4410: H&I3 Exam 3 - Cognition, Behavior
Which statement reflects a truth about rape? 1. Most rapes are planned. 2. Rapists are oversexed. 3. Some women want to be raped. 4. Most women are raped by strangers.
1 Many myths about rape exist. Most rapes are not impulsive, spur-of-the-moment acts, but are carefully planned and orchestrated. All the remaining options are common myths about the act of rape.
Benzodiazepines are useful for treating alcohol withdrawal because they are associated with which action? 1. Exerting a calming effect 2. Decreasing serotonin availability 3. Increasing dopamine release 4. Blocking cortisol secretion
1. Benzodiazepines act by binding to α-aminobutyric acid benzodiazepine receptor sites, producing a calming effect. Benzodiazepines are not associated with any of the other suggested actions
A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? 1. Ciprofloxacin 2. Fosfomycin 3. Nitrofurantoin 4. Trimethoprim-sulfamethoxazole
1. This UTI is a complicated UTI because the patient has type 2 diabetes, and the UTI is recurrent. Ciprofloxacin would be used for a complicated UTI. Fosfomycin, nitrofurantoin , and trimethoprim-sulfamethoxazole should be used for uncomplicated UTIs.
A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. What factors should the case management nurse assess for at the facility? (Select all that apply.) 1. Documentation of prescribed physical therapy sessions 2. Skin breakdown in residents resulting from poor hygiene 3. Altered cognitive function of residents 4. Unexplained bruising of residents 5. High ratio of overweight residents
2, 3, 4 In addition to psychological signs such as depression, signs of elder abuse include bruising from physical abuse and skin breakdown from neglect of hygiene and nutrition; frailty and decreased cognitive function are also risk factors for abuse. Overweight residents and following prescribed treatments are not indicators of abuse or neglect.
Which signs and symptoms are associated with opioid withdrawal? 1. Synesthesia, depersonalization, and hallucinations. 2. Lacrimation, rhinorrhea, dilated pupils, and muscle aches. 3. Illusions, disorientation, tachycardia, and tremors. 4. Fatigue, lethargy, sleepiness, and convulsions.
2. Symptoms of opioid withdrawal resemble the "flu"; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever. None of the other options are generally related to opioid withdrawal. (remember, pinpoint pupils are a sign of opioid toxicity; withdrawal signs would look like the opposite of that- dilated pupils)
What statement made by a client taking disulfiram reveals a need for further teaching? 1. "I take ibuprofen or acetaminophen for headache." 2. "I have had to give up using aftershave lotion." 3. "Most over-the-counter cough syrups are safe for me to use." 4. "I usually treat heartburn with antacids."
3. The client taking disulfiram has to avoid hidden sources of alcohol. Many cough syrups contain alcohol. The remaining statements are correct. Disulfiram (Antabuse): Alcoholism med. It can treat problem drinking by creating an unpleasant reaction to alcohol. At therapeutic doses of disulfiram, alcohol consumption results in increased serum acetaldehyde, causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia. This aggregation of symptoms is known as the disulfiram-alcohol reaction and discourages alcohol intake. It's used in recovery programs that include medical supervision and counseling.
What are the foundational concerns regarding the use of restraint and seclusion when providing care to children? (Select all that apply.) 1. Parents may initiate a lawsuit if injury occurs. 2. Staff tends to be undertrained in use of restraints in children. 3. Staff have conflicted feelings leading to ineffectiveness. 4. The principle of least restrictive intervention is a primary concern. 5. Research suggests both are psychologically and physically harmful.
4, 5 Restraint and seclusion have been shown to be psychologically harmful and may also be physically harmful and result in injury or death. To ensure that the civil and legal rights of individuals are maintained, techniques are selected according to the principle of least restrictive intervention. This principle requires that you use more-restrictive interventions only after attempting less restrictive interventions to manage the behavior that have been unsuccessful. The other options are not correct reasons why restraint and seclusion are controversial in children.
A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is an appropriate response by the nurse? (Select all that apply.) 1. "You will not become physically addicted, but you may develop a physiological addiction." 2. "You will likely experience euphoria from the medication." 3. "You will likely become dependent on this medication and require other medications to control your pain." 4. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." 5. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic."
4, 5 Tolerance is an increasing need for a substance or a lack of effect when a certain dose is given over time. Withdrawal is a syndrome of symptoms that result from stopping the use of a substance. Dependency and psychological addiction do not usually occur with patients that are in pain, because the pain receptors are not being artificially stimulated.
