Module 3 Textbook Questions Chapters 28, 29, 34, 40, 41, 42, 43, 45, 46

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A) Circadian rhythm sleep-wake disorder B) Narcolepsy C) Enuresis D) Sleep apnea

B

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing? A) Spiritual Alienation B) Spiritual Despair C) Spiritual Anxiety D) Spiritual Pain

A

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

50 gtts/min

A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED, but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? A) Getting the patient into a safe environment and mobilizing support for her B) Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped C) Convincing the student to be assessed for pregnancy, STIs, or other complications D) Convincing the student to tell her parents so that she can receive their support

A

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? A) The patient B) The patient's daughter C) The patient's health care provider D) The ethics consult team

A

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? A) "Are you worried about failing your exams?" B) "Have you been staying up late studying?" C) "Are you using any recreational drugs?" D) "Do you have trouble managing your time?"

A

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? A) Acceptance B) Anger C) Bargaining D) Denial

A

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide? A) The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. B) The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. C) After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." D) The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

A

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? A) Increase physical activities during the day. B) Encourage short periods of napping during the day. C) Increase fluids during the evening. D) Dispense diuretics during the afternoon hours.

A

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A) Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. B) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. C) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. D) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

A

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identity by performing which action? A) Asking the patient his name and birthdate B) Reading the patient's name on the sign over the bed C) Asking the patient's roommate to verify his name D) Asking, "Are you Mr. Brown?"

A

A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation? A) Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration. B) Notify the primary care provider that medication cannot be given to the patient at this time via the gastric tube. C) Remove the tube in place and replace it with another tube prior to administering the medication. D) Flush the tube with 60 mL of water prior to administering the medication.

A

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? A) The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain. B) The nurse prepares the patient's health care provider-approved herbal tea and uses meditation to relax the patient prior to bed. C) The nurse administers naproxen and performs prescribed range-of-motion exercises. D) The nurse arranges for acupuncture for the patient and designs a menu high in omega-3 fatty acids.

A

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? A) Monitoring food and drink temperatures to prevent burns B) Providing adequate pain relief measures to reduce stress C) Monitoring for depression related to social isolation D) Providing meals high in carbohydrates to promote healing

A

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? A) Realistic and positively motivating his development B) Unrealistic and negatively motivating his development C) Unrealistic but positively motivating his development D) Realistic but negatively motivating his development

A

A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? A) "We're at the age when we should consider ceasing sexual activity." B) "We need more time for sexual stimulation than we used to." C) "If we are unable to have sex we can still have an intimate relationship." D) "If we change our position we can still have sex and be more comfortable."

A

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? A) Remove the IV from the site and start at another location. B) Immediately notify the primary care provider. C) Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. D) Aspirate the catheter and attempt to flush again.

A

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D) Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

A

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? A) The nurse leaves the patient in a sitting position while the family visits. B) The nurse places identification tags on both the shroud and the ankle. C) The nurse removes soiled dressings and tubes. D) The nurse makes sure a death certificate is issued and signed.

A

A nurse manager who works in a hospital setting is researching the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CHA? A) A patient who is anxious about residual pain from cervical spinal surgery B) A patient who is experiencing abdominal discomfort C) A patient who has chronic pain from diabetes D) A patient who has frequent cluster headaches

A

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A) No action is necessary as this is a normal finding during sleep. B) Call the primary care provider to report possible neurologic deficit. C) Lower the temperature in the patient's room. D) Awaken the patient as this is an indication of night terrors.

A

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A) A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) B) A young clergyperson whose vocal cords are paralyzed after a motorbike accident C) A 32-year-old accountant who survives a massive heart attack D) A 23-year-old model who just learned that she has breast cancer

A

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? A) "I need to identify the problem first." B) "Listing alternatives is the initial step." C) "I will list alternatives after I develop the plan." D) "I do not need to evaluate the outcome of my plan."

A

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife's health care provider about which type of order? A) Comfort Measures Only B) Do Not Hospitalize C) Do Not Resuscitate D) Slow Code Only

A

A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? A) Diaphragm B) Oral contraceptive pills C) Depo-Provera D) Evra patch

A

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

A

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? A) "HPV causes genital warts and cervical and other genital cancers." B) "HPV causes a single painless genital lesion and can lead to sterility." C) "50% of women between the ages of 14 and 19 are infected with HPV." D) "The HPV vaccination is only recommended for the female population."

