Practice test 8

Which of the following statements made by a patient who is scheduled for a lumbar puncture, indicates that he understands the procedure? "The speed of my nerve impulses will be measured." "Fluid will be removed from my spinal canal." "Dye will be injected into my arm." "My brain waves will be studied."

"Fluid will be removed from my spinal canal." Explanation: Client Need: Physiological Integrity Rationale: B. A lumbar puncture is carried out by inserting a needle into the subarachnoid space to withdraw cerebrospinal fluid for diagnostic and therapeutic purposes. The patient's statement indicates a correct understanding of the procedure. A. Electromyography measures electrical activity associated with innervation of skeletal muscle. C. Dyes are not used in a lumbar puncture. D. Studying brain waves is accomplished through electroencephalography.

A patient who has a sustained a fracture of the femur is at risk for which of the following complications in the immediate post- fracture period? Electrolyte imbalance Fat embolus Fluid volume deficit Disuse syndrome

Fat embolus Explanation: Client Need: Physiological Integrity Rationale: B. Complications of fractures include infection, compartment syndrome, venous thrombosis and fat embolism. A and C. Electrolyte imbalance and fluid volume deficit may occur post-surgery but they are not evident in the immediate post-fracture period. D. Disuse syndrome may occur late into the post-fracture period but is not seen immediately.

The nurse is assessing a patient who has cirrhosis of the liver. Which of the following findings would indicate that the patient's condition is worsening? Positive Babinski sign Visual field loss Flapping hand tremors Bibasilar lung crackles

Flapping hand tremors Explanation: Client Need: Physiological Integrity Rationale: C. Clinical manifestations of impending hepatic coma include disorientation and asterixis or flapping hand tremors. A, B and D. These options are not identified as impending signs of hepatic coma, encephalopathy, ascites or esophageal varices.

Which of the following symptoms would help a nurse to establish a nursing diagnosis of potential for violence for a patient who has a diagnosis of schizophrenia, paranoid type? Avoidance of staff and other patients Verbal threats to other patients Refusal to other patients Continual change of position.

Verbal threats to other patients Explanation: Client Need: Psychosocial Integrity Rationale: B. Clues to aggressive behavior include expressing intent to harm others and being threatening to others. A and C. Avoidance of staff and other patients by a paranoid schizophrenic patient may indicate fear that others will harm the patient, or that the patient may be afraid of harming other, and therefore, chooses to avoid contact. However, by observing just this behavior, one cannot assume that the patient is potentially violent. D. Continually changing position may show agitation in the patient, but this behavior alone does not indicate that the patient is potentially violent.

Immediately after a femoral artery cardiac catheterization of a nine-year-old child, all of the following orders are written. Which one should the nurse question? Maintain pressure dressing for 24 hours. Assess brachial pulses q 1hr x 4. Maintain recumbent position for eight hours. Assess color of lower extremities q 1hr x 4.

Assess brachial pulses q 1hr x 4 Explanation: Client Need: Safe Effective Care Environment Rationale: B. Pulses distal to the catheterization site should be checked for equality and symmetry. The nurse should question checking of the brachial pulse. A. The child will have a pressure dressing over the catheterization site. C. Depending upon the hospital policy, the child may be kept in bed with the affected extremity in a straight position for four to six hours after venous catheterization and six to eight hours after arterial catheterization to facilitate healing of the cannulated vessel. D. The nurse should assess the temperature and color of the affected extremity.

The nurse should asses a patient who has bipolar disorder, manic episode for which of the following manifestations? Waxy flexibility Flat affect Flight of ideas Hypersomnia

Flight of ideas Explanation: Client Need: Psychosocial Integrity Rationale: C. Flight of ideas is a manifestation of mania. As the patient's mood state becomes increasingly expansive, speech may become full of irrelevancies. The manic patient jumps quickly from topic to topic, and rapid thinking proceeds to racing and disjointed thinking. A. Waxy flexibility, a condition in which the patient remains in any body position in which he/she is placed, is seen in patients with catatonia. B. Flat affect, the absence of emotional expression, is seen in depressed or psychotic patient. D. Hypersomnia, excessive sleepiness, is seen in depressed patient.

Which of the following statements would a nurse include in the preoperative instruction of a patient who is scheduled for an ileostomy? P "You will have one bowel movement per day." "The school drainage will be of liquid consistency." "The pouch will be located on the left side of your abdomen." "You will be taught how to irrigate your bowel through the stoma."

The school drainage will be of liquid consistency Explanation: Client Need: Physiological Integrity Rationale: B. The nurse should make the patient aware that after surgery, the fecal drainage from the ileostomy is liquid and may be constant. A. The drainage from an ileostomy is liquid rather than formed. C. The stoma site for an ileostomy is right midline. D. Ileostomy stomas should not be irrigated.

Which of the following instruction should a nurse discuss to a patient who has a prescription for cimetidine (Tagamet) for gastroesophageal reflux disease (GERD)? "Take this medication on an empty stomach." "You will have to take these pills for the rest of your life..." "Inform your health care providers before taking any other drugs." "this drug may cause ringing in your ears."

"Inform your health care providers before taking any other drugs." Explanation: Client Need: Physiological Integrity Rationale: C. To prevent drug interactions the patient should be instructed to notify his/her physician prior to taking other medications. A. Tagamet does not need to be taken on an empty stomach. B. Tagamet does not have to be taken for the rest of the patient's life. D. Tagamet does not cause ringing in the ears.

A patient tells the nurse, "The therapist doesn't like me." Which of the following responses made by the nurse would be the MOST therapeutic? "Why do you say that?" "I wouldn't take personally." "Would you like me to talk to the therapist for you?" "You need to discuss that concern with the therapist."

"You need to discuss that concern with the therapist." Explanation: Client Need: Psychosocial Integrity Rationale: D. The nurse should avoid participating in criticism of another staff person. The concern needs to be resolved between those involved, namely the therapist and the patient. With this statement the nurse conveys confidence in the patient's ability to speak for him/herself. A. By asking this question the nurse becomes involved in a situation that does not concern the nurse and does not teach the patient the appropriate process of resolving conflict. Also, the nurse should avoid use of the word "why" because it challenges the person's position and the response is usually to defend one's position rather than address the real issue. B. In this example the nurse gives a stereotypical response, which belittles the patient's concern, gives advice and does not direct the patient to deal with the concern appropriately. C. By talking to the therapist on behalf of the patient, the nurse accepts responsibility for solving the patient's problem and misses and opportunity to teach the patient how to communicate effectively to resolve conflict.

A seven-year-old child who weighs 60 lb (27.6kg) after an appendectomy, has an order for intravenous hydration. The child is to receive 1640 ml of solution in 24 hours. How many drops per minute should a nurse administer, when using an administration set that delivers 15 drops per mi,? 17 45 51 68

17 Explanation: Client Need: Physiological Integrity Rationale: A. The nurse would first determine the number of milliliters to be administered per hour by dividing the total solution by the number of hours of administration. To determine the flow rate of the intravenous, multiply the number of milliliters per hour by the number of drops per milliliter and divide by the number of minutes in one hour. FORMULA: gtt/min = Total Volume x drop factor / time in minutes SOLUTION: gtt/min = 1640 mL x 15 gtt/mL / 24 hours x 60 min/hr gtt/min = 24600/1440 ANSWER: gtt/min = 17.08 or 17

Following an amniocentesis, the nurse should instruct a client to immediately report which of the following signs and symptoms? Flu-like symptoms Inability to sleep A decrease in uterine contraction An increase in uterine contractions

An increase in uterine contractions Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Following an amniocentesis, the patient is at risk for contractions and preterm labor. A. Flu-like symptoms are not associated with amniocentesis. B. Inability to sleep is associated with advancing pregnancy. It is not related to amniocentesis. C. Contractions should not be present at this time.

A child is being treated for acute lymphocytic leukemia and has a platelet count of 50,000 cells/cu mm. Which of the following measures would a nurse include in the care plan? Avoid rectal route when obtaining temperature. Institute respiratory isolation. Offer a bland diet. Maintain strict bedrest.

Avoid rectal route when obtaining temperature Explanation: Client Need: Physiological Integrity Rationale: A. Infection increases the tendency toward hemorrhage, and since bleeding sites become more easily infected, special care is taken to avoid performing skin punctures whenever possible. When finger sticks, venipunctures, intramuscular injections and bone marrow tests are performed, aseptic technique must be employed with continued observation for bleeding. Since the rectal area is prone to ulceration from various drugs, hygiene is essential. To prevent additional trauma, rectal temperatures and suppositories are avoided. B. Respiratory isolation is not indicated for a decreased platelet count. C. Meticulous mouth care, rather than a bland diet, is essential since gingival bleeding with resultant mucositis is a frequent problem. D. Most bleeding episodes can be controlled with judicious administration of platelet concentrates or platelet-rich plasma. Severe spontaneous internal hemorrhage usually does not occur until the platelet count is less than 20,000/mm.