The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern the nurse should address? A. Supervising medication administration B. Managing the patient's pain from arthritis C. Promoting at least 6 hours of sleep a night D. Encouraging an oral intake of 1200 calories per day
A Safety is the priority concern for the cognitively impaired patient; safely taking medication addresses safety needs for the patient. Sleep, nutrition, and management of pain are important components of the patient's care and can affect overall health, but safety is the highest priority.
The most common course of schizophrenia is an initial episode followed by what course of events? A. Recurrent acute exacerbations and deterioration B. Continuous deterioration C. Recurrent acute exacerbations D. Complete recovery
A Schizophrenia is usually a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.
A patient with Alzheimer's Disease attempts to brush their teeth with a spoon. Which problem is evident? A.Aphasia B.Apraxia C.Agnosia D.Perseveration
ANS: C Agnosia is the term used to describe the loss of the ability to recognize what objects are and what they are used for. Agnosia is the term used to describe the loss of the ability to recognize what objects are and what they are used for. Aphasia is the loss of language ability. Apraxia is the inability to perform tasks or movements on command Perseveration is the repetition of a word or phrase, regardless of whether a stimulus is present or removed
Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible. b. Identify the trigger for the anger. c. Behave calmly and respectfully. d. Recognize the patient's need for increased personal space. e. Demands are agreed to as long as they will not result in harm to anyone.
All but e
A patient presents to a rural clinic complaining of substernal chest pain radiating to the jaw and left arm. The patient's electrocardiogram shows ST-segment elevation in leads V3 and V4; BP is 210/135 and HR is 93. The closest facility offering percutaneous coronary intervention (PCI) is 50 miles away but helicopters are grounded due to a blizzard. The priority medication the emergency department nurse should administer at this time is: A. Alteplase IV push B. Heparin IV gtt C. Hydralazine PO D. Nicardipine IV gtt
Answer is D. Nicardipine. Alteplase is currently contraindicated because pt presents with significant HTN (guidelines are SBP must be <180 and DBP must be <110)
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply.) 1. Ticlopidine 2. Clopidogrel 3. Enoxaparin 4. Dipyridamole 5. Enteric-coated aspirin 6. Tissue plasminogen activator (tPA)
Answers: 1, 2, 4, 5 Rationale: Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel, dipyridamole, ticlopidine, combined dipyridamole and aspirin, and anticoagulant drugs such as oral warfarin. Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs or strokes.
Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse? A. Schedule the client to attend group therapy that includes those who have relapsed. B. Teach the client and family about behaviors associated with relapse. C. Remind the client of the need to return for periodic blood draws to minimize the risk for Relapse. D. Help the client and family adapt to the stigma of chronic mental illness and periodic relapses.
B By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted. None of the other options are effective interventions when considering relapse prevention.
Which social behavior is often a result of a child having been exposed to some form of abuse? A. Speech disorders B. Bullying others C. Eating disorders D. Delayed motor skills
B Children who have experienced abuse are at risk for identifying with their aggressor and may act out, bully others, become abusers, or develop dysfunctional interpersonal relationships in adulthood. None of the remaining options are as directly associated with abuse as bullying.
A 72-year-old patient is hospitalized diagnosed with pneumonia and experiencing delirium. The client points to the IV pole and screams, "Get him out of here! He's going to hurt me!". The nurse would use what term to document the response? A. hallucination. B. illusion. C. confabulation. D. delusion.
B Illusions are errors in perception of sensory stimuli. The stimulus is a real object in the environment; however, it is misinterpreted and often becomes the object of the patient's projected fear. Hallucinations are false sensory stimuli. For example, individuals experiencing delirium may become terrified when they "see" giant spiders crawling over the bedclothes or "feel" bugs crawling on or under their bodies. A delusion is described as thinking or believing something that is not true and is seen more often in schizophrenia. For example, a patient may firmly believe that government agencies can read and are monitoring his or her thoughts or that neighbors can see him or her through walls. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem.
Which statement is an accurate depiction of sexual assault? a. Rape is a sexual act. b. Most rapes occur in the home. c. Rape is usually an impulsive act. d. Women are usually raped by strangers.
B Rape is an act of violence, not a sexual act. Most rapes are planned events that are perpetrated by someone the victim knows.
