NURSING Fundamentals. Chapter 26 & 27.

The mind and body are connected in the provision of care. This statement describes:

holistic care.

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?

"Having sexual relationships does not put a woman at risk for developing an UTI."

A patient has suffered a severe laceration to his thumb and index finger during a workplace accident, and local anesthetic is to be utilized to facilitate suturing. Which of the patient's following statements should prompt the nurse to provide further health education?

"I'm feeling pretty queasy about getting stitches, so I'm glad they'll be knocking me out."

A patient with dermatitis has sought care from a homeopathic practitioner seeking treatment for her dry, itchy, and inflamed skin. Which of the following statements is characteristic of homeopathy?

"I'm going to recommend a diluted solution that is derived from poison ivy."

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?

"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response?

"It's important that we list all your home care needs for the hospital."

A parent asks the nurse when an 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

"One signal of preparedness is when your child is dry for at least 2 hours."

The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial."

A female client is diagnosed with a urinary tract infection (UTI) and states this is her second one in the last 6 months. In teaching the client about health promotion, the nurse would include which statement?

"Try to urinate immediately after sexual intercourse."

The nurse administers an oral opioid analgesic to a client at 6 PM for pain documented as 6 on a scale of 0 to 10. At 6:30 PM, the client states that the pain level is 3 on a scale of 0 to 10, and that level is acceptable to him. The client asks the nurse why another assessment was necessary after the administration of the pain medication. What is the nurse's best response to this client about proper pain management?

"We assess every client in relation to pain, initially to determine appropriate interventions and later to determine whether the interventions were effective in preventing or relieving pain."

A nurse has entered a patient's room at the beginning of a shift in order to quickly assess the patient's airway, breathing, circulation, and consciousness. The nurse observes that the patient is wincing, stating, "I'm having a lot of pain right now." What question should the nurse next ask this patient?

"Where exactly are you having pain right now?"

Which of the following should be included when assessing pain? Select all that apply.

-Location of the pain • What factors cause the pain to improve or worsen • Intensity of pain • What medications client usually takes to relieve the pain

The client is to take almotriptan 6.25 mg orally for her migraine. Almotriptan is sent to the unit in 12.5 mg tablets. The nurse will administer how many tablet(s)?

0.5

How quickly does naloxone (Narcan) work to reverse opioid induced respiratory depression? (Choose one)

1 to 2 minutes

A 36-year-old patient will receive Carbocaine for a dental procedure. The maximum dose of mepivacaine (Carbocaine, Polocaine) is 6 mg/kg. If this patient weighs 60 kg, what is the maximum dose he or she could receive?

360

Opioid antagonists may produce withdrawal symptoms in patients physically dependent on which of the following? (Choose one)

Opioids

You are the nurse working in the postanesthesia care unit and several patients are having surgery today. Which one would be at greatest risk for complications after surgery?

A 72-year-old female who had general anesthesia for lung removal

When administering an opioid antagonist drug to a client, the primary goal of the therapy is to provide which of the following?

A return to normal respiratory rate, rhythm, and depth

Which of the following clients is more likely to have respiratory depression when receiving an opioid medication, requiring administration of an opioid antagonist?

A surgical client who is not used to taking opioid analgesics

An acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client?

Acupuncture is used to correct disharmony.

The client comes to the clinic and the physician suggests that a chiropractor see the client. The nurse discusses this option with the client and explains that the primary approach by the chiropractor will most likely be which of the following?

Adjustment of the spine

The client who is newly diagnosed with diabetes mellitus type 2 is concerned about eating products with sugar in them. What information does the nurse explain to the client regarding the use of sugar?

An excess increases demand on the pancreas.

The nurse instructs a client to use benzocaine to soothe the itching and pain related to an insect bite. Benzocaine is considered to be what type of dermatologic agent?

Anesthetic

A patient is prescribed zolmitriptan for migraine headaches. The nurse would instruct the patient to administer this drug most likely by which route?

