebral perfusion pressure (CPP). How should the nurse interpret the results? A. The CPP is so low that brain death is imminent. B. The CPP is low and can cause brain ischemia from reduced cerebral blood flow. C. The CPP is high leading to increased cerebral blood flow D. The CPP is adequate for normal cerebral blood flow.

Answer: B (The CPP is low (47), causing ischemia). Rationale: The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain to prevent secondary brain injury. CPP should be kept between 60 & 70mm Hg CPP >50 mm Hg is associated with ischemia and neuronal death. CPP <30 mm Hg results in ischemia and is incompatible with life. It is critical to maintain MAP when ICP is elevated. A patient with a head injury may require a higher blood pressure, increasing MAP and CPP, to increase perfusion to the brain and prevent further tissue damage . MAP = [2 x DBP + SBP / 3]. BP=95/50 MAP = 2 (50) + 95 / 3 MAP = 100 + 95 / 3 MAP = 65 mmHg CPP = MAP - ICP CPP = 65 - 18 CPP = 47 (low)

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: A. breathe with respiratory support. B. drive a vehicle with hand controls. C. ambulate with long-leg braces and crutches. D. use a powered device to handle eating utensils.

Answer: B (drive a vehicle with hand controls) A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: Ability to transfer self to wheelchair Roll over and sit up in bed Push self on most surfaces Perform most self-care Use wheelchair independently Drive a car with powered hand controls (in some patients)

A patient is hospitalized following a motor vehicle accident and exhibits signs of alcohol withdrawal delirium (DTs). Which assessment findings does the nurse identify as signs of the condition? Select all that apply. A. Nausea B. Seizures C. Sweating D. Disorientation E. Visualhallucinations

Answer: B, D, & E Rationale Visual auditory, or tactile hallucinations, as well as seizures and disorientation, are signs of alcohol withdrawal delirium (DTs). Sweating and nausea are some of the signs of alcohol withdrawal. These symptoms may also be present during alcohol withdrawal delirium, but these symptoms alone would not be enough to identify the condition

Which clinical manifestation indicates the patient is nearing death? A. The patient responds to noises B. The patient's skin is mottled and wax like C. The heart rate and blood pressure increase. D. The patient reviews his or her life with his or her family.

Answer: B. The patient's skin is mottled and wax like Rationale: When a patient is very near death, the skin will be wax like, cold, clammy, and mottled or cyanotic. Although hearing is the last sense patients lose before death, it is unlikely that the patient will respond to noises when very near death. Initially the heart rate increases but later slows, and the blood pressure decreases. Near death, speaking may be slow and unusual and indicate confusion.

Which of the following statements by a patient with schizophrenia indicates to the nurse that the patient is having a delusion? A. "I hear the President telling me to leave the hospital." B. "I smell palm trees and the ocean in my room." C. "I am the President of the United States." D. "I see lions hiding in the corners of my room."

Answer: C Rationale: Delusions are fixed beliefs that are not based in reality, such as believing that one is President. The other statements represent auditory, visual, and olfactory hallucinations. Hallucinations are sensory perceptions that occur without an external stimulus.

A client diagnosed with Schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."

Answer: C Rationale: The statement, "I'm sure the voices sound scary. I don't hear any voices speaking," is the most appropriate. The nurse is communicating empathy, acceptance, and is reassuring the patient while not reinforcing the hallucination.

The nurse is caring for a patient with a head injury. Which finding requires immediate nursing interventions? A. Increased pupil size B. Nausea and vomiting C. Agitation and confusion D. Elevated blood pressure

Answer: C The 1st sign or ↑ ICP is a declining or changing level of consciousness (LOC). The nurse must assess the patient immediately when this symptom is present. Patients may be agitated & slightly confused before progressing too difficult to arouse as an early assessment finding of increase ICP. Changes in vital signs, N&V, & pupillary response occur as ICP increases.