The nurse should teach a patient who has cirrhosis of the liver to limit the intake of which of the following food? Baked chicken Apple pie Spinach Enhance mental acuity

Baked chicken Explanation: Client Need: Physiological Integrity Rationale: A. The diet for cirrhosis includes restricting protein to approximately 35 to 50 grams per day. Carbohydrate intake should be 300 to 400 grams per day. Baked chicken = 27 grams of protein. B. Apple pie = 3 grams of protein C. Macaroni = 5 grams of protein D. Spinach = 5 grams of protein

The nurse should instruct a patient who has a diagnosis of folic acid deficiency anemia to increase the intake of which of the following food? Dairy products Green, leafy vegetables Citrus juices Fish and poultry

Green, leafy vegetables Explanation: Client Need: Physiological Integrity Rationale: B. Foods high in folic acid include green and yellow vegetables, liver, citrus fruits, whole grains yeast and legumes. A, C and D. Dairy products, citrus juices, and fish and poultry are not high in folic acid

Which of the following comments made by the patient who was administered with phenazopyridene hydrochloride Pyridium) would indicate that the medication is effective? "There is no swelling in my ankles." "It does not hurt when voiding." "I do not have diarrhea." "My head is not spinning." .

It does not hurt when voiding Explanation: Client Need: Physiological Integrity Rationale: B. Pyridium is prescribed for symptomatic relief of pain, burning, frequency and urgency arising from irritation of the urinary tract. A, C and D. Ankle edema, absence of diarrhea and absence of vertigo are not intended effects of Pyridium

A patient with a head injury is admitted to the hospital with a BP of 130/70 mm Hg, a heart rate of 100 bpm and respiratory rate of 16 brpm. The patient's respiration increases to 24 and the heart rate decreases to 60. Which of the following medication should a nurse anticipate the HCP to order? Phenytoin (Dilantin) Mannitol (Osmitrol) Theophylline (Theo-Dur) Atropine sulfate (Atopisol)

Mannitol (Osmitrol) Explanation: Client Need: Physiological Integrity Rationale: B. Patient manifestations indicate the decompensation phase of increased intracranial pressure. Osmotic diuretics, such as mannitol, are given to reduce cerebral edema. A. Dilantin is an anticonvulsant and is not used to reduce cerebral edema. C. Theophylline in a bronchodilator and is not used to reduce cerebral edema. D. Atropine sulfate is an autonomic nervous system agent and is not used in the treatment of cerebral edema.

A child is being treated for lead poisoning (plumbism). Prior to the administration of dimercaprol (BAL in Oil), it essential that a nurse assess the child for an allergy to: peanuts. eggs. erythromycin. iodine.

Peanut Explanation: Client Need: Physiological Integrity Rationale: A. Children with allergies to peanuts or penicillin cannot receive dimercaprol (BAL) or D-penicillamine, respectively. B, C and D. Allergies to eggs, erythromycin or iodine should be noted by the nurse. However, such allergies do not necessarily contradict the use of BAL in Oil.

A nurse assesses a patient who is in cervical traction with a halo apparatus. Which finding would require immediate intervention? The halo pins have loosen. The halo pin insertion sites are crusted. The halo vest is snug-fitting. The straps of the halo vest are loose.

The halos pins have loosen Explanation: Client Need: Safe Effective Care Environment Rationale: A. The nurse should check the pins and screws for loosening since the halo apparatus is to remain intact without movement. The nurse would notify the physician if there is any sign of loosening in the apparatus and keep a wrench at the bedside. B. The halo pin insertion sites should be kept clean and free from crusts. However, crusting would not require immediate intervention. C and D. Halo traction is usually anchored to a body cast and not contained within a vest.

A mother asks a nurse why haemophilus B conjugate (Hibiter) immunization is required for her two-month-old infant. That nurse should respond that Hibiter will protect the infant against certain diseases, which includes: hepatitis. encephalitis. epiglottitis. bronchiolitis.

epiglottitis. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Hemophilus influenza type B conjugate vaccines are routinely administered to children beginning at two months of age to protect against epiglottitis. A, B and D. Hibiter does not protect against hepatitis, encephalitis or bronchiolitis.

When caring for an adolescent who is diagnosed with idiopathic scoliosis, a nurse should recognize that the PRIORITY concern for the adolescent is related to: body image activity limitations financial burden imposed dependence

imposed dependence Explanation: Client Need: Physiological Integrity Rationale: D. It is difficult for a child to be restricted at any phase of development, but the teenager needs continual positive reinforcement, encouragement, and as much independence as can be safely assumed during this time. Guidance and assistance regarding participation in social activities are appreciated by adolescent feel worthwhile. A, B and D. Body image, activity limitation and financial burdens may be concerns of the adolescent with scoliosis, but the need for independence takes priority at this stage of development.

A child has an order of morphine sulfate (Roxanol) and acetaminophen (Tylenol) for postoperative pain. The parent asks the nurse. "Why is my child getting two medications for pain at the same time?" The nurse's response would be based on the understanding that: children are more sensitive to the effects of opiates and non-opiates to help counteract this effect. non-opiates stimulate the respiratory system thereby minimizing the depressant effects of opiates. children often experience nausea from opiates, and non-opiates reduce this effect. non-opiates affect the peripheral nervous system, while opiates affect the central nervous system.

non-opiates affect the peripheral nervous system, while opiates affect the central nervous system. Explanation: Client Need: Physiological Integrity Rationale: D. Non-opioids, including acetaminophen, and non-steroidal anti-inflammatory agents are suitable for mild to moderate pain. Opiates are required for moderate to severe pain. A combination of the two analgesics attacks pain on two levels: non-opioids at the level of the peripheral nervous system and opiates at the central nervous system. This approach provides increased analgesia without increase side effects. A, B and C. These options do not indicate the purpose for administering a combination of opiates and non-opiates to control pain.

Several patients have reported to the charge nurse that one of the nurses doesn't come when called and is very grouchy and ill-humored. The charge nurse knows that the nurse is having personal problems. The charge nurse's BEST initial action would be to: ask each of the patients to talk more about the nurse's behavior. tell the patients that the nurse is going through some difficult times. report these complaints to the nursing supervisor. tell the nurse the comments the patients have been making about her.

tell the nurse the comments the patients have been making about her. Explanation: Client Need: Safe Effective Care Environment Rationale: D. The charge nurse should discuss patient comments with the nurse and work with the nurse to develop a plan that promotes change in the behavior. A. The charge nurse has enough information to begin exploring the situation with the identified nurse. Continuing discussion with the patients is not appropriate unless a piece of information needs to be clarified. B. The charge nurse should not discuss the potential reasons for the nurses behavior with the patients. This violates the nurse's right to confidentiality. C. The charge nurse in the first in the chain of command and should address the issues with the nurse.

Which of the following immediate orders in a patient's chart following a total gastrectomy would a nurse question? "Infuse intravenous fluids at the rate of 150 ml/hr." "Turn, cough and deep breathe every two hours." "Advance nasogastric tube one inch every hour." "Maintain the head of the bed at a 30-degree elevation."

"Advance nasogastric tube one inch every hour." Explanation: Client Need: Physiological Integrity Rationale: C. To protect the healing suture line, the nurse should not routinely irrigate or reposition the nasogastric tube. This order should be questioned by the nurse. A. Fluids are given parenterally until the nasogastric tube is removed and the patient is able to drink enough fluids orally. Generally, 1000 ml intravenous solutions are infused at a rate of 125 ml/hr over eight hours. B. Turning, deep breathing, incentive spirometry and ambulation are stressed during the period when the pain medication is at its peak effectiveness. D. The patient should never lie flat in bed. The accepted position is mid-to-Fowler's

A patient who has a pituitary adenoma is scheduled for a transsphenoidalhypophysectomy. A nurse is teaching the patient about what to expect in the immediate postoperative period. Which of these statements by the nurse would be accurate? "You will have a pressure dressing on your head" "You will have to lie flat in bed" "You will be unable to suck through a straw" "You will be unable to brush your teeth"

"You will be unable to brush your teeth" Explanation: Client Need: Physiological Integrity Rationale: D. The patient has a suture line at the junction of the gums and upper lip. Toothbrushes with bristles may irritate the suture line and delay healing. A. The patient has nasal packing and a gauze dressing under the nose. B. The head of the bed should be elevated 30 degrees at all times to reduce cerebral edema. C. The patient should avoid sneezing, coughing, bending, vigorous hair brushing, or any activity that will increase intracranial pressure.

Which of the following statements made by a patient who has hypertension would indicate the need for FURTHER teaching about antihypertensive medications? "I should arise slowly from chair after taking my blood pressure medicine." "l will not need my blood pressure medicine when my headaches go away." "The water pills I take will make me go to the bathroom often." "My water pills are most effective when I take them first thing in the morning."

"l will not need my blood pressure medicine when my headaches go away." Explanation: Client Need: Physiological Integrity Rationale: B. It is important to help the patient understand that hypertension is a chronic condition that cannot be cured but can be controlled with drug therapy, diet therapy, an exercise program, periodic evaluation and other lifestyle changes. The patient's statement indicates an need for further instruction. A. The patient is aware that to decrease orthostatic hypotension, he/she should arise slowly from the bed and stand slowly. C and D. The patient is aware that since frequent urination can interrupt sleep, diuretics work best when taken early in the morning rather than at night.

Four patients who are in group therapy behave in the following ways. Which behavior would indicate that the patient is benefiting from the therapy? A depressed patient verbalizes angry feelings to another patient. A codependent patient accepts responsibility for harmony in the group. A narcissistic patient focuses on recovery. A borderline personality patient recognizes the faults of others.

A narcissistic patient focuses on recovery. Explanation: Client Need: Psychosocial Integrity Rationale: C. The goal of a therapy group is for each individual to work towards self-understanding and more satisfactory ways of relating to and handling stress. A. Confrontation is used for the purpose of making the second patient change his/her behavior to that desired by the first patient. The first patient is trying to elicit the support of the group to pressure the second patient into the change. The group would benefit the first patient by holding to the norm that the only behavior a person has the power to change is his/her own. B. Taking responsibility for maintaining harmony in the group prevents others from feeling and dealing with the anxiety in the group. This behavior by the codependent patient shows preoccupation with the thoughts and feelings of others as opposed to dealing with his/her own behavior. D. Focusing on the problems of others allows this patient to avoid awareness of his/her own problems.