Oral

Gas anesthetics such as nitrous oxide must be combined with what element before they are inhaled by the client?

Oxygen

The nurse is caring for a 48-year-old Native American man hospitalized following an MI. The client asks to see his medicine man. What would be the nurse's best response to this client?

Arrange for a visit with the medicine man in the hospital.

A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient?

Assessment of vital signs and respiratory status

A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following?

Assisting the client to find an appropriate imagery tape to use.

Why is Zen meditation effective for a client with generalized anxiety disorder?

Assists client to enter state of calmness

The nurse is caring for a postoperative client receiving an opioid medication for pain management. The nurse finds the client lethargic with a respiratory rate of 6 breaths per minute. Which of the following actions should be performed first?

Attempt to arouse the client and coach his or her breathing pattern.

An boy 18 years of age is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following?

Automobile accidents

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

Understanding one's dosha, or basic constitution, is central to which type of whole medical system?

Ayurveda

Which of the following would a nurse identify as a local anesthetic agent?

Benzocaine

A patient is suffering from a migraine headache. What is the action of sumatriptan (Imitrex)?

Binding to serotonin to produce vasoconstriction

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

Blood

What type of health care practice was first challenged by clients who wanted to be treated as whole persons, not just as a disease?

allopathic medicine

A nurse is assessing and documenting the eating habits of a client with repeated reports of flatus. Which food item produces gas that could lead to flatus?

Cabbage

The nurse has administered a dose of naloxone (Narcan) and the client's respiratory depression improved within five minutes. When the nurse reassessed the client two hours later, the client again demonstrates symptoms of respiratory depression. Which of the following actions should the nurse perform next?

Call the provider as another dose of opioid antagonist may be necessary.

An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what?

Carpal tunnel syndrome

A client comes into the clinic stating he has been experiencing insomnia for a couple of weeks. After a thorough exam revealed no medical cause for the symptom, the nurse practitioner suggested the use of aromatherapy. Which of the following might the nurse suggest for its use in helping insomnia?

Chamomile

Administration of which class of medications can decrease secretions of the upper respiratory tract?

Cholinergic antagonists

A client is to receive a narcotic cough syrup. The nurse would expect this preparation to contain which of the following?

Codeine

A chant is a form of which category of meditation?

Concentrative

The nurse administered morphine 30 minutes ago to a client in the postanesthesia recovery unit (PACU), and now notes that the client vital signs are: T-97.9 F, P-98 bpm, R-9 breaths/min, and BP- 107/69. What is the nurse's next best action?

Contact the health care provider.

Your client returns from the post anesthesia recovery unit. You note a respiratory rate of 6. Which of the following drugs would you anticipate being given immediately?

Narcan

Which agent would the nurse identify as always being given with oxygen?

Nitrous oxide

A man with no significant medical history is being prepared for outpatient surgery under general anesthesia. As part of the preparation for surgery, the anesthesiologist administers atropine, a anticholinergic agent. What is the purpose of administering this medication at this time?

Dry up secretions in the respiratory tract.

Michelle has cut her leg playing soccer. The physician is planning to suture Michelle's leg. As the nurse caring for Michelle, you note that she is nervous. You have already informed her in a calm and reassuring manner about how the local anesthetic works and that the area will be numb before the procedure begins. What else must you tell her to ensure that she is free of concerns throughout the procedure?

Encourage the patient to verbalize any discomfort during the procedure.

What is the most important nursing action when a client is admitted to the postanesthesia recovery unit (PACU)?

Ensure the client has adequate respirations.

Which drug can be mixed, in certain situations, with an injectable local anesthetic in order to cause local vasoconstriction?

Epinephrine

Beta receptors react with endorphins in the periphery to modulate pain transmission.

False

A nursing instructor invites a nurse who specializes in healing touch to her classroom to discuss with students the effect healing touch has on pain management. This is an example of what?