Which statement by the nurse would be most helpful when assisting the family member of a dying patient? A. "Just hold onto your loved one's hand; they are unable to hear you." B. "Your loved one can see your lips moving because vision diminishes last." C. "Hearing disappears last, so talking to your loved one can be comforting." D. "Even if your loved one cannot hear your voice, they can feel the vibration."

Answer: C "Hearing disappears last, so talking to your loved one can be comforting." Rationale: The most accurate and helpful nursing response to the family member of a dying patient is to explain that hearing is often the last sense to disappear and that talking to the patient can be comforting. Dying patients experience progressive visual blurring and eventual absence of the blink reflex. A reduced touch sensation occurs as death progresses. Saying that the dying patient can no longer hear is incorrect.

JL is agitated and has multiple cerebral contusions reported on the CT of the head. The intracranial pressure monitor reveals a pressure of 28 mmHg. What drug will the nurse anticipate being prescribed for JL? A. Morphine B. Lorazepam C. Mannitol D. Phenytoin

Answer: C (Mannitol) Increased ICP is often the result of cerebral edema, as a result of traumatic brain injury. Therefore, an osmotic agent (Mannitol)is administered. It draws fluid from the brain into the blood to decrease cerebral edema. Monitor for adverse effects: hypotension, fluid & electrolyte imbalance (i.e., hyponatremia, hypokalemia), pulmonary edema, rebound ↑ ICP The other drugs are not appropriate to manage increasing ICP.

An elderly patient receiving hospice care is not responding to a nurse's questions and seems to be withdrawn. Which action would the nurse implement? A. Avoid talking to the patient B. Refer the patient to another nurse C. Continue talking as though the patient were alert D. Report it to the health care provider immediately

Answer: C Continue talking as though the patient were alert Rationale: A terminally ill patient may be withdrawn from the physical environment. The patient can hear but is unable to respond. In such a case, the nurse must continue talking to the patient in a soft voice, as if the patient were alert. The nurse need not report this to the health care provider immediately but can do so later. It is inappropriate to stop talking to the patient or to refer the patient to another nurse.

The psychiatric nurse is completing the Abnormal Involuntary Movement Scale (AIMS) for patients on antipsychotic medications. Which patient's scores require immediate intervention? A. The patient who scored a 2 on the scale B. The patient who scored a 6 on the scale C. The patient who scored a 0 on the scale D. The patient who scored a 24 on the scale

Answer: D Rationale: This patient with a score of 24 is exhibiting severe abnormal behavior and the antipsychotic medication should be held & provider notified. (taper med) The AIMS test was devised to detect extrapyramidal symptoms. If continued, the patient will have permanent tardive dyskinesia from the medication • Ascoreof≥2intwoormorebody areas (items 1-7) suggest probable TD. • A score of ≥ 3 in at least one body area (items 1-7) suggest probable TD. FYI

Which nursing intervention is most appropriate when caring for an acutely agitated client with paranoia? A. Provide bright lights and soft music B. Maintain continual eye contact throughout the interview C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries

Answer: D Rationale: The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. Lights and music add to environmental stimuli and can increase the client's agitation.

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? A. Sims B. Prone C. Trendelenburg D. Semi-Fowlers

Answer: D (semi fowlers) Position a patient with an increased ICP with his or her head elevated, as in semi-Fowler's position (at least 30 degrees). Sims' position (side-lying with one leg flexed), prone position (flat with the face down), Trendelenburg position (supine with the feet higher than the head) are all dangerous for someone with ICP because the head is not elevated in these positions and can increase ICP.

The nurse is caring for a 78-year-old patient who is an alcoholic. The nurse anticipates that the physician will order thiamine (vitamin B1) to prevent what disorder? A. Acute pancreatitis B. Cirrhosis of the liver C. Hepatic encephalopathy D. Wernicke encephalopathy

Answer: D Wernicke encephalopathy Rationale People with chronic alcoholism have significant malnutrition issues. Thiamine depletion (B1) can cause neurological problems and cognitive impairment. Thiamine replacement can help prevent this from occurring. The other choices are not caused by thiamine deficiency.