The nurse is receiving the American Diebetic Association (ADA) diet with a 10 year old child who has diabetes mellitus. The child's selection of which of the following food in exchange for a serving of meat indicates that the child understands the instructions? Cheese omelet Bacon Chocolate milk Baked beans

Cheese omelet Explanation: Client Need: Physiological Integrity Rationale: A. The diabetic exchange list for meat includes the choice of cheese and eggs. B, C and D. Bacon, chocolate milk and baked beans are not included under the meat exchange list as equal substitutes.

Which of the following actions should the nurse take FIRST following a violent episode on a psychiatric unit? Conduct a staff debriefing. Contact the hospital administration. Discuss the incident with the other patients. Call the hospital security.

Conduct a staff debriefing Explanation: Client Need: Psychosocial Integrity Rationale: A. After the crisis (violent episode) is over, it is recommended that the team discuss any concerns they may have during the crisis, since this type of occurrence can be stressful for staff as well as patients. B. The nursing supervisor would be notified of the violent episode. Hospital administration would not be notified unless serious complications arose from the situation. C. The incident would be discussed with other patients as a group but would not be done until staff reviewed the situation. D. Hospital security may be called during the violent episode but is not usually called afterward.

Filgrastim (Neupogen) should be administered to a patient who has aplastic anemia to: stimulate synthesis of erythropoietin. elevate the white blood cell count. enhance maturation of red blood cells. increase the production of platelets.

Elevate the white blood cell count Explanation: Client Need: Physiological Integrity Rationale: B. Filgrastim (Neupogen) stimulates proliferation and differentiation of neutrophils. It is used to increase the white blood cell count in patients with neutropenia. A. The drug does not stimulate the production of erythropoietin C. Filgrastim has no action on red blood cell maturation D. An adverse reaction of the drug is thrombocytopenia, or a decrease in platelets.

Which of the following statements made by a patient who has diverticulosis would indicate that the patient is following the diet plan CORRECTLY? "l eat meat five times a week." "l do not eat fried foods." "l drink decaffeinated coffee." "l eat a green salad every day."

I eat a green salad everyday Explanation: Client Need: Physiological Integrity Rationale: D. Treatment of diverticulosis involves adherence to a high-fiber diet. Foods high in fiber include bran, whole wheat and fresh vegetables. A, B and C. Eating meat five times a week, eliminating fat from the diet and drinking decaffeinated beverages are not identified as part of the management of diverticular disease.

A three-year-old child is brought to the emergency department with a suspected diagnosis of acute epiglottitis. Which of the following actions would be MOST APPROPRIATE for a nurse to take when caring for this child? Place the child in an upright position in the parent's lap. Inspect the oropharynx with a lighted instrument. Obtain the child's weight on an upright scale. Encourage small amounts of liquid frequently.

Place the child in an upright position in the parent's lap Explanation: Client Need: Physiological Integrity Rationale: A. Epiglottitis is frightening for both child and parents. The child is allowed to remain in the position that provides the most comfort and security. The child generally insists on sitting upright, leaning forward. This is easily accomplished by the child sitting in the parent's lap to reduce distress. B. Throat inspection should only be attempted when immediate intubation can be performed if needed. C. Obtaining the child's weight is not a priority at this time. Epiglottitis is an emergency situation. D. The child should be kept NPO.

When taking a history from the parent of an eight-year-old child who has rheumatic fever, a nurse would expect the child's parent to report a recent episode of: urinary tract infection. acute gastroenteritis. contact dermatitis. acute pharyngitis.

acute pharyngitis. Explanation: Client Need: Physiological Integrity Rationale: D. Strong evidence supports a relationship between upper respiratory infection with group A streptococci and subsequent development of rheumatic fever. A. Urinary tract infections are mostly cause by E-coli bacteria. B. Organisms causing acute gastroenteritis do not cause rheumatic fever. C. Contact dermatitis is an inflammatory reaction, not an infectious process.

A nurse should recognize that a patient who has coronary artery disease is receiving acetylsalicylic acid (Aspirin) to: relieve pain. reduce fever. diminish inflammation. decrease platelet adhesion.

decrease platelet adhesion. Explanation: Client Need: Physiological Integrity Rationale: D. Aspirin prevents platelet aggregation. It is used to prevent the recurrence of transient ischemic attacks (TIAs) and myocardial infarction (MI) and as prophylaxis against myocardial infarction due to fibrin platelet emboli. A, B and C. While Aspirin can be used to relieve pain, and reduce fever and inflammation, these are not desired outcomes for a patient with coronary artery disease (CAD).

When preparing to discharge an infant who is born to a known cocaine abuser, the nurse's teaching plan would include information about the infant's: need to restrict fluids. tendency to sleep for long periods. potential for developing congestive heart failure. increased risk for sudden infant death syndrome.

increased risk for sudden infant death syndrome. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. There may be an increased risk of sudden infant death syndrome (SIDS) in infants whose mothers abused cocaine while pregnant. A. In light of diarrhea, fluids may need to be increased to prevent dehydration and electrolyte imbalances. B. Infants born to cocaine abusing mother's sleep for short periods. C. Infants born to cocaine-abusing mothers often experience irritability, marked nervousness, rapid changes in mood and hypersensitivity to noise and external stimuli. These neonates exhibits poor feeding, irregular sleep patterns, tachypnea, trachycardia and, often, diarrhea.

A patient who have undergone L, above-the-knee amputation, asks a nurse why there is a sensation of pain in the left foot. The nurse should know that this sensation is called: intractable pain radiating pain phantom pain referred pain

phantom pain Explanation: Client Need: Physiological Integrity Rationale: C. Phantom pain is used to describe the normal perception of the missing extremity that most amputees feel. When the leg is amputated, the patient will feel the presence of the missing limb for many weeks. This is due to intact peripheral nerves proximal to the amputation site that used to carry messages between the brain and the now amputated part. A. Intractable pain is that which is not relieved by the usual medication regimes comfort measures. It is often experience by cancer patients. B. Radiating pain is that which spreads out from its original source, e.g., pain of cardiac origin spreading to the shoulder, jaw and arm. D. Referred pain is that which is felt at a site distal to the original, e.g., pain in the shoulder caused by abdominal gas pockets pressing on the diaphragm.

After administering an injection of haloperidol decanoate (Haldol), the nurse should instruct the patient to: stay recumbent for four hours. avoid tyramine-containing food. return for the next injection in four weeks. decrease salt intake.

return for the next injection in four weeks. Explanation: Client Need: Physiological Integrity Rationale: C. Haldol decanoate is released slowly from the muscle into which it was injected; therefore, the effects of the medication last for two to four weeks. A. It is not necessary for the patient to stay recumbent for any length of time after an injection of Haldol decanoate. Although rare, some patients experience orthostatic hypotension. All patients receiving Haldol should be taught to rise slowly from a recumbent position and to sit for a few minutes before standing. B. Avoidance of tyramine-rich foods is indicated for patients taking monoamine oxidase inhibitors, not haloperidol. D. Taking salt supplements in not indicated when being treated with haloperidol.

When making a postpartum home visit, the nurse observes that the newborn is sleeping comfortably in a prone position. The parent teaching during this visit will focus on: reinforcing this correct position for the infant since the baby is comfortable. teaching the parents that infant should be placed on their backs to sleep. teaching the parents to alternate the infant's sleeping position from front to back. teaching the parents that, although the baby appears comfortable, infants sleep best on their backs.

teaching the parents that infant should be placed on their backs to sleep. Explanation: Client Need: Safe Effective Care Environment Rationale: B. The nurse should instruct the parents that correct positioning to prevent sudden infant death syndrome (SIDS) is the supine position or the side-lying position. A. The prone position is not recommended by the American Academy of Pediatrics. C. Sleeping on the back or side only is recommended. D. Infants generally sleep in whatever position they are placed. The major reason for placing the infant on its back or side is to prevent SIDS.

Which of the following questions is MOST important for a nurse to ask from a patient who has a history of peripheral vascular disease? "Have you had recent lapses of memory?" "Do you require several pillows to sleep?" "Have you noticed weakness in your legs?" "Do you have pain in your calves when you walk?"

"Do you have pain in your calves when you walk?" Explanation: Client Need: Health Promotion and Maintenance Rationale: D. A severe cramp-like pain, intermittent claudication is experienced in the extremities after activity by patients with peripheral arterial insufficiency. When the patient rests, and thereby decreases the metabolic needs of the muscles, the pain subsides. The site of arterial disease can be deduced from the location of the claudication. Calf pain may accompany reduced blood flow through the superficial femoral or popliteal arteries. A. Lapse of memory is present in neurological disorders. B. Sleeping on several pillows is seen in the patient who has cardiac failure. C. Weakness in the legs may be seen in neurological disorders.

A nurse has given instructions about making appropriate lifestyle changes to a patient who has venous insufficiency. Which of the following comments made by the patient, would indicate compliance with the instructions? "l eat fried chicken during the week." "l put on a girdle in the morning." "I place a stool under my legs when I sit." "I drink a beer every night after eating."