Evidenced Based approaches to prevent Ventilator-Associated Pneumonia (VAP) includes: SATA A. Elevate HOB 15 degrees B. Daily sedation vacation and assessment of readiness to extubate C. Daily oral care using chlorhexidine solution D. Proton pump inhibitor or Histamine-2 antagonist E. Anticoagulants and/or sequential compression devices (SCDs)
B, C, D, E We want HOB elevated 45 degrees (exception: high intracranial pressure pts). Pantoprazole (protonix) or Famotidine prevent gastric ulcers (correlations between gastric ulcers and VAP)
A 78-yr-old man with a history of diabetes has confusion and temperature of 104°F (40°C). There is a wound on his right heel with purulent drainage. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
B. septic shock
Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.
C Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain cause a decrease in blood supply.
Compensation for metabolic acidosis is done how? a. by the kidneys, by excretion of metabolic acids b. by the kidneys, by retention of metabolic acids c. by the lungs, by blowing off CO2 d. by the lungs, hypoventilation and retaining CO2
C. Compensation is done by the opposite organ. Correction is done by the offending organ
Children with Down syndrome should be screened for what potential problem before participating in sports or activities due to risk of spinal cord compression?
Cervical spine (Atlanta-axial) instability
Which type of dementia has a clear genetic link? A. Multi-infarct dementia B. Alcohol-induced dementia C. Creutzfeldt-Jakob disease D. Alzheimer's disease
D Family members of people with Alzheimer's disease have a higher risk of developing the disease than does the general population. Research does not support such a claim for any of the other options.
Which patient has the greatest risk of developing delirium? A. An older patient whose recent CT scan shows brain atrophy. B. A patient with fibromyalgia whose chronic pain has worsened. C. A patient with a fracture who spent the night in the emergency department. An older patient who takes multiple medications to treat various health problems.
D Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.
The mechanism of action of first-generation (typical) antipsychotic medications is related to limiting the availability of which neurotransmitter?
Dopamine
****Additional cognitive impairments (with definitions) related to Alzheimer's disease:
Dysphasia: difficulty comprehending language oral communication Apraxia: inability to manipulate objects or perform purposeful acts Visual agnosia: inability recognize objects by sight Dysgraphia: difficulty communicating via writing Agnosia: inability to recognize familiar objects or family and friends Confabulation: creation of stories/answers in place of actual memories, in order to maintain self-esteem and mask memory loss (subconsciously) Perseveration: persistent repetition of word, phrase, gesture Hyperorality: tendency to put things in the mouth Sundowning: increase agitation in evening Wandering
True or False: Cognitive impairment and intellectual loss is a normal part of aging that is related to a decrease in size and weight of brain, as well as loss of neurons over time.
False Although size, weight, and number of neurons in brain do decrease with age, cognitive decline is not considered a normal occurrence in older age; rather, it is indicative of disease
True or False: IV Inotropes are frequently prescribed for the treatment of both cardiogenic shock and septic shock
False. IV inotropes are used for cardiogenic shock, not septic
What is the spectrum of disorders that is the most unrecognized/undiagnosed, but also the most preventable cause of developmental disabilities in the US?
Fetal Alcohol Spectrum Disorder (FASD)
True or False: Alcohol withdrawal Peaks at 24-96 hours after last drink (usually around 48 hours)
TRUE
True or False? Anion Gap Acidosis occurs because of a gain of metabolic acid.
TRUE
True or False •Chlordiazepoxide, when used in combo with other drugs, has antecedently worked better to treat withdrawal from alcohol than treating with Ativan alone
TRUE Chlordiazepoxide (Librium) has a longer half life than other benzodiazepines, which may blunt the effects of withdrawal. Side effects include respiratory depression, bradycardia, and hypotension
True or False: Vascular dementia can often be prevented through treatment of risk factors.
TRUE Vascular dementia, aka vascular cognitive impairment, is the second most common type of neuro-cognitive impairment. It results from damage to cerebral blood vessels; thus it represents a number of underlying conditions. Risk factors include Hypertension, diabetes, smoking, hypercholesterolemia and plaque formation, cardiac dysrhythmias (Afib), stroke (*stroke is the greatest risk factor for vascular dementia). Vascular dementia (Stroke) tends to be abrupt or progress in a stepwise pattern. Symptoms include impaired judgment, poor decision-making, planning and organizing (executive functions), personality, and mood changes.