When caring for a patient with AUD, the nurse understands that the expected effects of a disulfiram reaction include which of the following? A. Chest pain, chills, and hypertension B. Slow pulse, chills, and excitation C. Slow pulse, slow respiratory rate, and hypertension D. Chest pain, headache, and hypotension

Answer: D. Rationale: Ingestion of alcohol, even in small amounts (i.e., avoid extracts, liquid meds, mouthwash) causes a significant physical reaction that includes shortness of breath, chest pain, nausea, vomiting, facial flushing, headache, red eyes, blurred vision, sweating, tachycardia, hypotension, & fainting.

Upon referral to palliative care services, the patient asks, "Will I have to stay here in the hospital to get that care or can I go home?" Which response will the nurse use? A. "A rehabilitation facility or an acute care hospital is able to provide palliative care." B. "Nursing homes are able to provide palliative care but cannot be provided at your personal residence." C. "Palliative care is not available in your home. You have to go to an outpatient clinic each week." D. "Palliative care is available in various settings including home, long-term care, hospitals, mental health facilities, and prisons."

Answer: D. Palliative care is available in various settings including home, long-term care, hospitals, mental health facilities, and prisons." Rationale: Palliative care is available in multiple settings, including personal residences, long-term care facilities, hospitals, mental health facilities, rehabilitation centers, and prisons. Palliative care services are not limited to rehabilitation facilities, outpatient clinics, or acute care hospitals. Palliative care is available in nursing homes, personal residences, and outpatient clinics.

Man with SCI will never become a father? A. True B. False

Answer: False Pregnancy rates in partners of men with SCI are lower than in the general population, but there is a good chance (>50%) that men with SCI can become biological fathers with advances in reproductive assisted technology. T10 & above injury: sperm retrieval

A pregnant woman heard from her friends that drinking alcohol in moderation is permissible during pregnancy. Is this statement true or false? A. True B. False

Answer: False Rationale During pregnancy alcohol should be completely avoided in order to prevent fetal alcohol syndrome (FAS) in the baby. • It is not known what quantity of alcohol is needed to cause FAS or at what stage of pregnancy alcohol exposure causes FAS, but the dose and duration of alcohol exposure appear to be directly related to risk of FAS. FAS is a mix of physical, behavior, and learning problems. Other risks to the fetus include cerebral palsy, premature birth, miscarriage, and stillbirth.

People with schizophrenia are dangerous. A. True B. False

Answer: Myth (false) Rationale: Although the delusional thoughts and hallucinations of schizophrenia sometimes lead to violent behavior, most people with schizophrenia are neither violent nor a danger to others. If violent, the violence is most often directed towards themselves: suicide.

Schizophrenia can't be treated. A. True B. False

Answer: Myth (false) Rationale: Although it's true that schizophrenia cannot be cured, it can be successfully treated. Medication, rehabilitation practices and psychosocial therapies can help individuals with schizophrenia lead independent and productive lives.

People with schizophrenia have multiple personalities. A. True B. False

Answer: Myth (false) Rationale: Schizophrenia often involves a variety of symptoms, but not one involves multiple personalities. People with schizophrenia do not have split personalities. Rather, they are "split off" from reality. Multiple personality disorder is a different and much less common disorder than schizophrenia.

An increase in the volume of 1 component of the intracranial content will result in a decrease of volume in 1 or 2 of the other components. A.True B. False

Answer: True The Monro-Kellie doctrine states Intracranial contents are contained in a fixed vault (the skull); therefore, their total volume must remain constant. If 1 of the components increases a reciprocal decrease in 1 or both of the other components must occur or an overall increase in ICP will result. Ability to compensate is limited. If the volume continues to increase, the compensatory mechanisms deteriorate, resulting in neurologic decline, increase ICP, and ischemia

Acute sustained elevations in ICP above 20 mmHg will result in reduced cerebral perfusion pressure (CPP) and cause cerebral ischemia. A.True B. False

Answer: True When ICP rises, cerebral perfusion pressure (CPP) falls. When CPP falls, blood flow to the brain is compromised, brain cells become ischemic and begin to die.