A

After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? A) Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands." B) Patient has slept from 10 PM to 6 AM for three consecutive nights without medication. C) Patient has developed mutually caring relationships with two women and one man. D) Patient has identified several spiritual beliefs that give purpose to her life.

A

To promote sleep in a patient, a nurse suggests what intervention? A) Follow the usual bedtime routine if possible. B) Drink two or three glasses of water at bedtime. C) Have a large snack at bedtime. D) Take a sedative-hypnotic every night at bedtime.

A

A nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. A) Applying heat or ice to an extremity B) Explaining the use of electrical stimulation C) Teaching a patient relaxation techniques D) Teaching a patient about a prescription E) Explaining an invasive procedure to a patient F) Teaching about dietary supplements

A, B, C, F

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. A) Changes in appetite B) Changes in elimination patterns C) Decreased pulse and respirations D) Use of ineffective coping mechanisms E) Withdrawal F) Attention-seeking behaviors

A, B

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A) A patient who has uncontrolled hypothyroidism. B) A patient with coronary artery disease. C) A patient who has GERD. D) A patient who is HIV positive. E) A patient who is taking corticosteroids for arthritis. F) A patient with a urinary tract infection.

A, B, C

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. A) Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. B) Explain to the family what will happen at each phase of the weaning and offer support. C) Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. D) Tell the family that death will occur almost immediately after the patient is removed from the ventilator. E) Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. F) Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

A, B, C

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. A) Actual B) Perceived C) Psychological D) Anticipatory E) Physical F) Maturational

A, B, C

Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. A) A patient who is breast-feeding B) A patient who is diagnosed with anorexia C) A patient who chooses to abstain from sexual intercourse D) A patient who has pelvic inflammatory disease E) A patient who is obsessed with exercising F) A patient who has a spinal cord injury

A, B, D, E

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply. A) The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days. B) A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. C) A nurse administering medications to a Muslim patient avoids touching the patient's lips D) A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday. E) The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient. F) The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

A, B, D, F

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. A) Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. B) Some people experience the same response with a placebo as with the active drug used in studies. C) People with liver disease metabolize drugs more quickly than people with normal liver functioning. D) A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. E) Oral medications should not be given with food as the food may delay the absorption of the medications. F) Circadian rhythms and cycles may influence drug action.

A, B, D, F

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. A) Daily mental activities B) Daily physical activities C) Morning and evening body temperature D) Daily measurement of fluid intake and output E) Presence of anxiety or worries affecting sleep F) Morning and evening blood pressure readings

A, B, E

A nurse mentor is teaching a new nurse about the underlying beliefs of CHAs versus allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. A) "CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." B) "CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." C) "Allopathy proponents believe that the main cause of illness is an imbalance or disharmony in the body systems." D) "Curing according to CHA proponents seeks to destroy the invading organism or repair the affected part." E) "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." F) "According to CHA proponents, health is the absence of disease."

A, B, E

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. A) Progressive muscle relaxation B) Meditation C) Anticipatory socialization D) Biofeedback E) Rhythmic breathing F) Guided imagery

A, B, E, F

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A) Arrange for assessment for depression and treatment. B) Discourage napping during the day. C) Decrease fluids during the evening. D) Administer diuretics in the morning. E) Encourage patient to engage in some type of physical activity. F) Assess medication for side effects of sleep pattern disturbances.

A, B, E, F

A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. A) "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." B) "I should wean my infant by 4 months and encourage him to use a sippy cup." C) "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." D) "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." E) "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." F) "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

A, B, E, F

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. A) The family arranges for a funeral for their loved one. B) The family arranges for a memorial scholarship for their loved one. C) The coroner pronounces the patient's death. D) The family arranges for hospice for their loved one. E) The patient is diagnosed with terminal cancer. F) The patient's daughter writes a poem expressing her sorrow.

A, B, F

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. A) The nurse makes a point to address the patient by name upon entering the room. B) The nurse avoids fatiguing the patient by performing all procedures in silence. C) The nurse performs care in a manner that respects the patient's privacy and sensibilities. D) The nurse offers the patient a simple explanation before moving her in any way. E) The nurse ignores negative feelings from the patient since they are part of the grieving process. F) The nurse avoids conversing with the patient about her life, family, and occupation.