Which finding in a patient with Alzheimer's disease best describes the term agnosia? A. The patient uses a fork to eat a bowl of soup. B. The patient makes up a word to recall the name of an object. C. The patient can't recall their address. D. The patient is unable to perform the movements needed to use their hair brush.
The answer is A. agnosia is the inability to interpret sensations and hence to recognize familiar objects, typically as a result of brain damage. Option b describes anomia, option c describes amnesia, option d describes apraxia.
You're providing education about testing for Alzheimer's disease. Which tests below can a patient have to check for beta-amyloid proteins in the brain? Select all that apply: A. X-ray B. Spinal tap C. PET scan D. MRI scan
The answers are B and C. Currently, cerebrospinal fluid can be removed via a spinal tap to check for these proteins along with an amyloid PET scan. Recently, a new blood test has been created that can detected these proteins but may not be readily available for all patient at this time.
What is the Abnormal Involuntary Movement Scale (AIMS)?
This assessment tool is used to identify and track involuntary movements in patients taking antipsychotic medications.
Which intervention(s) should the nurse implement when helping a patient who expresses anger in an inappropriate manner? Select all that apply. a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. c. Warn the patient that being angry is not a healthy emotional state. d. Set limits on the angry behavior that will be tolerated. e. Allow any expression of anger as long as no one is hurt.
a, b, d
What side effects should the nurse monitor for while caring for a patient taking donepezil (Aricept)? Select all that apply. a. Insomnia b. Constipation c. Bradycardia d. Signs of dizziness e. Reports of headache
a, c, d, e, Donepezil is used to treat confusion (dementia) related to Alzheimer's disease. Donepezil is an Acetylcholinesterase Inhibitor, it binds reversibly to acetylcholinesterase and inhibits the hydrolysis of acetylcholine, thus increasing the availability of acetylcholine at the synapses, enhancing cholinergic transmission.
The nurse would suspect cocaine toxicity in the patient who is experiencing a. agitation, dysrhythmias, and seizures. b. blurred vision, restlessness, and irritability. c. diarrhea, nausea and vomiting, and confusion. d. slow, shallow respirations; bradycardia; and hypotension.
a. Rationale: The following symptoms may occur with a cocaine overdose: agitation; increases in temperature, pulse, respiratory rate, and BP; cardiac dysrhythmias and myocardial infarction; hallucinations; seizures; and possible death.
Which of the following is the most common comorbid diagnosis associated with Fetal Alcohol Syndrome? a. Down Syndrome b. Attention Deficit Hyperactivity Disorder c. Depression d. Schozophrenia
b. ADHD
Which physical skin finding indicates opioid abuse? a. Diaphoresis b. Needle marks c. Spider angiomas d. Red, dry skin
b. needle marks (Diaphoresis may be associated with opioid withdrawal). Clinical manifestations of depressant toxicity: CNS: vAggressive behavior vAgitation vConfusion vLethargy vStupor vHallucinations vDepression vSlurred speech vPinpoint pupils vNystagmus vSeizures Cardiovascular: vRapid, weak pulse vHypotension vDysrhythmias vECG changes
Which neurotransmitter is potentiated by benzodiazepines? a. Acetylcholine b. Dopamine c. γ-aminobutyric acid d. Serotonin
c Benzodiazepines promote the activity of γ-aminobutyric acid (GABA) by binding to a specific site on the GABAA receptor complex. This binding results in an increased frequency of chloride channel opening, causing membrane hyperpolarization, which reduces cellular excitation. If cellular excitation is decreased, the result is a calming effect. Fig. 3.10 shows that benzodiazepines enhance the effects of GABA. (Halter, 2022, p. 49)
5. Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia
d. Paranoia
Negative symptoms of Schizophrenia, definitions:
• Anhedonia (an = without + hedonia = pleasure): A reduced ability or the inability to experience pleasure. • Avolition (a = without + volition = initiating an action): reduced motivation or goal-directed behavior; difficulty beginning and sustaining goal-directed activities. • Asociality: Decreased desire for social interaction or discomfort during it; social withdrawal. • Affective blunting: Reduced or constricted affect. • Apathy: Decreased interest in activities or beliefs that would otherwise be interesting or important or little attention to them. • Alogia: Reduction in speech, sometimes called poverty of speech.