Co-occurring substance use and mental illness are common A. True B. False

Answer: True Rationale: Co-occurring substance use, and mental illness are common. Mental illness & substance use is often conceptualized as having a bidirectional relationship—in that substance use often leads to and exacerbates mental illness & mental illness can be a precursor for substance misuse.

Alcohol use disorder (AUD) is the most commonly diagnosed substance use disorder (SUD) in the US A. True B. False

Answer: True Rationale: AUD is the most commonly diagnosed substance use disorder in the US, affecting more than 14 million people. Its prevalence is highest among young adults aged 18 to 25 years, and Alaska Native individuals, - individuals, and Despite this, less than 10% of those with AUD report receiving treatment in the past year and fewer than 20% have ever received treatment.

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? A. "I am thinking of getting a second opinion." B. "I am hoping this will limit my discomfort." C. "This treatment should help me live a little longer." D. "This is not working and I plan to stop treatment."

B. "I am hoping this will limit my discomfort." Rationale: Clients receiving palliative care are aware that the outcome is to prevent suffering and provide the best possible quality of life.

A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? (Select all that apply.) A. "Music therapy will increase her basal metabolic rate." B. "Music therapy can help her verbally express emotions." C. "Music therapy will improve her appetite and decrease the nausea." D. "Music therapy works as a distraction and can help alleviate her pain." E. "Music therapy can help facilitate movement in some clients who have mobility limitations."

B. "Music therapy can help her verbally express emotions." D. "Music therapy works as a distraction and can help alleviate her pain." E. "Music therapy can help facilitate movement in some clients who have mobility limitations." Rationale: "Music therapy will increase her basal metabolic rate" is incorrect. The basal metabolic rate is the energy a person needs for life-sustaining activities such as breathing and maintaining circulation at rest. Music therapy relaxes and calms, which would decrease energy expenditure rather than increasing it."Music therapy can help her verbally express emotions" is correct. Music therapy helps improve communication and develop emotional expression."Music therapy will improve her appetite and decrease the nausea" is incorrect. Music relaxes and calms but does not necessarily increase appetite or reduce nausea. Measures to increase a client's appetite include offering the client small portions of her favorite foods, providing oral hygiene, and keeping the client comfortable."Music therapy works as a distraction and can help alleviate her pain" is correct. Music therapy helps distract people from pain. Music often calms and relaxes clients, diverting their attention away from the pain."Music therapy can help facilitate movement in some clients who have mobility limitations" is correct. Music therapy improves physical movement, especially for clients who are ill or have disabilities.

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." B. "What do you think your spouse would have wanted?" C. "Most religions support organ donation, so don't let that stand in the way." D. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

B. "What do you think your spouse would have wanted?" Rationale: Federal law requires facilities to have policies and procedures in place about making a request for organ and tissue donation at the time of death. The request is made by an employee, often a social worker, who has advanced training and can request the donations in a caring, sensitive manner. The role of the nurse is to provide emotional support to the family. Family members should consider the deceased person's wishes when making their decision.

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight B. A client who has terminal cancer and needs assistance with pain management C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work D. A client who has dementia and needs help with activities of daily living

B. A client who has terminal cancer and needs assistance with pain management Rationale: A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Justice

B. Autonomy Rationale: The issue here is the client's right to choose. The ethical principle of autonomy applies to an individual's right to choose and control what happens to him. Respecting autonomy requires the nurse to recognize the client's choice is based on personal values and those values do not have to be shared by the nurse.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? A. Bargaining B. Denial C. Depression D. Anger

B. Denial Rationale: During the denial stage of Kübler-Ross's stages of grieving, the client acts as though nothing has happened and might refuse to believe or understand that a loss has occurred.