Familiarizing students with CAM modalities

Naloxone (Narcan) will reverse the effects of which of the following drugs? (Choose one)

Fentanyl (Duragesic)

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Fire safety

A 28-year-old patient has a history of malignant hyperthermia following anesthesia. Today, this patient is on the operating room schedule for a D&C;. Which of the following methods of anesthesia would not be acceptable for this patient?

General anesthesia with an inhalation agent

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

A client asks the nurse about the use of healing touch. Which statement regarding healing touch is accurate?

Healing touch does not use injections.

Prior to receiving procaine, the nurse takes the client's medical history. The nurse will notify the physician immediately when the client reveals he is being treated for which condition?

Heart failure

A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy?

Holism

The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students?

Holism perspective

Which of the following most likely would be a component of a narcotic cough syrup?

Hydrocodone

A patient has been administered an opioid. For which of the following effects should the patient be assessed?

Hypotension

Which of the following has been known to achieve benefits for clients with cancer through the use of the mind to visualize a positive physiologic effect?

Imagery

The leading causes of death for children ages 1 to 4 in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

Implement drowning-prevention strategies.

The nurse is assessing a patient who was recently administered procaine for local anesthesia. Which of the following assessment findings would suggest the possibility of adverse effects?

Increased heart rate

Ayurvedic medicine has its roots in which of the following areas?

India

Prior to the administration of a topical local anesthetic, what is the nurse's priority assessment?

Intact skin

As identified by the National Center for Complementary and Alternative Medicine, which of the following is not a major domain of CAM?

Integrative systems

A nurse is researching a standardized herbal supplement to help a client with pain. What does the word standardized mean?

It contains a certain amount of an active ingredient.

Massage therapy is being used on clients during chemotherapy treatments. How does massage therapy help these patients?

It relaxes muscles to increase circulation and release tension.

Which anesthetic would have the fastest onset of action?

Ketamine

Because of the risk of a spinal epidural hematoma, a patient taking which of the following medications is not a candidate for an epidural or spinal anesthesia?

Low molecular weight heparin (LMWH)

The practitioner is working with structures and systems within the human body, including the bones, muscles, joints, and circulatory system. Which one of the complementary and alternative therapy domains is being used?

Manipulative and body-based practice

Which agent would be used as part of a treatment plan for narcotic detoxification?

Methadone

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation, rather than burns.

A patient has been given MS Contin. You enter the room and the patient is unresponsive. His respirations are 8 per minute. What medication will be ordered for the patient?

Naloxone (Narcan)

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client?

Placing the client in a bed with a bed alarm

A nurse is caring for a 49-year-old woman in the intensive care unit. The patient was in a motor vehicle accident and is in severe pain. She is being given morphine. After 2 days in the unit, the nurse suspects that the patient is developing a cold. The nurse will monitor for which of the following?

Pneumonia

The nurse in the intensive care unit prepares to administer a medication that is used for induction and maintenance of anesthesia, but may also be used to continuously administer sedation to clients who are intubated. Which medication is it?

Propofol (Diprivan)

What is the primary role of the nurse in the care of clients that experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

Which principle does not encompass the basic goals of integrative medicine?

Reject allopathic medicine and embrace CAM practices.

A nurse is caring for a patient with chronic pain who has been prescribed epidural analgesia. The nurse should monitor the patient for which of the following conditions after insertion of the epidural catheter and throughout the therapy?

Respiratory depression

The nurse would assess the patient for which of the following during recovery from midazolam?

Respiratory depression and CNS suppression

The nurse is administering morphine sulfate to a client who had a myocardial infarction. What vital sign would the nurse monitor that directly relates to the use of this narcotic?

Respiratory rate

The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for poisoning related to poor eyesight and the inability to read medication labels

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

A patient who has suffered a crushing injury to his thumb and two of his fingers in an accident at a factory is relieved to be administered a local anesthetic prior to treatment. The drugs that were administered decrease the permeability of the nerve cell membrane to

Sodium

The nurse is caring for a woman who is about to deliver her infant by Caesarean section and prepares the client for what type of anesthesia?