The medication prescribed for a client acts by blocking reuptake of both serotonin and norepinephrine. The nurse evaluates the treatment as successful when observing which client behavior? 1. Apologizing for being sarcastic 2. Laughing at a joke 3. Going to his room to "calm down" 4. Writing down a telephone number
2 Depression is thought to be at least in part caused by lowered levels of serotonin and norepinephrine. Increasing the amount of these transmitters in the brain by blocking reuptake may result in mood elevation. While the other options demonstrate positive behaviors, none are directly associated with such a medication.
An elderly woman who has been abused by her caregiver daughter tells the nurse, "You don't have to worry about me. My daughter cried and apologized. She promised me she will never hit me again." The nurse recognizes that the client is describing which stage of the cycle of violence? 1. Escalation 2. Honeymoon 3. Acute battering 4. Tension building
2 During the honeymoon stage, the perpetrator apologizes, promises never to abuse again, and tries to make up for the violence. This stage is usually brief. None of the other stages in this cycle are characterized by this behavior.
The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? 1. "If you have questions, its best to ask the doctor." 2. "Starting him on treatment now gives your child a much greater chance for a productive life." 3. "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." 4. "If your child starts therapy now, he will be able to stop therapy sooner."
2 Early intervention for children with autism can greatly enhance their potential for a full, productive life. 3 years old is not too young to start therapy since the sooner therapy is started, the better the outcome. The patient will most likely not be able to stop therapy as interventions will continue indefinitely. Telling the mother to ask her provider abdicates the nurse's responsibility to provide education to patients and families.
When interviewing an adult victim of abuse, what is the nurse's best approach when asking relevant questions? 1. Gentle but direct 2. Direct and professional 3. Sympathetic but detached 4. Confrontational and assertive
2 Expressing strong emotion does not help the victim. A direct, honest, and professional manner of asking questions produces the best results. None of the other options are recognized as being effective in this type of interview situation.
Which statement reflects a fact about family violence? 1. Alcohol and stress are the major causes of abuse. 2. Violence occurs in families of all backgrounds. 3. The victim's behavior is often the cause of the violence. 4. Ninety-five percent of abuse victims are women.
2 Family violence is a serious community health problem common among all backgrounds. None of the other statements provide accurate information about family violence.
A patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. What is the most appropriate intervention by the nurse? 1. Challenge the patient's delusion. 2. Provide canned food while expressing reasonable doubt. 3. Agree with the patient's decision. 4. Dismiss her fears and insecurities.
2 Highly suspicious patients may refuse to eat food from an individually prepared tray. While not reinforcing the patient's delusion by agreeing with it, providing canned food may be an acceptable alternative to ensure proper nutrition. Challenging the delusion may increase the patient's anxiety. Dismissing her fears and insecurities invalidates the patient's emotional state.
An adolescent is swearing and shouting at the primary care provider who refused to agree to a pass to leave the unit. What is the primary importance of this behavior? 1. It can be attributed to lack of parental controls applied at an early age. 2. It is a major indicator that the client may become physically aggressive. 3. It is acceptable if directed at staff but not when directed at other clients. 4. It may reduce tension and prevent the client from physically acting out.
2 Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors. It is not acceptable behavior regardless of its focus nor is it generally associated with a lack of parental controls. The release of tension is not the focus of this question.
A client has a 4-year history of using cocaine intranasally. When brought to the hospital in an unconscious state, what nursing measure should be included in the client's plan of care? 1. Induction of vomiting 2. Observation for tachycardia and seizures 3. Monitoring of opiate withdrawal symptoms 4. Administration of ammonium chloride
2 Tachycardia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose. None of the other options are associated with the nursing care required of cocaine stimulation.
When should the nurse expect the abuse of a victim to worsen? 1. The perpetrator is feeling remorseful for being abusive. 2. The victim moves toward independence from the abuser. 3. The victim submits to the domination of the perpetrator. 4. The perpetrator feels he is in complete control.
2 When the abuser thinks they are losing control over the victim, the violence escalates. None of the other options are associated with the escalation of abuse by the perpetrator against the victim.
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1. Place in a warm, dry environment. 2. Maintain standard and contact precautions. 3. Administer prescribed antibiotic immediately. 4. Allow parents and siblings to room in with the infant.
2. RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.
A client is admitted to the hospital after vomiting for 3 day. What arterial blood gas (ABG) results should the nurse expect? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.34; PaCO2 50; HCO3 28 4. pH 7.48; PaCO2 30; HCO3 23
2. pH 7.47; PaCO2 43; HCO3 28 Rationale: Vomiting leads to the loss of hydrochloric acid from gastric acids. Hydrogen ions must leave the blood to replace this acidity in the stomach. Metabolic alkalosis occurs and is reflected by elevated pH and HCO3 - and normal PaCO2. The ABG with the pH of 7.30 is incorrect because it reflects respiratory acidosis with partial compensation (decreased pH and elevated PaCO2 and HCO3 -). The ABG with the pH of 7.34 is incorrect because it reflects a mixed acid-base imbalance (metabolic alkalosis with respiratory acidosis) with a normal pH and elevated PaCO2 and HCO3 -. The ABG with the pH of 7.48 is incorrect because it reflects respiratory alkalosis (increased pH, decreased PaCO2, and normal HCO3 -)
Which nursing intervention is best directed at the psychological needs of a physically abused client? 1. Encourage the client to immediately leave the abuser. 2. Provide a referral to social services for economic problems. 3. Affirm that the client did not deserve or cause the abuse. 4. Facilitate contact with law enforcement to take legal action.
3 Abused clients often believe that they are deserving of the abuse and, in some way, prompt the abuser to attack. They need specific reassurance that they did not deserve to be abused and they did not cause the attack. The remaining options are directed to either safety or physical needs.
The nurse responsible for the care of a client prescribed clonazepam should evaluate treatment as being successful when the client demonstrates which behavior? 1. Normal appetite 2. Improved physical balance 3. Less anxiety 4. Reduced auditory hallucinations
3 Clonazepam is a benzodiazepine thought to enhance the effects of GABA. GABA is associated with the production of a calming emotional state. None of the other options are associated with clonazepam.
Which statement, made by a female adult concerning her boyfriend, should cause the nurse to suspect that the client is at risk for being emotionally abused? 1. "He has a good job and keeps control of all the finances but our electricity still got turned off last week." 2. "I didn't tell him I was coming because he is under so much stress at work I didn't want to add to it." 3. "He yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." 4. "He has always had a fiery temper."
3 Emotional abuse may be less obvious and more difficult to assess than physical violence, but it can be identified through indicators such as low self-esteem, reported feelings of inadequacy, and anxiety. Controlling the finances and having the electricity turned off describes the possibility of economic abuse. Not wanting to add to the boyfriend's stress does not describe an abusive situation. Describing the boyfriend as having a temper would more likely hint at physical abuse rather than emotional.
Which neurotransmitter imbalance has been shown to be related to impulsive aggression? 1. High levels of norepinephrine 2. Low levels of ã-aminobutyric acid 3. Low levels of serotonin 4. High levels of acetylcholine
3 Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression. Research does not support any of the other options.
The nurse performing the assessment of a wheelchair-bound client suspects that his wife's explanation of how he sustained facial contusions and a broken nose may not be entirely truthful. The nurse should implement which assessment intervention? 1. Document the suspicion and follow a policy of "wait and see" whether he returns again. 2. Report the husband's injuries to the police and ask for a confidential investigation. 3. Have the wife wait in the waiting room so her husband can be interviewed in private. 4. Confront the wife with the suspicion that her husband's injuries are the result of abuse.
3 Suspected victims of abuse should always be interviewed in private. If the perpetrator is in the room, the victim cannot speak freely. Confronting the wife would likely cause her to be uncooperative and increase tensions. Neither of the other options address the assessment interview process.
Which statement best illustrates support in giving care to a patient who has just been sexually assaulted? 1. "Don't worry. It's hard now, but everything will be alright." 2. "I'm so sorry for what you have been through." 3. "I am going to stay with you. We can talk as long as you want to." 4. "Let's talk about new coping skills you can use."
3 The most effective approach for counseling in the emergency department or crisis center is to provide nonjudgmental care and optimal emotional support. Sympathy is not a therapeutic response and does not focus on the patient. Telling the patient not to worry is false reassurance. It is too soon to try to learn new coping skills because the patient is in an acute stress phase.
A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. What action the nurse should take? 1. Ask the supervising nurse to reassign the client. 2. Refer the woman for social services counseling. 3. Report and document the request. 4. Ask the client to reevaluate her request after 24 hours.