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? (Select all that apply) A. Provide stimulation to the patient to avoid comatose behaviors. B. Keep suction equipment readily available at the patient's bedside. C. Restrain the patient to the bed to protect from injury. D. Pad side rails and maintain an airway at the bedside per facility protocol.

B. Keep suction equipment readily available at the patient's bedside. D. Pad side rails and maintain an airway at the bedside per facility protocol. - Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Providing stimulation to the patient may aggravate the condition; therefore, the environment should be quiet. Do not restrain the patient, chances of injury are higher.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism B. Nonmaleficence C. Fidelity D. Veracity

B. Nonmaleficence Rationale: Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? A. Refer the patient to an alcohol-abuse counselor B. Promote a safe, calm, and comfortable environment C. Describe how the alcohol is causing the withdrawal effects. D. Leave the patient by him/herself so as not to cause agitation

B. Promote a safe, calm, and comfortable environment Rationale: The main priority is the patient's safety due to risk of harm from seizures, DT's and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? A. "I know that I will get a kidney transplant. I am a good candidate." B. "I can now eat whatever I want. The dialysis will remove it from my system." C. "I just can't believe that this dialysis is going to ruin my whole life." D. "I know that kidney disease runs in my family, but I can prevent it."

C. "I just can't believe that this dialysis is going to ruin my whole life." Rationale: This statement is an example of anticipatory grief, which often manifests through anger and denial of the fear of an upcoming loss.

A client with a history of heavy alcohol use is brought to an emergency department by family member who state that the client has had nothing to drink in the last 24 hours. Which client symptoms should the nurse immediately report to the ED physician? A. mood rating of 2/10 B. Dehydration C. BP 180/100 mmHg D. Antecubital bruising

C. BP 180/100 mmHg Rationale: High bp should immediately be reported to the physician. High bp and other complications associated with alcohol withdrawal may progress to delirium tremens and seizures within 48-72 hours following cessation of prolonged alcohol consumption.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A. Kussmaul respirations B. Apneustic respirations C. Cheyne-Stokes respirations D. Stridor

C. Cheyne-Stokes respirations Rationale: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

Which is a priority nonoperative treatment following a spinal cord injury? A. Spinal fusion B. Cervical traction C. Stabilization D. Pain management

C. Stabilization -Stabilization eliminates any damaging motion at the injury site to avoid worsening the patients condition. Pain management is important but it is a lower priority than stabilization. Spinal fusion is a surgical procedure. Cervical traction is a closed reduction with skeletal traction and is used for early realignment of the injury, the patient should be stabilized before a care plan is implemented.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? A. The partner has placed locks at the top of the doors leading to the outside. B. The partner has hired a house cleaner. C. The partner has lost 20 lb in the past 2 months. D. The partner redirects the client when the client is frustrated.

C. The partner has lost 20 lb in the past 2 months. Rationale: A large weight loss by the caregiver is an indication of caregiver role strain.

The nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, the nurse instructs the patient to avoid which occurrence? A. Exposure to secondhand smoke .B. Being in contact with people with upper respiratory infections. C. Urine retention D. Emotional stress

C. Urine retention - Autonomic reflexia is a medical emergency that occurs when sensory stimulation below the spinal injury triggers a reaction in the intact autonomic system, with resulting reflex arteriolar spams that increase BP to an extremely high level. A distended ladder is a common trigger of this condition. Profuse sweating below the level of injury and bradycardia are also seen. Although emotion stress, being exposed to secondhand smoke, and exposure to upper respiratory infections should e avoided by the patient with a spinal cord injury.