A, C, D

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. A) Increased heart rate B) Decreased muscle strength C) Increased mental alertness D) Increased blood glucose levels E) Decreased cardiac output F) Decreased peristalsis

A, C, D

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. A) "Try to drink at least six to eight glasses of water each day." B) "Try to limit your fluid intake to 1 quart of water daily." C) "Limit sugar, salt, and alcohol in your diet." D) "Report side effects of medications you are taking, especially diarrhea." E) "Temporarily increase foods containing caffeine for their diuretic effect." F) "Weigh yourself daily and report any changes in your weight."

A, C, D, F

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply. A) Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer. B) Take shallow breaths when breathing through the spacer. C) Depress the canister releasing one puff into the spacer and inhale slowly and deeply. D) After inhaling, exhale quickly through pursed lips. E) Wait 1 to 5 minutes as prescribed before administering the next puff. F) Gargle and rinse with salt water after using the MDI.

A, C, E

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. A) Teach the parents to reinforce their child's positive qualities. B) Teach the parents to overlook occasional negative behavior. C) Teach parents to ignore neutral behavior that is a matter of personal preference. D) Teach parents to listen and "fix things" for their children. E) Teach parents to describe the child's behavior and judge it. F) Teach parents to let their children practice skills and make it safe to fail.

A, C, F

A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. A) A 72-year-old man with a history of diabetes B) A 78-year-old man who has a new partner C) A 75-year-old man who has Parkinson's disease D) An 80-year-old man who is an alcoholic E) An 85-year-old man who takes antihypertensive medication F) A 76-year-old man who smokes tobacco

A, D, E

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. A) Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. B) Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. C) Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. D) During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. E) The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. F) Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

A, D, F

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? A) "I must breathe in and out in rhythm." B) "I should take my pulse and expect it to be faster." C) "I can expect my muscles to feel less tense." D) "I will be more relaxed and less aware."

B

A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care? A) To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient. B) The nurse sits on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient. C) The nurse refers to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father. D) The nurse tells a dying patient to sit back and relax and performs patient hygiene for the patient because it is easier than having the patient help.

B

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? A) Projection B) Denial C) Displacement D) Repression

B

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?A) Encourage foods and fluids with high sodium content. B) Administer oral K supplements as ordered. C) Caution the patient about eating foods high in potassium content. D) Discuss calcium-losing aspects of nicotine and alcohol use.

B

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? A) "Oh, don't worry about that now. You need to sleep." B) "What seems to be concerning you the most?" C) "I have talked to your wife and she told me she will be fine." D) "I'm not qualified to advise you, I suggest you discuss this with your wife."

B

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? A) The patient will make above-B grades in all tests at school. B) The patient will demonstrate, by diet control and skin care, increased interest in control of acne. C) The patient reports that she feels more self-confident in her music and art, which she enjoys. D) The patient expresses that she is very smart in school.

B

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

B

A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? A) A single dose during the postoperative period B) Doses administered as needed for pain relief C) One dose administered immediately D) Doses routinely administered as a standing order

B

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? A) Lack of self-esteem B) Deficient self-knowledge C) Unrealistic self-expectation D) Inability to evaluate himself

B

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: A) Kidneys B) Lungs C) Adrenal glands D) Blood vessels

B

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A) Keep the room light dimmed during the day. B) Keep the room cool. C) Keep the door of the room open. D) Offer a sleep aid medication to patients on a regular basis.

B

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the nurse would be most appropriate? A) "You can't be feeling this way. You know you are going to die." B) "It does seem unfair. Tell me more about how you are feeling." C) "You'll be all right; who knows how much time any of us has." D) "Tell me about your pain. Did it keep you awake last night?"

B

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A) "I can expect my newborn to sleep an average of 16 to 24 hours a day." B) "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C) "I will place my infant on his back to sleep." D) "I will not place pillows or blankets in the crib to prevent suffocation."