3 The nurse's ethical beliefs should never interfere with client rights. The nurse should report and document the client's request.
The nurse caring for a client prescribed an antidepressant medication that produces anticholinergic side effects should assess for which possible side effects? (Select all that apply.) 1. Memory dysfunction 2. Ejaculatory dysfunction 3. Dry mouth 4. Constipation 5 Blurred vision
3, 4, 5 Anticholinergic effects are the effects produced by atropine: dry mouth, dry eyes, blurred vision, constipation, and urinary retention. None of the remaining options are associated with anticholinergic side effects. (Chris's way to remember: "No see, no pee, no spit, no sh**")
A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? (Select all that apply.) 1. Is capable of providing effective oral self-care 2. Enjoy interacting with developmentally similar peers 3. Physically lashes out when frustrated 4. Reads below age level 5. Unable to explain the phrase, "Raining cats and dogs"
3, 4, 5 IDD is characterized by severe deficits in three major areas of functioning: intellectual, social, and managing daily life. These children demonstrate difficulty with self care and with almost any social interactions.
The nurse is assessing a 4-year-old child in a health clinic. Which situation should cause the nurse to explore for possible abuse? 1. The caregiver reporting angry outbursts from the child while they were in a store 2. Being brought to the clinic from daycare 3. Recent scrapes and bruises on both knees 4. Different explanations of the injury from the child's parent
4 Inconsistent explanations from parents for how injuries occurred is a cause for further investigation. Being brought in from daycare, school, camp, or other public areas does not automatically indicate abuse. Scrapes on the knees are a common developmental injury for a 4 year old. Angry outbursts or tantrums in children in this age-group are still expected developmental behaviors.
A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? 1. The patient may be having an acute psychotic episode related to her mental illness. 2. The patient may be a very demanding and particular person. 3. The patient may be abusing street drugs and needs a drug screening test. 4. The patient may have been the victim of an acute assault.
4 Refusing care from a caregiver of another gender, wanting easy escape access, and having poor eye contact all indicate that an assault may have occurred. Acute psychosis, use of street drugs, or being a demanding person does not elicit the signs of wanting to protect herself from others.
When approaching a client who is acting out aggressively, what interventions should the nurse implement to assure personal safety? 1. Take the client to his/her room so that his/her privacy will be protected. 2. Stand close to the client for reassurance and to convey caring. 3. Call security and wait until they arrive before approaching the client. 4. Have other staff as backup, and stay out of the client's personal space.
4 Safety considerations for staff include enlisting other staff to be present, keeping a safe distance from the patient, and approaching the patient in a nonthreatening or nonconfrontational manner. None of the other options focus appropriately on staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, being alone in the client's room is not a safe environment when aggressive behavior is being demonstrated.
A client has a history of demonstrating aggression physically. What short-term goal will best help the client manage this anger? 1. Strike objects rather than people. 2. Isolate in lieu of striking people. 3. Limit aggression to verbal outbursts. 4. Identify situations that precipitate hostility.
4 The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies. All the remaining options only suggest limiting the anger.
During the immediate post-rape period what verbal nursing intervention would best lower client anxiety and increase feelings of well-being? 1. "When you leave you will be given follow-up appointments for pregnancy and sexually transmitted disease screening." 2. "I know you feel confused. We will make all the necessary decisions for you." 3. "Please tell me as much about the details of the rape as you can remember." 4. "You are safe here. I will stay with you while you have your examination."
4 The presence of the nurse is reassuring, especially when the client is experiencing disorganization and the environment is confusing. Safety is the primary concern for both the client and the nurse. The nurse's presence conveys a sense of safety to the client. None of the other options address safety and well-being.
A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by implementing which intervention? 1. Continuing to manage the situation personally. 2. Apologizing for upsetting the client. 3. Telling the client, "It isn't safe for me to leave the room." 4. Moving outside of the client's personal space.
4 There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable. None of the other options are addressing the client's reasonable request.
What older concept of care is being used currently to help in violence reduction in disruptive clients? 1. Aired grievances 2. Shared governance 3. Learned helplessness 4. Trauma-informed care
4 Trauma-informed care is an older concept of providing care that has been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patients' past experiences of violence or trauma and the role it currently plays in their lives. None of the other options refer to a care concept that helps reduce violence.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe. 1. Respirations that cease for several seconds 2. Respirations that are regular but abnormally slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate.