"I place a stool under my legs when I sit." Explanation: Client Need: Physiological Integrity Rationale: C. Elevating the legs decrease edema, promotes venous return and provides symptomatic relief. The legs should be elevated frequently throughout the day, preferably for at least 30 minutes every two hours. A and D. Modifications in diet and alcohol intake will not provide relief to patients with venous insufficiency. B. Constricting garments such as girdles or garters should be avoided.

Which of the following statements made by a patient who is scheduled for a sigmoid colostomy, would indicate that the patient needs FURTHER instruction? "I will have one formed bowel movement daily." "I will have continuous drainages of liquid stool." "The pouch will be located on the left side of my abdomen." "I will be taught how to irrigate my bowel through the stoma."

"I will have continuous drainages of liquid stool." Explanation: Client Need: Physiological Integrity Rationale: B. The stool from a sigmoid colostomy will be formed rather than liquid, Liquid stool is expected with an ileostomy. The patient should have additional teaching in this regard. A, C and D. These patient statements indicate a correct understanding of the surgery.

A patient who has pyelonephritis is given home care instructions by the nurse. Which of the following statements indicates that the patient understands the instructions? "I will need to take antibiotics for at least three months." "I will have to drink cranberry juice every day." "I will need to strain my morning urine." "I will have to weigh myself daily."

"I will need to take antibiotics for at least three months." Explanation: Client Need: Physiological Integrity Rationale: A. The course of antibiotic therapy for pyelonephritis may extend over weeks. If the infection becomes chronic, maintenance drug therapy may continue indefinitely. B. Cranberry juice in large amounts will acidify the urine and prevent urinary tract infections. It is not used in the treatment of pyelonephritis. C. Straining of urine is indicated for patients with renal calculi. D. Daily weight would be indicated for patients with urinary retention and/or renal failure.

Which of the following statementsmade by a patient who is administered with sulfasalazine Azulfidine) would indicate understanding of the medication? "I will brush my teeth with a soft-bristle toothbrush." "I will report greenish halos around lights." "I will need to wear a hat while I am outdoors." "I will expect a tingling sensation around my mouth."

"I will need to wear a hat while I am outdoors." Explanation: Client Need: Physiological Integrity Rationale: C. Photosensitivity may occur as a side effect of Azulfidine. The patient should be instructed to wear a wide-brimmed hat and long sleeves when out-of-doors. A, B and D. Bleeding gums, seeing halos around lights and a tingling sensation around the mouth are not associated with administration of Azulfidine.

A patient had a total gastrectomy. Which of the following instruction should nurse discuss to the patient on how to avoid dumping syndrome? "Add polyunsaturated fats to your daily meals." "Eat three balanced meals per day." "Include complex carbohydrate with your meals." "Limit fluid intake with your meals."

"Limit fluid intake with your meals." Explanation: Client Need: Physiological Integrity Rationale: D. Prevention is the most effective means of controlling dumping syndrome. The nurse should instruct the patient to follow a moderate-fat, high-protein diet, with limited carbohydrates. Simple sugars should be avoided, and fluids with meals are discouraged because they increase total volume. The patient should eat small, frequent meals. A. A diet with moderate fat is encouraged to delay gastric emptying. Adding polyunsaturated fats to daily meals is not necessary. B. Small frequent meals rather than three large meals should be encouraged to decrease total volume. C. Complex carbohydrates are limited and simple sugars should be avoided because they leave the stomach more quickly than fats and proteins.

A patient who is receiving pyridostigmine bromide (Mestinon) makes all of the following statements. Which one should indicate to the nurse that the Mestinon is having its therapeutic effect? "My urine has no odor." "My headaches are gone." "My vision is less blurry." "My chewing is stronger."

"My chewing is stronger." Explanation: Client Need: Physiological Integrity Rationale: D. Anticholinesterase agents, such as pyridostigmine bromide, act by increasing the relative concentration of available acetylcholine at the neuromuscular junction. They increase the response of the muscle to nerve impulses and improve strength. The dosage of pyridostigmine bromide is gradually increased until maximal benefits are achieve (additional strength and less fatigue). The patient is instructed to take the medication 30 minutes before meals for maximal muscle strength. A, B and C. Pyridostigmine bromide does not affect the urine, does not relieve headache and does not improve vision.

Which of the following statements made by a patient who is administered with doxorubicin hydrochloride (Adriamycin) would indicate that the patient needs FURTHER instruction about the adverse effects of the drug? "My hair is going to fall out." "My urine will turn red." "l can expect to become constipated." "l may develop an irregular heartbeat."

"l can expect to become constipated." Explanation: Client Need: Physiological Integrity Rationale: C. Administration of Adriamycin would cause diarrhea rather than constipation. The patient needs additional instruction about the medication. A. Administration of Adriamycin will cause complete alopecia that is reversible. B. Adriamycin will cause the urine to be reddish in color for one to two days after administration. D. Administration of Adriamycin can cause ventricular disrhythmias and cardiotoxicity.

A patient has severe burns involving the hands, chest and head. Which of the following nursing actions will prevent contractures? Maintaining a semi-Fowler's position Applying splints to hands and wrists Placing sandbags on either side of the chest Placing two pillows under the head

Applying splints to hands and wrists Explanation: Client Need: Physiological Integrity Rationale: B. Positioning is critical for patients with burn injuries because the position of comfort for the patient is often one of joint flexion, which leads to contracture development. Maintain the patient in a neutral body position with minimal flexion. Best practices for preventing contractures are listed in Chart 28-6. Splints and other devices may help the patient maintain good positioning. These devices usually are used on the hands, elbows, knees, neck, and axillae. A and D. Placing pillows under the head or maintaining semi-Fowler's position contributes to flexion contractures. C. Sandbags on either side of the chest will not prevent contractures.

A patient says to the nurse, "I'm less of a man since I've taking my Elavil." Which of the following responses by the nurse would be therapeutic? "Are you saying that the medication interferes with sexual intimacy?" "Compliance with your medication regimen is the most important issue here." "When was the last time you had sex." "Are you involved in an intimate relationship?"

Are you saying the medication interferes with sexual intimacy Explanation: Client Need: Psychosocial Integrity Rationale: A. Some antidepressants interfere with libido. The nurse should clarify the meaning of the patient's statement and convey to the patient a willingness to talk about sexual intimacy concerns with the patient. B. This response by the nurse negates the patient's concerns and does not allow for open discussion. C. The nurse should clarify the meaning of the patient's comment before asking for additional information. D. The should first clarify the patient's original statement.

A patient who has mental retardation is admitted to a general psychiatric unit. Which of the following actions should the nurse include initially in the patient's plan of care? Provide reality orientation. Asses the patient's level of functioning. Involve the patient in cognitive activities. Encourage participation in the existing program.

Asses the patient's level of functioning Explanation: Client Need: Psychosocial Integrity Rationale: B. Assessing several areas of functioning such as intellectual functioning, activities of daily living and coping mechanisms helps the nurse to fully develop the plan of care. A, C and D. The nurse cannot know the patient's needs or if the patient is capable of participating in these interventions until the level of functioning is determined.

A patient experiences nausea following the removal of a nasogastric tube. Which of the following actions would a nurse take FIRST? Teach relaxation techniques. Auscultate the bowel. Reinsert the nasogastric tube. Administer the prescribed medication.

Auscultate the bowel Explanation: Client Need: Safe Effective Care Environment Rationale: B. The patient should be assessed for nausea, abdominal discomfort and the presence of bowel sounds. A, C and D. Before removal of a gastrointestinal tube, GI function is assessed. Bowel sounds are auscultated, the abdomen is observed for distention, the patient is asked whether flatus has been passed and the patient's tolerance of tube clamping and ice chips in noted. Relaxation techniques, reinserting the tube and administering medication may be logical interventions but would not be the first priority.

A nurse is caring for a patient who is one hour postpartum. Which of the following assessment finding requires immediate intervention? Uterine funds 2 cm below umbilicus Lower abdominal cramping Bright red vaginal bleeding Temperature elevation of 100.6 °F (38.1 °C)

Bright red vaginal bleeding Explanation: Client Need: Health Promotion and Maintenance Rationale: C. During the first three days after delivery, vaginal discharge is usually bright red. Abnormal bleeding from lacerations usually spurt, instead of trickling. In the first hour postpartum, the bleeding will be bright red or rubra. The amount of bleeding is more significant than the color at this time. A. At the end of the third stage of labor the fundus is approximately two centimeters below the level of the umbilicus. Within 12 hours, the fundus may be one centimeter above the umbilicus. B. The intensity of uterine contraction increases immediately after birth. D. During the first 24 hours after delivery the woman's temperature may rise to 100.4 OF (38 OC) due to the dehydrating effects of labor.

A patient is suspected of having a subarachnoid hemorrhage. A nurse should prepare the patient for which of the following diagnostic tests? Cerebral arteriogram Intravenous pyelogram (IVP) Gallium scan Carotid Doppler study

Cerebral arteriogram Explanation: Client Need: Physiological Integrity Rationale: A. Cerebral arteriogram or angiogram illuminates the cerebral circulation. This test is used for the diagnosis of vascular aneurysms, malformations, displacements and occluded or leaking blood vessels. B. An intravenous pyelogram (IVP) provides information about the number, size and location of the kidneys ureters. C. A gallium scan is useful in detecting bone problems, and can also be useful in the examination of brain, heart, liver and breast tissue. D. Carotid Doppler studies are use to determine narrowing or occlusion of the carotid arteries.