B

A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients? A) Calling the patient's own spiritual adviser first B) Asking whether the patient has a spiritual adviser the patient wishes to consult C) Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser D) Advising the patient and spiritual adviser concerning health options and the best choices for the patient

B

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? A) A patient who has insomnia B) A patient who has nausea C) A patient who has dementia D) A patient who has migraine headaches

B

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A) Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. B) Keeping fluids readily available for the patient. C) Emphasizing the long-term outcome of increasing fluids when the patient returns home. D) Planning to offer most daily fluids in the evening.

B

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? A) Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. B) Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. C) Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. D) Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

B

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare? A) POLST form B) Durable power of attorney for health care C) Living will D) Allow Natural Death (AND) form

B

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? A) "Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worrying about doing yoga." B) "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into." C) "Ashtanga yoga is a gentle paced yoga that would help with your breathing and blood pressure." D) "Yoga is contraindicated for patients who have had a heart attack."

B

Ms. Hall has an order for hydromorphone, 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to hydromorphone. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? A) Administer the medication; the doctor is responsible for medication administration. B) Call Dr. Long and ask that the medication be changed. C) Ask the supervisor to administer the medication. D) Ask the pharmacist to provide a medication to take the place of hydromorphone.

B

The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? A) "Children should be taught not to masturbate because most people believe self-stimulation is wrong." B) "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." C) "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." D) "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

B

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? A) 1 B) 2 C) 3 D) 4

B

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A) A patient who is taking iron supplements for anemia. B) A patient with Parkinson's disease who is taking dopamine. C) An older adult taking diuretics for congestive heart failure. D) A patient who is taking antibiotics for an ear infection. E) A patient who is prescribed antidepressants. F) A patient who is taking low-dose aspirin prophylactically.

B, C, E

A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply. A) LGBT youth are four times more likely to attempt suicide. B) LGBT youth are more likely to be homeless. C) Lesbians are less likely to get preventive services for cancer. D) Lesbians and bisexual females are more likely to be underweight. E) Transgender people have a high prevalence of HIV and sexually transmitted infections. F) LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

B, C, E

A nurse works for a health care provider who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. A) Treating the symptoms of the disease B) Providing patient education C) Focusing on treating individual body systems D) Making appropriate interventions to prevent illness E) Believing in the healing power of nature F) Encouraging patients to take responsibility for their own health

B, D, E, F

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

C

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? A) Give the patient a hug and tell him that his life still has meaning. B) Arrange for a spiritual adviser to visit the patient. C) Ask if the patient would like to talk about his feelings. D) Call in a close friend or relative to talk to the patient.

C

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan? A) Ask the patient which spiritual adviser he would like you to call. B) Recommend that the patient read spiritual biographies or religious books. C) Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past. D) Introduce the belief that God is a loving and personal God.

C

A medication order reads: "K-Dur, 20 mEq po BID." When and how does the nurse correctly give this drug? A) Daily at bedtime by subcutaneous route B) Every other day by mouth C) Twice a day by the oral route D) Once a week by transdermal patch

C

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? A) Recommend that she discipline her daughter more strictly and consistently. B) Make a list of things her husband can do to give her more time and help her improve her parenting skills. C) Assist the mother to identify both what she believes is preventing her success and what she can do to improve. D) Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

C

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? A) Readminister the medication and notify the primary care provider. B) Readminister the pill in a liquid form if possible. C) Assess the vomit, looking for the pill. D) Notify the primary care provider.

C

A nurse is providing a lecture on CHAs to a group of patients in a rehabilitation facility. Which teaching point should the nurse include? A) CHAs are safe interventions used to supplement traditional care. B) Many patients use CHA as outpatients but do not wish to continue as inpatients. C) Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients. D) Most complementary and alternative therapies are relatively new and their efficacy has not been established.

C

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? A) The nurse teaches a patient rhythmic breathing to perform prior to the procedure. B) The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. C) The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. D) The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

C

A nurse discovers that a medication error occurred. What should be the nurse's first response? A) Record the error on the medication sheet. B) Notify the physician regarding course of action. C) Check the patient's condition to note any possible effect of the error. D) Complete an incident report, explaining how the mistake was made.

C

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? A) Somatic grief B) Anticipatory grief C) Unresolved grief D) Inhibited grief

C

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? A) Aspirate before giving and gently massage after the injection. B) Do not aspirate; massage the site for 1 minute. C) Do not aspirate before or massage after the injection. D) Massage the site of the injection; aspiration is not necessary but will do no harm.