Spinal

The nursing instructor is teaching students about anesthesia and instructs that general surgical anesthesia is divided into four different stages. In which stage would you expect to see delirium?

Stage 2 Explanation: Stage 1 is analgesia, stage 2 is delirium, stage 3 is surgical anesthesia, and stage 4 is respiratory paralysis.

When describing the stages of anesthesia, during which stage does pupillary dilation occur?

Stage 3

The patient is undergoing surgery for a small bowel resection. At this time he is experiencing complete respiratory paralysis and is in the most dangerous stage of general anesthesia. Which stage would you say this patient is in by this description?

Stage 4

The circulating nurse is aware that extra caution is needed during the stage of general anesthesia when the client may experience brief periods of delirium and excitement. Which stage is this?

Stage II

A surgical nurse is documenting the different stages of anesthesia on a patient's chart. Which stage will the nurse describe in documentation just before the surgeon makes the incision?

Stage III

The circulating nurse in the operating room knows that which stage of anesthesia is most dangerous to the client?

Stage IV

A postsurgical patient is awake and extremely anxious while in the postanesthesia recovery unit. She states that "my arms and legs feel like tree trunks and they are hard to move." She also states that "my head feels fuzzy and the right words will not come out." Which of the following is the most appropriate nursing action for this patient?

Stay with the patient as much as possible and provide reassurance

Which agent would a nurse expect to be prescribed for a patient with migraine headaches?

Sumatriptan

A 29-year-old patient in labor has just received epidural anesthesia. Before the procedure her blood pressure was 120/78 and her pulse was 60 bpm. Now her blood pressure is 100/60 and her pulse is 80 bpm. She reports a metallic taste in her mouth, hears a ringing in her ears, and appears confused. What is this patient most likely experiencing?

Systemic toxicity from local anesthesia

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient?

Take the restraints off, stay with her, and talk gently to her.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

The 2-year-old leaning against the screen of a window in a classroom.

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before.

The nurse is caring for a postoperative client with a history of opioid abuse who has been ordered to receive a dose of an opioid antagonist medication. Which of the following issues should the nurse be prepared to address?

The client may begin to demonstrate symptoms of withdrawal.

Which of these assessment findings indicate a positive outcome for a client after acupuncture?

The client reports a reduction in pain level to 3 out of 10.

A 39-year-old patient is about to undergo combined spinal/epidural anesthesia for lower abdominal surgery. Which area of the spine should the nurse prep with antiseptic for the procedure? Select the BEST answer.

The lumbar portion of the spine

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

Morphine, an opioid agonist, is administered for both acute and chronic pain. Along with the administered dosage, which of the following determines the patient's response to morphine?

The route of administration

A man 80 years of age has been prescribed oxycodone (OxyContin) for severe, noncancer, chronic pain. He tells the nurse that he has difficulty swallowing and asks if he can crush the tablet before swallowing. What will the nurse need to advise the client?

The tablet provides around-the-clock pain management and should not be crushed, chewed, or broken.

A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch (TT)

A holistic nurse is caring for a client experiencing anxiety. The nurse assesses the client's energy field then uses her hands to promote comfort and a feeling of well being. This practice is termed:

Therapeutic Touch (TT).

When the physician or dentist mixes epinephrine with a local injectable anesthetic, it is done for what purpose?

To cause vasoconstriction

In which CAM modality are the concepts of Yin and Yang important for diagnosis?

Traditional Chinese Medicine

The nurse is aware that topical anesthesia may be used to numb mucous membranes prior to the administration of local anesthesia. It is also used for what other purpose?

Treatment of chronic pain

A-delta fibers are small myelinated fibers that respond quickly to acute pain.

True

A group of students are reviewing the various methods for assessing pain. The students demonstrate understanding of the material when they identify which of the following as the most reliable method?