A pregnant woman who has abruptio placentae has an order of emergency cesarean section under general anesthesia. Which of the following measures should be included in the care plan while the patient is admitted in the recovery room? Maintaining the patient in left lateral Sim's position Observing the patient for manifestation of infection v Checking the characteristics of the patient's lochia Assessing the patient for a positive Homans' sign

Checking the characteristics of the patient's lochia Explanation: Client Need: Psychosocial Integrity Rationale: C. Lochial flow should be assessed for amount, odor and presence of clots in the early postpartum period. A. A fresh postoperative patient should not be placed in the left lateral Sim's position because it puts pressure on the new incision line. B. An assessment of signs and symptoms of infection should be completed, but is not part of the initial postpartum assessment in the recovery room. D. Homans' sign generally should be assessed in the postpartum period; however, this patient had general anesthesia and will be unable to state pain discrimination.

Which of the following food selections during lunch would be MOST APPROPRIATE for a patient with bipolar disorder, manic episode? Cheese sandwich, banana and milk shake Vegetables soup, applesauce and tea Rice and beans, custard and carbonated water Beef stew, peas and milk

Cheese sandwich, banana and milk shake Explanation: Client Need: Psychosocial Integrity Rationale: A. Manic patients demonstrate hyperactive behavior, as well as poor concentration and attention span, making it difficult for them to sit long enough or focus long enough to eat certain types of foods. Because of these behavior, such patients are at risk for alteration in nutrition: less than body requirements. Finger foods that are high in nutritious calories and easily portable will decrease the risk of altered nutrition. B, C and D. While nutritious, these foods are not portable and would not be suitable for a patient with bipolar disorder, manic phase.

A child who has sickle-cell anemia has been admitted to the hospital. Which of the following signs and symptoms must be reported to the physician immediately? Decreased urine output Vomiting and diarrhea Chest pain Nonproductive cough

Chest pain Explanation: Client Need: Physiological Integrity Rationale: C. Chest pain may indicate an emergency situation (acute chest syndrome) and should be reported to the physician immediately. A. While there can be renal involvement in sickle cell anemia, decreased urinary output is not an emergency. B. Vomiting and diarrhea can be seen with sickle cell anemia but do not require emergency management as does chest pain. D. A nonproductive cough may be present in sickle cell anemia but it does not require emergency intervention.

A patient makes sexually inappropriate comments to the nurse. Which of the following measures would MOST likely prevent such behavior? Clarify nurse-patient roles with the patient. Refrain from being alone with the patient. Avoid sexual topics of discussion with the patient. Assign a staff member of the same gender to care for the patient.

Clarifying nurse-patient roles with the patient Explanation: Client Need: Psychosocial Integrity Rationale: A. Frequently restating the nurse's role throughout the relationship can help the patient to maintain boundaries. B, C and D. Therapeutic nursing responses to sexual advances by a patient include clarifying nurse-patient roles, setting limits on expected behaviors and exploring the meaning of the patient's behavior.

A nurse observes a coworker being verbally abusive to a demented patient. The nurse should report the incident to the: patient's family. physician. co-worker's supervisor. state board of nursing.

Co-worker's supervisor Explanation: Client Need: Safe Effective Care Environment Rationale: C. The supervisor is the person next in the chain of command. It is the supervisor's responsibility to call together the interdisciplinary team to decide on the appropriate intervention. A and D. The interdisciplinary team will decide, based on policy, if and when it is appropriate to notify the family and/or the state board of nursing. B. The physician will be notified by the supervisor since the physician is part of the interdisciplinary team.

When teaching an obese patient about diet for weight reduction, the nurse should include which of the following instructions? "Divide your daily calories into six small meals." "Decrease your daily intake to 700 calories." "Select 90 percent of your daily calories." "Consume half of your daily caloric allotment at dinner"

Divine your daily calories into six small meals Explanation: Rationale: A. Some nutritionists recommend eating several small meals a day because the body's metabolic rate is temporarily increased immediately after eating. When several small meals a day are ingested, more calories are burned due to an increased metabolic rate. B. The caloric intake may need to be reduced to 800-1200 calories daily, but the person will need frequent professional monitoring. The nurse should not instruct a patient to reduce his/her intake to this level without medical supervision. C. An obese person needs to follow a well-balanced, low-caloric diet. D. There is general agreement that consuming most of the daily caloric intake at a large evening meal results in less weight loss than when the calories are more evenly distribute throughout the day.

Which of following findings would a nurse expect of observe when assessing a patient who has myasthenia gravis? Tongue deviation Intention tremor Plantar flexion Drooping eyelids

Drooping eyelids Explanation: Client Need: Physiological Integrity Rationale: D. Because of involvement of the ocular muscles, diplopia and ptosis are early symptoms of myasthenia gravis. A, B and C. These options are not identified as clinical manifestations of myasthenia gravis but are found in other neuromuscular diseases.

The bowel retraining program for a patient with cerebrovascular accident should include which of the following measures? Checking for impaction daily Increasing the intake of milk products Utilizing incontinent pads until control is achieved Establishing a consistent time for elimination

Establishing a consistent time for elimination Explanation: Client Need: Physiological Integrity Rationale: D. Bowel retraining is established by providing a consistent time for stool evacuation each day. A. Checking for impaction daily is not indicated and can interfere with sphincter control. B. Fluids should be increased to at least 3000 ml per day, unless contraindicated by cardiac or renal disease. Dairy products are high in calcium and may be constipating for the patient. C. Using incontinent pads does not help in bowel retraining and may encourage incontinence.

A 36-hour-old newborn infant appears slightly jaundiced and has a bilirubin level of 10 mg/dL. A nurse would give the parent which of the following instructions? "Feed the baby at least every three hours." "Give the baby formula milk instead of breastfeeding for 48 hours." "Check the baby's temperature every four hours." "Expose the baby's skin to direct sunlight daily for one hour."

Feed the baby at least every three hours Explanation: Client Need: Health Promotion and Maintenance Rationale: A. The newborn should be fed eight or more times per day. The mother is encouraged to feed her infant around the clock. Early, frequent nursing will enhance meconium excratin and decrease bilibrubin levels. Nurseries now initiate early first feeding. Feeding of the new born soon after birth stimulates the gastrocolic reflex and the passage of meconium. Because bilirubin is excreted in meconium, early feeding may help to prevent jaundice. B. Breastfeeding and the need for cessation of breastfeeding to decrease hyperbilirubenemia are not well documented in the nursing research. C. There is no need to check the temperature unless the infant is under photography D. Expose to direct sunlight is an advice given to parent of an infant with only slightly elevation of bilirubin levels, but its relative success in decreasing bilirubin levels is still unknown.

Which of the following findings on a child with cystic fibrosis would indicate that the pulmonary treatment is achieving its therapeutic effect? Nonproductive cough Decreased tidal volume Fewer mucopurulent secretions Adventitious breath sounds

Fewer mucopurulent secretions Explanation: Client Need: Physiological Integrity Rationale: C. Management of pulmonary problems in cystic fibrosis (CF) is directed toward prevention and treatment of pulmonary infection by improving aeration and removing mucopurulent secretions. A. Initial pulmonary manifestations of CF are wheezing and a dry, nonproductive cough that eventually becomes loose and productive. B. As thick, tenacious mucus accumulates, obstruction occurs and the flow of air is impaired. There is an increase in residual volume and subsequent decrease in vital capacity. D. Adventitious sounds are additional respiratory sounds not normally heard.

When taking a history from a patient who has a diagnosis of pyelonephritis, a nurse should expect the patient to report which of the following symptoms? Pain referred to the left shoulder Low back pain Flank pain Right upper quadrant pain

Flank pain Explanation: Client Need: Physiological Integrity Rationale: C. Clinical manifestation of pyelonephritis include acute flank pain, fever, chills, malaise, leukocytosis and bacteria in the urine. A. Pain referred to the left shoulder may be the result of "gas" pains and abdominal distention. B. Flank pain, rather than low back pain, is symptomatic of pyelonephritis. D. Right upper quadrant pain is indicative of liver or gall bladder disease.

A patient who is scheduled to begin peritoneal dialysis treatment at home asks a nurse regarding what to expect. Which of these responses by the nurse would be MOST accurate? "Fluid will be instilled into your abdominal cavity on a routine basis." "You will need to be admitted to an acute care center for this treatment." "You will have a permanent vascular access site created in your arm." "You will be restricted to bed while this procedure is being carried out."

Fluid will be instilled into your abdominal cavity on a routine basis Explanation: Client Need: Physiological Integrity Rationale: A. Peritoneal dialysis involves repeated cycles of instilling dialysate into the peritoneal cavity, allowing time for substance exchange and then removing the dialysate. B. One of the primary advantages of peritoneal dialysis is the relative ease of administration that allows it to be used in community health centers without elaborate and sophisticated equipment. It can be easily managed and often provides the patient with greater independence and mobility than hemodialysis. C. Different types of catheters are used in peritoneal dialysis. The catheters are usually tunneled under the skin and inserted into the peritoneum to allow exchange of fluids. Permanent vascular access is used in hemodialysis. D. In continuous ambulatory peritoneal dialysis the dialysate is instilled into the abdomen and left in place for four to eight hours. The empty dialysis bag is folded up and carried in a pouch or pocket until it is time to drain the dialysate. The patient's activities are not restricted.

Which of the following statements by a patient with schizophrenia indicates an UNDERSTANDING of the antipsychotic medication therapy? "I need to follow the dose schedule and tell my nurse if I have any problems." "When I'm feeling better, I can use smaller doses of my medicine." "If I don't hear the voice, I don't need the medicine." "I don't have to worry about many side effects with this medicine."