C

A nurse is assessing a patient who is visiting her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? A) Human papillomavirus (HPV) B) Syphilis C) Trichomoniasis D) Herpes simplex virus

C

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? A) An infant who learns to turn over B) A school-aged child who learns how to add and subtract C) An adolescent who is a "loner" D) A young adult who has a variety of friends

C

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? A) Decreasing pulse B) Increasing sleepiness C) Increasing energy levels D) Decreasing respirations

C

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A) The use of a central nervous system stimulant B) Continuous positive airway pressure machine (CPAP) C) Chronotherapy D) The application of heat or cold therapy to promote sleep

C

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A) Drinking a cup of regular tea at night induces sleep. B) Using alcohol moderately promotes a deep sleep. C) Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D) Exercising right before bedtime can hinder sleep.

C

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psychological balance? A) Teach the patient to always lie down in a comfortable position during meditation. B) Teach the patient to focus on multiple problems that the patient feels demand attention. C) Teach the patient to let distractions come and go naturally without judging them. D) Teach the patient to suppress distracting or wandering thoughts to maintain focus.

C

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? A) 1+ pitting edema B) 2+ pitting edema C) 3+ pitting edema D) 4+ pitting edema

C

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? A) Negative self-concept and low self-esteem B) Negative self-concept and high self-esteem C) Positive self-concept and fairly high self-esteem D) Positive self-concept and low self-esteem

C

A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? A) Ineffective Coping related to the new parenting role B) Ineffective Denial related to ability to care for a newborn C) Anxiety related to change in role status D) Situational Low Self-Esteem related to fear of parenting

C

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A) A pinched and drawn facial expression B) Deep, rapid respirations. C) Moist crackles heard upon auscultation D) Tachycardia

C

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs? A) Can you describe your usual spiritual practices and how you maintain them daily? B) Are your spiritual beliefs causing you any concern? C) How can I and the other nurses help you maintain your spiritual practices? D) How do your religious beliefs help you to feel at peace?

C

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended?A) The nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected. B) The nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site. C) The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track. D) The nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended site.

C

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality? A) The child's church or religious organization B) What parents say about God and religion C) How parents behave in relationship to one another, their children, others, and to God D) The spiritual adviser for the family

C

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also from God—if there is a God." Analysis of these data reveals which unmet spiritual need? A) Need for meaning and purpose B) Need for forgiveness C) Need for love and relatedness D) Need for strength for everyday living

C

A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery? A) A patient of the Adventist faith B) A patient who practices Buddhism C) A patient who is a Jehovah's Witness D) A patient who is an Orthodox Jew

C

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A) Preparing the family for a diagnosis of insomnia and related treatments. B) Preparing the family for a diagnosis of narcolepsy and related treatments. C) Anticipating the scheduling of polysomnography to confirm OSA. D) No action would be taken, as this is a normal finding for hospitalized children.

C

A patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. How would the nurse document this data? A) Masochism B) Pedophilia C) Voyeurism D) Sadism

C

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document? A) Grieving B) Ineffective Coping C) Caregiver Role Strain D) Powerlessness

C

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? A) "I love my child so much I 'hug him to death' every day." B) "I think children need challenges, don't you?" C) "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." D) "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

C

An 18-year-old presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? A) "Vaginal intercourse is most commonly performed in the missionary position." B) "The side-by-side position achieves better clitoral stimulation than the missionary position." C) "Achieving simultaneous orgasms is the goal of vaginal intercourse." D) "The period after coitus is just as significant as the events leading up to it."

C

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness? A) Assure Mr. Brown that many parents feel the same way. B) Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass. C) Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive. D) Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

C

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis

C

The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? Select all that apply. A) Crush the enteric-coated pill for mixing in a liquid. B) Flush open the tube with 60 mL of very warm water. C) Use the recommended procedure for checking tube placement in the stomach or intestine. D) Give each medication separately and flush with water between each drug. E) Lower the head of the bed to prevent reflux. F) Adjust the amount of water used if patient's fluid intake is restricted.

C, D, F

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A) He is aware of his surroundings at this point. B) He is in delta sleep at this time. C) It would be most difficult to awaken him at this time. D) This is most likely an NREM stage. E) This stage constitutes around 20% to 25% of total sleep. F) The muscles are relaxed in this stage.