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? A. Discussing advance directives with the client and the client's family B. Providing comfort care measures to the client C. Withholding a dose of narcotic pain medication when the client has respiratory depression D. Allowing the client's family unlimited visitation at the time of death

C. Withholding a dose of narcotic pain medication when the client has respiratory depression Rationale: The principle of nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence.

A patient is 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: A. "I will get a PRN medication for agitation" B. "You are confused, I will take you to your room to rest a while" C. "You are having problems with your speech. You need to try harder to be clear." D. "I am sorry, I didn't understand that. Do you want to talk more about your mother?"

D. "I am sorry, I didn't understand that. Do you want to talk more about your mother?"

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? A. Tactile hallucination B. Visual hallucination C. Gustatory hallucination D. Command hallucination

D. Command hallucination Rationale: Command hallucinations are priority due to the increased risk for harm to self or others. Visual (seeing persons or things), gustatory (experiencing tastes), and tactile (feeling sensations) hallucinatins are importnat finsings; however they do not pose the greatest risk and therefore are not the priotiy oncern.

A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following? A. Slander B. Invasion of privacy C. Defamation of character D. False imprisonment

D. False imprisonment Rationale: Unlawfully restraining a client is false imprisonment. Clients have the right to refuse treatment.

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence

D. Nonmaleficence Rationale: Nonmaleficence, as a principle in research, is the obligation to do no harm to the client. Intentionally exposing clients to serious or permanent harm is unacceptable. Should such a situation emerge during the conduct of a study, the study should be terminated immediately.

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first? A. Assist the client with transferring to the gynecology unit. B. Administer alprazolam 0.5 mg PO. C. Contact the health care facility's clergy. D. Offer mother private time with the newborn.

D. Offer mother private time with the newborn. Rationale: It is critical for the nurse to help the client acknowledge the loss and begin the grieving process. Providing private time with the newborn provides an opportunity for the client to overcome feelings of powerlessness and actualize the loss in a safe and supportive environment.

A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals? A. The client will verbalize an understanding of the mode of disease transmission. B. The client will experience a weight gain of one to two pounds per week. C. The client will increase attendance at community social activities. D. The client will receive medication to minimize episodes of breakthrough pain.

D. The client will receive medication to minimize episodes of breakthrough pain. Rationale: The client should receive medication to minimize episodes of breakthrough pain as a goal for the end of life care.

A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context? A. The sense of self among individual family members B. The future goals of the family C. The roles of family members D. The family's religious practices

D. The family's religious practices Rationale: This is appropriate when assessing the sociocultural context of the family.

L5 injury will affect the patient's ability to move the fingers. True or false

False. The injury results in some loss of function in the hips & legs, therefore

Complete SCI has a better prognosis than an incomplete SCI. True or false

False: A complete SCI fully severs the spinal cord at the injury site, losing all feeling & function for anything connected to nerves below the injury site. Whereas incomplete SCI, only partially severs the spinal cord, allowing some signals to pass through the level of injury

C4 injury will affect the patient's ability to breathe. True or false

True. C4 injury could leave the muscles that control breathing completely paralyzed. They may also require a ventilator to provide breathing assistance because this section of the spinal cord plays a role in the control and function of the diaphragm.

C7 injury will require assisted coughing techniques due to weak intercostal muscle function. True or false

True. C7 injury.

All spinal injuries will affect the patient's bowel and bladder function True or false

True. Nearly always affects control over the bladder and bowel (i.e., incontinence, urinary retention, overactive bladder, constipation)

What is the priority to monitor for Clozapine?

complete blood count and absolute neutrophil count - WC < 5,000 is abnormal ***CloZAPine = zaps wbc

Haloperidol 5 mg 2X/day. Nurse observes what symptoms?

dizziness and lightheadedness muscle spasm and stiffness

What should someone e concerned of when taking antipsychotic meds?

fever and muscle stiffness

A client is prescribed multiple antipsychotic meds, has rigid extremities, hypertension, hyper reflexia, and diaphoresis? What is this indicating?

neuroleptic malignant syndrome