I need to follow the dose schedule and tell my nurse if i have any problems Explanation: Client Need: Psychosocial Integrity Rationale: A. When teaching clients about schizophrenia, the nurse should include the need to take medication regularly, expected side effects, what to do for the side effects, signs of problems and who to call if problems occur. B and C. The patient should be taught not to decrease the medication dosage or to stop the medication unless instructed to do so by the physician. D. Side effects of antipsychotic medications include extrapyramidal effects such as tardive dyskinesiak akathisia, parkinsonism and dystonia. Anticholinergic side effects include blurred vision., nasal congestion, dry mouth, constipation and urinary hesitancy.

A patient who is human immunodeficiency virus (HIV) positive has a CD4 count of 200. Which of the following measures in patient's plan of care should the nurse PRIORITIZE? Implement reverse isolation. Limit the number of venipunctures. Institute regular position changes. Monitor intake and output.

Implement reverse isolation Explanation: Client Need: Safe Effective Care Environment Rationale: A. As immune system depletion progresses, CD4 count decreases and patient becomes at greater risk for opportunistic infection, cancer, and other complications. B, C and D. Limiting the number of venipuntures, instituting regular position changes and monitoring intake and output are important in the treatment plan of the patient with a decreased CD- 4 count, but protection from infection would be the priority.

A nurse is assessing patient for discharge to a residential treatment center. Which of the following factors should a nurse give the highest PRIORITY? Family history of mental illness Developmental history Individual's strength Social support system

Individual's strength Explanation: Client Need: Psychosocial Integrity Rationale: C. The individual's strengths are those effective coping mechanisms on which the individual can draw when encountering difficulty. The patient needs a repertoire of effective coping mechanisms in order to function more independently in the residential treatment center. A. Although family history of mental illness may influence the style of coping a patient uses, assessment of present coping abilities and strengths is essential to determining the patient's readness for discharge. B. Developmental history may influence the type of program in which the patient is placed. Individual strengths are not necessarily dependent upon one's developmental history. D. The patient's social support system is important to success in the residential treatment program. However, a patient's strengths determine how that patient uses and maintains the support system.

Which of the following nursing diagnoses would be given priority when caring for a client diagnosed with Guillain Barre syndrome? Ineffective airway clearance Self-care deficit Fluid volume Risk for injury

Ineffective airway clearance Explanation: Client Need: Safe Effective Care Environment Rationale: A. The patient is at particularly high risk if he/she is unable to cough effectively to clear the airway and has difficulty is swallowing, which may cause aspiration of saliva and precipitate acute respiratory failure. B. Later in the course of the disease motor paralysis or weakness will affect the patient's ability to self-feed. C. Muscle paralysis in severe cases may lead to low blood pressure and the need for vasopressant agents and volume expanders. The priority of care is airway maintenance. D. A total self-care deficit relates to inability to use muscle to protect oneself and places the patient at risk for injury. However, the priority of care is maintenance of a patient airway.

A patient's blood test results reveal a hematocrit of 66%. Which of the following nursing diagnoses would a nurse PRIORITIZE? Ineffective breathing pattern Activity intolerance Hyperthermia Dysreflexia

Ineffective breathing pattern Explanation: Client Need: Safe Effective Care Environment Rationale: A. When shock is caused by dehydration or a fluid shift, hematocrit and hemoglobin levels are elevated. The priority problems for patients with hypovolemic shock are: 1. Hypoxia related to hypovolemia 2. Hypoperfusion related to active fluid volume loss and hypotension 3. Anxiety related to potential for death and decreased cerebral perfusion 4. Confusion related to decreased cerebral perfusion The purposes of shock management are to maintain tissue oxygenation, increase vascular volume to normal range, and support compensatory mechanisms. Oxygen therapy, fluid replacement therapy, and drug therapy are useful for this problem. B, C, and D. Activity intolerance, hyperthermia and dysreflexia are not included in the priority diagnoses.

A patient who is admitted to the emergency department reports visual hallucinations and appears disoriented. To determine whether the patient is delirious or demented, a nurse should assess for: memory impairment. level of consciousness. auditory hallucinations. cognitive functioning.

Level of consciousness Explanation: Client Need: Physiological Integrity Rationale: B. Clouding of consciousness and fluctuating level of awareness are symptoms seen in delirium but not dementia. A, B and D. Memory impairment, auditory hallucinations and cognitive disturbances are manifestations of both dementia and delirium.

Which of the following actions would a nurse take when caring for a patient who is brought to the emergency department with a suspected spinal cord injury? Taping the patient's eyelids closed. Elevating the head of the patient's bed. Placing the patient in a side-lying position. Maintaining the patient's neck in extension.

Maintaining the patient's neck in extension. Explanation: Client Need: Physiological Integrity Rationale: D. The patient must always be maintained in an extended position. No part of the body should be twisted or turned, and the patient cannot be allowed to assume a sitting position. A head immobilizer is used to secure the head and neck in alignment. A. There is no indication that taping the eyelids shut is necessary in this situation. B and C. Use of these positions could cause severance of the spinal cord from bone fragments.

A nurse is planning to teach parents in a parenting class about ways to reduce the incidence of sudden infant death syndrome (SIDS). Which of the following strategies should the nurse include? Position the infant on the back or side when left unattended on a crib. Put a cool mist humidifier in close proximity to the sleeping infant. Avoid placing large stuffed toys in the infant's crib Place the infant in an infant seat for two hours after feedings

Position the infant on the back or side when left unattended on a crib Explanation: Client Need: Health Promotion and maintenance Rationale: A. Parents need to be educated that infants should be placed on their sides or supine on a firm sleep surface to help prevent sudden infant death syndrome (SIDS). B, C and D. The infant's position during sleep is a critical factor in SIDS. Infants who sleep in a prone position are at greater risk of during from SIDS than infants who are positioned on their backs or sides. The prone position may cause oropharyngeal obstruction; affect thermoregulation, causing overheating of the infant; or affect the arousal state. A cool mist humidifier, avoiding stuffed animals and placing the infant in an infant seat after feeding will not prevent the incidence of SIDS.

The nurse caring for a patient who is receiving furosemide (Lasix) should monitor the patient's serum level of: potassium. glucose. protein. creatinine.

Potassium Explanation: Client Need: Physiological Integrity Rationale: A. Electrolyte imbalances may occur with the administration of Lasix. Side effects of Lasix incude hypovolemia, dehydration, hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, hypomagnesemia and ypocalcemia. Nursing measures include monitoring the patient for hypkalemia. B. While glucose may also be elevated with the administration of Lasix, potassium values are more critical. Sudden death from cardiac arrest has been reported with the administration of Lasix C and D. Protein and creatinine alterations are not identified as adverse effects of Lasix therapy

A nurse witnesses a two-year-old child experiencing a generalized seizure while being evaluated in the emergency department for a high-grade fever. Which of the following actions would a nurse take FIRST? Protect the child from physical injury. Administer an antipyretic medication rectally. Apply cool compresses to the axilla and groin. Reassure the parents that this is a common occurrence.

Protect the child from physical injury Explanation: Client Need: Physiological Integrity Rationale: A. It is impossible to halt a seizure once it has begun and no attempt should be made to do so. The nurse must remain calm, stay with the child and prevent the child from sustaining any harm during the seizure. B. Attempts to lower the child's temperature will not prevent or stop the seizure. Sponging is indicated for elevated temperatures from hyperthermia rather than fever. Ice water and alcohol are inappropriate, potentially dangerous solutions. Sponging or tepid baths are ineffective in treating febrile children, either when used alone or in combination with antipyretics and cause considerable discomfort. C. Administering medications via rectal route at this time is contraindicated as it can lead to further injury and stimulation of vagal reflex. D. Parents need to be educated

A three-year-old child to is receive pyrvinium pamoate (Povan) as part of the treatment plan for pinworm infestation. A nurse would instruct the child's parent to be aware of which side-effect? Dry, scaly skin Bleeding gums Tea-colored urine Red -colored stool

Red -colored stool Explanation: Client Need: Physiological Integrity Rationale: D. Povan stains the stool and vomitus bright red. A, B and C. Dry scaly skin, bleeding gums and tea-colored urine are not side effects of treatment with Povan.

Which of the following instructions would a nurse include in the teaching plan of a patient who has regional enteritis? "Limit your dietary protein intake." "Reduce stress in your lifestyle." "Decrease your activity level." "Avoid drinking fruit juices."

Reduce stress in your lifestyle Explanation: Client Need: Psychosocial Integrity Rationale: B. The patient with regional enteritis or Crohn's disease must identify stressors and methods to eliminate or reduce them. A. The nurse should assist the patient in selecting high-calorie, high-protein, low-fiber meals. Adequate intake of vitamins and minerals, especially vitamin C found in citrus fruits and juices should be encouraged. C. The patient will maintain a balanced activity-rest periods. D. Strained juices are permitted on a low-fiber diet.

A two year old child who has a 48-hour history of loose stools is diagnosed with mild dehydration. As part of the child's treatment plan, which of the following oral rehydration solutions would a nurse recommend to the child's parent? Uncarbonated cola Apple juice Rice-based oral solution Mineral water

Rice-based oral solution Explanation: Client Need: Physiological Integrity Rationale: C. Rice-based oral rehydration solution (ORS) has been developed as an alternative to the standard glucose oral rehydration solution. These nutrient-based solutions may decrease diarrheal volume loss and shorten the duration of the disease. A, B and D. Diarrhea is not managed by encouraging intake of clear fluids such as fruit juices, uncarbonated soft drinks and mineral water, since these fluids usually have a high carbohydrate content, a low electrolyte content and high osmolality.