C, E

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? A) There is no disturbance in self-concept. B) This patient has ego strength and high self-esteem but may have a disturbance of body image. C) The area of self-esteem has very low priority at this time and should be ignored until much later. D) It is probable that there are disturbances in self-esteem and body image.

D

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. What should the nurse do? A) Give all the medication in the cartridge because it expanded when it was mixed and this is what the pharmacy sent. B) Call the pharmacy and request the proper dose. C) Refuse to give the medication and document refusal in the EHR. D) Dispose of 0.2 mL before administering the drug; verify the waste with another nurse.

D

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? A) Negative self-concept B) Modesty (lack of conceit) C) Body image disturbance D) Low self-esteem

D

A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? A) "Patient displays moderate anxiety related to her situation." B) "Patient manifests panic related to feelings of impending doom." C) "Patient describes severe anxiety related to her situation." D) "Patient expresses fear of her husband."

D

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A) Recording intake and output. B) Testing skin turgor. C) Reviewing the complete blood count. D) Measuring weight daily.

D

A nurse is caring for a postoperative patient who is experiencing pain. Which CHA might the nurse use to ensure active participation by the patient to achieve effective pre- or postoperative pain control? A) Acupuncture B) TT C) Botanical supplements D) Guided imagery

D

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A) Reposition the extremity and raise the height of the IV pole. B) Apply pressure to the dressing on the IV. C) Pull the catheter out slightly and reinsert it. D) Put on gloves; remove the catheter

D

A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? A) Discouraging oververbalization of fears and anxieties B) Focusing on the outcome as opposed to the details of the surgery C) Providing time alone for reflection on personal strengths and weaknesses D) Mutually determining expected outcomes of the care plan

D

A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? A) "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." B) "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." C) "Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs." D) "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

D

A patient states she feels so isolated from her family and church, and even from God, "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress? A) The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living. B) The patient will identify spiritual beliefs that meet her need for meaning and purpose. C) The patient will express peaceful acceptance of limitations and failings. D) The patient will identify spiritual supports available to her in this medical center.

D

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding? A) The nurse should have ordered kosher dishes also. B) The staff must have behaved condescendingly or critically. C) Mr. Goldstein is a problem patient and difficult to satisfy. D) Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

D

A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? A) "Each person is born with a certain amount of sexual drive, which can be depleted in later years." B) "If you want to be a great athlete, sexual abstinence is necessary when you are training." C) "If you have a nocturnal emission (wet dream), it is an indicator of a sexual disorder." D) "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

D

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

D

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? A) Arrange to have the infant removed from the home. B) Inform other members of the family of the situation. C) Increase the number of visits by the visiting nurse. D) Notify the care provider and recommend respite care for the mother.

D

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation? A) Patients usually want to conceal information about their spiritual needs. B) Patients are not concerned about spiritual needs until after their spiritual adviser visits. C) Family members and close friends often initiate spiritual concerns. D) Illness increases spiritual concerns, which may be difficult for patients to express in words.

D

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed? A) Baptism frequently postpones or prevents death or suffering. B) It is legally required that nurses provide for this care when the family makes this request. C) It is a nursing function to assure the salvation of the baby. D) Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

D

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? A) "Do you currently have a new partner?" B) "Have you been diagnosed with a neurologic disorder?" C) "Do you take antihypertensive medication?" D) "Do you use antihistamines?"

D

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? A) Inform the family that there is no need for them to wash the body since the mortician typically does this. B) Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. C) Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. D) Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

D

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. A) 5% dextrose in 0.9% NaCl B) 0.9% NaCl (normal saline) C) Lactated Ringer's solution D) 0.33% NaCl (⅓-strength normal saline) E) 0.45% NaCl (½-strength normal saline) F) 5% dextrose in Lactated Ringer's solution

D, E

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. A) REM sleep constitutes much of the sleep cycle of a preschool child. B) By the age of 8 years, most children no longer take naps. C) Sleep needs usually decrease when physical growth peaks. D) Many adolescents do not get enough sleep. E) Total sleep decreases in adults with a decrease in stage IV sleep. F) Sleep is less sound in older adults and stage IV sleep may be absent.

D, E, F