Using a pain rating scale

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

The nurse has just administered an opioid antagonist to a client who had been experiencing respiratory depression. How soon can the nurse expect to see improvement in the client's respiratory function?

Within one to five minutes, an effect may be seen.

According to survey results, who are the most prevalent users of complementary or alternative therapies?

Women, ages 35-50, with college degree, former smokers

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which foods would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM?

restoring a healthy flow of energy along the meridians of the body

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard?

the first voiding of the day

A nurse is teaching a client with anxiety about the use of meditation. Which of these are important features of meditation? Select all that apply.

• A quiet location • An open attitude • A comfortable position

What are examples of developmental risk factors? Select all that apply.

• A toddler is allowed to crawl in a house that has not been childproofed. • An older adult woman in a long-term health care facility is at high risk for falls.

The anesthesia care provider bases the choice of type of drugs to administer to the patient during surgery on which of the following? (Select all that apply.)

• Anticipated length of the surgical procedure • Area, organ, or system being operated on • General physical condition of the patient

Prior to the administration of an opioid antagonist, the nurse must obtain which of the following? Select all that apply:

• Blood pressure • Pulse • Respiratory rate

An opioid antagonist will reverse which of the following opioid effects? Select all that apply:

• Bradycardia • Analgesia • Constipation • Hypotension • Respiratory depression

The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply.

• Buy herbs and supplements that are standardized. • Give the product adequate time to work. • Be knowledgeable about the product and its therapeutic actions.

In prenatal classes, the nurse teaches pregnant clients to use meditation during labor contractions to ease the pain. What does the nurse explain to the pregnant clients are the elements of meditation? Select all that apply.

• Comfortable position • Quiet environment • Focus of attention

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

• Communication ability • Mobility • Developmental level

A nurse is using the DAME acronym to perform fall assessments on older adults in a home health care setting. Which examples of nursing actions follow this guideline? (Select all that apply.)

• D—A nurse assesses drug and alcohol use of the patients. • A—A nurse assesses the age-related physiologic status of the patients. • M—A nurse reviews patient charts for medical problems affecting falls.

The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply.

• Give the product adequate time to work. • Be knowledgeable about the product and its therapeutic actions. • Buy herbs and supplements that are standardized.

A nurse attempts to integrate complementary and alternative therapies (CAT) into nursing practice. Which of the following are basic principles of CAT? Select all that apply.

• Health is a state characterized by a dynamic balance of mind, body, and spirit. • Illness is a manifestation of imbalance or disharmony and is a process.

A nurse is volunteering in a free community health clinic at the local YMCA. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply.

• Infants should be rear-facing up to the age of 2 years. • Booster seats should be used until the child is 4'9" (1.45 m) tall.

During an assessment, the nurse notes respiratory depression in a client receiving an opioid medication for pain. Which of the following actions should the nurse perform next? Select all that apply.

• Make an effort to arouse the patient to change his breathing pattern if possible. • Review the medical record for which drug could be causing the symptom. • Review the allergy and health histories and current treatment modalities.

The nurse is teaching a class on methods of relaxation to be used for stress management. Which methods should the nurse teach the participants? Select all that apply.

• Meditation • Biofeedback • Imagery • Focused breathing

The nursing student identifies which of the following to be qualifed to administer anesthesia? (Check all the apply.)

• Nurse anesthetist • Anesthesiologist

When local anesthetics are given, they are able to induce a loss of pain and motor sensations by which of the following methods? Select all that apply.

• They decrease the permeability of the cell membranes to sodium. • They decrease the excitability of the cell. • They inhibit nerve impulses and pain signals are therefore not sent to the brain

For which reasons can the nurse use healing touch when providing nursing care to clients? Select all that apply.

• To stimulate wound healing • To decrease pain • To promote health • To support end-of-life

The pharmacology instructor lists the following medications as examples of local anesthetics. (Select all that apply.)

• novocain • marcaine • xylocaine