A nurse is to give a newborn his first bath. The nurse should initially obtain which of the following assessment? Temperature Weight loss since birth Size of posterior fontanel Passage of meconium

Temperature Explanation: Client Need: Health Promotion and Maintenance Rationale: A. The infant's temperature must be stable prior to bathing. B. Infant's typically lose 5 to 10 percent of their birth weight prior to discharge. This weight loss is within normal limits. C. The posterior fontanel is triangular in shape (0.5 to 1.0 cm). The fontanel should not be depressed or bulging but soft and flat. Its size does not determine the timing of the first birth. D. Infants may not pass stool within the first 12 hours of life but should pass meconium within 24 hours. Passage of meconium does not influence the timing of the first bath.

Which of the following nursing diagnoses should a nurse give the highest PRIORITY in the care of a patient who has sustained severe burns? Hyperthermia Risk for infection Body image disturbance Impaired physical mobility

Risk for infection Explanation: Client Need: Safe Effective Care Environment Rationale: B. All burn patients are considered at risk for an often-fatal infection with Clostridium tetani. A routine prophylactic procedure when a patient is admitted to the hospital is the administration of tetanus toxic intramuscularly. Burn wound infection occurs through either auto-contamination or cross-contamination. The high risk for infection is related to loss of the barrier, an impaired immune response, the presence of invasive catheters and invasive procedures. Medical management of the patient during the acute burn phase focuses on infection control, wound care, wound closure, nutritional support, pain management and physical therapy. A. Hypothermia is a problem for the burn patient because skin assists in maintaining body temperature. C. Body image disturbance is an appropriate nursing diagnosis but does not have higher priority then risk for infection. D. Impaired physical mobility is a nursing diagnosis secondary to pain and immobility, but does not have a higher priority than risk for infection.

Which of the following strategies would be APPROPRIATE for a nurse to include in the rehabilitation teaching plan of a patient who is paraplegic? Self-catheterization Assisted coughing Adaptive feeding techniques Compensatory swallowing

Self- catheterization Explanation: Client Need: Psychological Integrity Rationale: A. Following a spinal cord injury, the bladder becomes atonic and cannot contract reflexively. The patient should be instructed in self-catheterization to avoid over-distention of the bladder. B. The paraplegic patient is able to cough, deep breathe and perform chest physiotherapy. There is no indication that assisted coughing is necessary. C and D. Paraplegia involves dysfunction of the lower extremities, bowel and bladder. There is no indication that adaptive feeding devices or compensatory swallowing techniques are necessary.

Which of the following pieces of equipment should a nurse keep at bedside when caring for a patient who has a bleeding esophageal varices? Chest tube Endotracheal tube Salem sump tube Sengstaken - Blakemore tube

Sengstaken - blakemore tube Explanation: Client Need: Physiological Integrity Rationale: D. If bleeding is not controlled by other methods, balloon tamponade of varices may be instituted. The esophagogastric tubes (Sengtaken-Blakemore or Minnesota) are three-lumen or four lumen tubes with two balloon attachments. One lumen serves as a nasogastric suction tube; the second is used to inflate the esophageal balloon. When the tube is in the stomach, the gastric balloon is inflated and the lumen clamped; the tube is then pulled slowly so that the balloon is held tightly against the cardioesophageal junction. A football helmet-shaped devices is used to keep traction on the tube, which keeps it in the proper position. If bleeding continues after the gastric balloon is inflated, the esophageal balloon is inflated to the desired amount of pressure, as determined by the physician, and then clamped. To stop the bleeding, the pressure must be greater than the individual's portal pressure. A. Chest tubes allow air and fluid to drain from the pleural space. They also prevent air or fluid from entering the pleural space. Chest tubes are not required for treatment of bleeding esophageal varices. B. Endotraceal tubes are artificial airways necessary when normal airway patency and protection cannot be maintained. These tubes are placed in the nose or mouth and passed to just above the tracheal carina. Unless airway patency is an issue, an endotracheal tube is not needed to treat bleeding esophageal varices. C. The Salem sump is a double lumen tube used for gastric decompression and can be used as a route for gastric suctioning and sampling. Since the Sengstaken-Blakemore and Minnesota tubes provide for suction, the Salem sump is not required.

A patient who has a spinal cord injury report symptoms of autonomic dysreflexia. Which of the following should the nurse assess immediately? Pedal pulses Skin inspection Breath sounds Pupillary response

Skin inspection Explanation: Client Need: Safe Effective Care Environment Rationale: B. The manifestations of autonomic dysreflexia result from an exaggerated sympathetic response to a noxious stimuli. Stimuli are commonly bladder and bowel distention, but can be pressure ulcers, spasms, pain and pressure on the penis or uterine contractions. The nurse should assess for pressure areas on the skin. A, C and D. Pedal pulses, breath sounds and papillary response are not priority assessments for autonomic dysreflexia.

When assessing a psychiatric patient, a nurse should recognize which of the following strengths as essential to successful living? Knowledge about medications Ability to work Ability to drive Social skills

Social skills Explanation: Client Need: Psychosocial Integrity Rationale: D. Social skills consist of simple interactions such as introducing one's self, starting and ending a conversation and asking for help. The patient must be able to effectively interact to get basic needs met. A, B and C. The ability to work and to drive and knowledge about medications may enhance the patient's success in the community, but these skills are not essential to successful living.

Which of the following behavior by a patient with schizophrenia indicates impaired judgment? Spending money on a new television instead of paying the electric bill Staying up all night to care for a sick child Going outside in the rain to help a neighbor change a tire Leaving and escaping from a house that has caught on fire

Spending money on a new television instead of paying the electric bill Explanation: Client Need: Psychosocial Integrity Rationale: A. Not only is the patient demonstrating poor judgment by making a socially irresponsible choice (not paying the electric bill), the patient will not be able to watch the new television if the electricity is turned off due to nonpayment of the bill. The patient shows poor judgment because he/she was not able to reach a logical decision after analyzing the possible consequences of the choice. B, C and D. These examples show involvement in activities and relationships that are healthy behavior. The person shows good judgment by making socially responsible choices.

To which of the following nursing actions would a nurse PRIORITIZE in the emergency care of a patient who has sustained a compound fracture of the femur? Splint the leg in its present position. Place the leg in neutral alignment. Irrigate the wound with normal saline. Apply pressure directly over the wound.

Splint the leg in its present position Explanation: Client Need: Physiological Integrity Rationale: A. It is important to immobilize the body part before the patient is moved. Adequate splinting is essential to prevent damage to the soft tissue by the bony fragments. No attempt is made to reduce an open fracture, even if bone fragments are protruding through the wound. B and D. The leg should be splinted in its present position rather than in a neutral position. Pressure should not be applied directly over the wound. C. In an open fracture the wound is covered with a clean (sterile) dressing to prevent contamination of deeper tissues.

A 16-year-old girl who is semiconscious is brought to the emergency department after ingesting an unknown quantity of acetaminophen (Tylenol) and alcohol. Which of the following actions would a nurse PRIORITIZE? Inserting a nasogastric tube Obtaining a urine toxicology sample Inducing vomiting Starting an intravenous infusion

Starting an intravenous infusion Explanation: Client Need: Physiological Integrity Rationale: D. The acronym SIRES is an aid in remembering the essential care in cases of poisoning: Stabilize the patient; Identify the toxic substance; Reverse its effect; Eliminate the substance from the body; and Support the patient and significant others both physically and psychologically. Airway, breathing and circulation must be stabilized. A rapid physical exam is performed. Intravenous lines are inserted and appropriate laboratory studies obtained. A and B. Neither of these options are a priority for emergency care of a patient who has ingested an unknown quantity of Tylenol and alcohol. C. Vomiting should not be induced in a semi-conscious patient because it could result in aspiration.

The PRIMARY purpose for using the Abnormal Involuntary Movement Scale (AIMS) for a patient who is taking a phenothiazine medication is to identify: tardive dyskinesia. motor in coordination. sluggish papillary response. a positive Babinski reflex.

Tardive dyskinesia Explanation: Client Need: Psychosocial Integrity Rationale: A. The abnormal involuntary movement scale (AIMS) is used for the assessment of extrapyramidal side effects of antipsychotic medications. Tardive dyskinesia is such a side effect and is characterized by abnormal, involuntary movements that usually begin in the face, neck and jaw, lip smacking and facial grimacing. B, C and D. Motor incoordination, sluggish papillary response and a positive Babinski reflex are not measured by the AIMS scale.

A parent ask a nurse for guidance regarding a homosexual child. Which of the following actions should the nurse take? Teach the parent that homosexuality is not a mental illness. Refer the parent to the local community mental health center. Teach the parent about sexual deviations. Refer the parent for religious guidance.

Teach the parent that homosexuality is not a mental illness Explanation: Client Need: Psychosocial Integrity Rationale: A. The majority of people who lead homosexual lifestyle are well-adjusted and have satisfying and productive lives. B and D. The parent may need mental health or religious support and counseling to accept the homosexuality of a child. The priority is to help the parent understand that homosexuality is not mental illness. C. Teaching the parent about sexual deviations is not appropriate.

A patient who has a long leg cast says to the nurse. "My thigh is itching under the cast." To provide relief, the nurse should: teach the patient guided imagery techniques. apply heat to the cast at the site of the itching. elevate the patient's affected leg on pillows. encourage the patient to move his/her toes.

Teach the patient guided imagery techniques Explanation: Client Need: Physiological Integrity Rationale: A. Itching under the cast can be extremely uncomfortable. The patient may be tempted to slip an object under the cast to scratch. This is a dangerous practice because of the possibility of breakage and/or skin irritation. Guided imagery is a way to help patients distract themselves from their pain and may produce a relaxation response. B. Heat increase itching due to vasodilatation. C. Elevation prevents dependent edema. D. Inability to move the toes indicates compression. The cast may be too tight if the patient is unable to move his/her toes.

A nurse should carefully assess a patient who has partial occlusion for the carotid arteries for development of which of the following conditions? Rapid eye movements Projectile vomiting Intermittent claudication Transient ischemic attacks

Transient ischemic attacks Explanation: Client Need: Physiological Integrity Rationale: D. The nurse of transient inschemic attacks (TIAs) is a temporary impairment of blood flow to a specific region of the brain due to a variety of reasons, including atherosclerosis of the vessels supplying the brain, obstruction of the cerebral microcirculation by a small embolus, a decrease in cerebral perfusion pressure or cardiac dysrhythmias. The most common sites of atherosclerosis in the extracranial arteries are at the bifurcation of the common carotid arteries and at the origin of the vertebral arteries. A. Rapid eye movements occur in inner ear and neurologic conditions. B. Projectile vomiting is present in increased intracranial pressure. C. Intermittent claudication is present in peripheral vascular disease.

Which of the following statements made by the patient with stress-induced asthma, indicates a need for FURTHER teaching? "The doctor told me that my asthma is all in my head." "I understand that my attacks are related to my mood." "l need to use my inhaler before I start exercising." "The doctor told me that biofeedback might be helpful for my condition."

The doctor told me that my asthma is all in my head Explanation: Client Need: Physiological Integrity Rationale: A. Emotional stress is not only component of asthma. Allergic, immunologic and emotional input can be responsible for asthma attacks. The patient should have further instruction regarding the cause of asthmatic episodes. B. Mood does play an important role in asthma attacks. The patient's statement indicates an understanding of the patient does not require further teaching. C. With exercise-induced asthma, use of an inhaler prior to exercise decreases the risk of, and the symptoms of, an asthma attacks. The patient's statement indicates an understanding of this and the patient does not require further teaching. D. Biofeedback in helpful in teaching a patient to manage stress before physiological problems occur. The patient's statement indicates an understanding of this and the patient does not require further teaching.

Which of the following observations would be MOST significant when assessing the parents of a child who is suspected of being physically abused? The parents appear distraught and upset when asked about the injuries. The parents give a history of the injuries that is not compatible of the actual injuries. The parents seem eager to take the child home as soon as possible. The parents cannot recall when the last series of immunizations was given.

The parents give a history of the injuries that is not compatible of the actual injuries. Explanation: Client Need: Psychosocial Integrity Rationale: B. Incompatibility between the history and the injury is probably the most important criterion on which to base the decision to report suspected abuse. A, C and D. All of these actions by the parents are appropriate and do not necessarily indicate child abuse.

A nurse is caring for a patient who is on balanced skeletal traction applied to the femur. Which of the following findings require immediate nursing intervention? The foot of the bed is elevated 30 degrees. The traction weights are resting on the bed frame. The patient's leg is suspended above the bed. The over bed trapeze is above the patient's chest.

The traction weights are resting on the bed frame Explanation: Client Need: Physiological Integrity Rationale: B. When skeletal traction is being used, the apparatus is checked to see that the weights hang freely. A. Balanced suspension provides counter traction so that the pulling force of the traction is not altered when the bed or patient is moved. C. Alignment of the patient's body in traction must be maintained as prescribed to promote an effective line of pull. D. The covered trapeze should be above the patient's chest.

A patient in an ambulatory care center is suspected of having an acoustic neuroma. Which of the following findings would support this diagnosis? Diplopia Dysphagia Tinnitus Ataxia

Tinnitus Explanation: Client Need: Physiological Integrity Rationale: C. Clinical manifestations of acoustic neuroma begin with tinnitus, or ringing in the ears, and progress to gradual sensorineural hearing loss. A. Diplopia is double vision and is not associated with acoustic neuroma. B. Dysphagia is difficulty swallowing and is not symptomatic of acoustic neuroma. D. Ataxia is lack of coordination in performing a planned, purposeful motion, such as walking. It is not associated with acoustic neuroma.

Which of the following snacks is MOST APPROPRIATE for meeting the nutritional needs of a patient with severe burns? Vanilla milk shake Carrot sticks Apple slices Flavored gelatin

Vanilla milk shake Explanation: Client Need: Physiological Integrity Rationale: A. The nurse should provide a high-carbohydrate, high-protein diet to meet the increased nutritional needs of the burn patient and to prevent malnutrition. A milk shake contains 11 grams of protein and 60 grams of carbohydrate. B. Carrot sticks contain one gram of protein and seven grams of carbohydrate. C. Apple slices contain a trace of protein and 17 grams of carbohydrate. D. Flavored gelatin contains four grams of protein and 34 grams of carbohydrate.

A nurse caring for a patient who is being treated with lithium carbonate (Eskalith) should be alert for which of the following signs and symptoms? Fine motor tremors Vomiting and diarrhea Still neck and shoulders Seeing halos around lights

Vomiting and diarrhea Explanation: Client Need: Physiological Integrity Rationale: B. Vomiting and diarrhea are early signs of lithium toxicity. Vomiting and diarrhea deplete sodium. Since Lithium is similar in chemical structure to sodium, as the kidneys attempt to compensate for sodium loss by reabsorption of sodium, they also reabsorb lithium, increasing the risk of lithium toxicity. A, C and D. Fine motor tremors, stiff neck and shoulders and seeing halos around lights are not indicative of lithium toxicity.

During an in-service education session for hospital staff, a nurse provides instruction about methods to prevent the spread of respiratory syncytial virus (RSV) on the pediatric unit. The nurse should stress the importance of which of the following measures as a means of control? Wearing a face mask when entering an infected patient's room. Washing hands carefully before and after patient contact. Using a negative pressure air-flow system in all patient rooms. Obtaining personal viral titer levels to establish susceptibility.

Washing hands carefully before and after patient contact. Explanation: Client Need: Health Promotion and Maintenance Rationale: B. The most important infection control procedures to be employed when taking care of a child with respiratory synctial virus (RSV) is consistent hand-washing and not touching the nasal mucosa or the conjunctiva. A.Routine use of gowns and masks has not been shown to be of additional benefit when caring for the patient with RSV. C and D. Other isolation procedures of potential benefit are those aimed at diminishing the number of hospital personnel, visitors and uninfected patients in contact with the child.

When a patient begins clozapine (Clozaril) therapy, a nurse should instruct the patient to return for blood level monitoring: weekly. every two weeks. monthly. every six moths.

Weekly Explanation: Client Need: Physiological Integrity Rationale: A. Because of the risk of agranulocytosis, a baseline white blood cell count before initial treatment, a count every week while on the medication and count for four weeks after discontinuing the drug is recommended. B, C and D. None of these time frames is indicated for blood level monitoring in the patient taking Clozaril.

A 10-year-old child who has cystic fibrosis is receiving pancrelipase (Pancrease) as part of the treatment plan. Which of the following responses by the child indicates that the medication has been effective? Increase in appetite Weight gain Thinning of respiratory secretions Improved pulmonary function

Weight gain Explanation: Client Need: Physiological Integrity Rationale: B. Digestive management of cystic fibrosis consists of pancreatic enzyme replacement, diet adjustment and, in some cases, fat-soluble supplementation to promote growth, adequate nutrition and normal bowel movements. Measurable weight gain is an indication of effectiveness of treatment. A. Nausea is one of the frequent, undesired, clinical responses to Pancrease. C. Pancrease does not thin respiratory secretions. D. Pancrease does not affect lung function.

A nurse is caring for a patient who is receiving lithium carbonate (Eskalith). Prior to administration of the next dose, the nurse finds that the patient's lithium blood level is 1.6 mEq/ L. Which of the following actions should the nurse take first? Call the primary physician. Withhold the dose. Take the patient's vital signs. Repeat the blood lithium level.

Withhold the dose Explanation: Client Need: Safe Effective Care Environment Rationale: B. The first step a nurse should take when a blood lithium level is 1.6 mEq/dL or above is to withhold the lithium dose. A. The physician should be called to re-evaluate the dose after the nurse has the results of a redrawn lithium level. C. Vital signs may be helpful in assessing if the patient is dehydrated, which can cause an increase in lithium levels. However, this should not be the initial action by the nurse. D. The nurse should re-check the lithium level after withholding the dose of lithium.

Which of the following statements is MOST APPROPRIATE for a nurse to make when initiating a painful procedure on a four-year-old boy? "You are a bug boy. I know you can handle this." "You can have your mom hold your hand." "You are not a baby. I know you won't cry." "You will get a treat if you are good."

You can have your mom hold your hand Explanation: Client Need: Health Promotion and Maintenance Rationale: B. When preparing the preschool child for a procedure, it is important to allow choices when possible and encourage parental presence. Other strategies for diverting attention so that the child will be less focused on the procedure include having the child tightly squeeze the hands of a parent or an assistant, count aloud, sing a familiar song such as a nursery rhyme or verbally express discomfort.