4-Rationale: Kussmal's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? 1. "It helps your mood so that you don't feel the need to do drugs." 2. "It is a sedative that will help you sleep at night, so you are more alert and able to make good decisions." 3. "It will keep you from experiencing flashbacks." 4. "It helps prevent relapse by reducing drug cravings."
4. Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone. Naltrexone (Vivitrol, Revia): pharmacologically effective against alcohol and opioids by blocking the mu-opioid receptor.
The family members of a client with early-stage Alzheimer's disease cannot provide adequate supervision for the client. What would be a reasonable alternative for the nurse to explore with them to meet their current needs? A. Day care B. Acute care hospitalization C. Long-term institutionalization Group home residency
A Day care is a good option for clients with early-stage Alzheimer's disease. It provides supervision, a protected environment, and supportive interactions. The other options may be considered as the client moves into the advance stages of the disease disorder.
A prescription for which medication would require the nurse to monitor the client for potential development of the side effect of hypothyroidism? A. Lithium B. Imipramine C. Bupropion D. Fluoxetine
A Long-term use of lithium may cause hypothyroidism. The other options refer to drugs whose long-term use does not cause hypothyroidism.
Which of the following would be assessed as a negative symptom of schizophrenia? A. Anhedonia B. Hostility C. Agitation D. Hallucinations
A Negative symptoms refer to deficits that characterize schizophrenia. They include the crippling symptoms of affective blunting (lack of facial expression), anergia (lack of energy), anhedonia (inability to experience happiness), avolition (lack of motivation), poverty of content of speech, poverty of speech, and thought blocking.
Which patient should receive a depression assessment first? A. A patient in the early stages of Alzheimer's disease B. A patient who is in the final stage of Alzheimer's disease C. A patient experiencing delirium secondary to dehydration A patient who has become delirious following an atypical drug response
A Patients in the early stages of Alzheimer's disease are particularly susceptible to depression because they are acutely aware of their cognitive changes and the expected disease trajectory. Delirium is typically a short-term health problem that does not typically pose a heightened risk of depression.
The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A. Provide a quiet environment in a private room. B. Keep a radio on all the time to provide sound for the patient. C. Decrease patient confusion by limiting verbal interactions. D. Limit family visits to one person for 30 minutes per day.
A The patient experiencing dementia needs a quiet environment with a minimum of unfamiliar stimulation from a roommate. A patient with dementia does not need extra stimulation from having a radio on continually. The nurse should speak clearly and quietly to the patient before any procedure or assistance to decrease agitation. Family visits would be encouraged because family members are familiar to the patient and their presence increases a sense of security.
A 78-yr-old woman was transferred to the intensive care unit after emergency abdominal surgery. The nurse notes the patient is disoriented and confused, has incoherent speech, is restless, and agitated. Which action by the nurse is most appropriate? A. Reorient the patient. B. Document the findings. C. Notify the health care provider. D. Administer lorazepam (Ativan)
A The patient has manifestations of delirium. Care of the patient with delirium is focused on eliminating precipitating factors and protecting the patient from harm. Give priority to creating a calm and safe environment. The nurse should stay at the bedside and provide reassurance and reorienting information as to place, time, and procedures. The nurse should reduce environmental stimuli, including noise and light levels. Avoid the use of chemical and physical restraints if possible.
Which statement by the wife of a patient with Alzheimer's disease demonstrates an accurate understanding of her husband's medication regimen? A. "I'm really hoping his medications will slow down his mental losses." B. "We're both holding out hope that this medication will cure his disease." C. "The medications might prevent a bodily decline while he declines mentally." D. "If we follow his medication schedule, he may not have any physical effects of his disease."
A There is presently no cure for AD, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) is reprimanded for taking the nurse's pen without asking first. He responds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding with which statement? A. "I do like you, but I don't like it when you grab my pen." B. "You must ask for permission before taking someone else's things." C. "Liking you has nothing to do with whether I will loan you my pen." D. "It sounds as though you are feeling helpless and insecure."
A This reply shows positive regard for the child while describing the behavior as undesirable. Feedback such as this helps the child feel accepted while making her aware of the effect her behavior has on others. None of the other options provide the necessary degree of positive regard.
The nurse is caring for a patient admitted to the hospital with pneumonia that has a history of misusing a variety of sedative-hypnotic drugs. Which manifestations noted by the nurse could be attributed to withdrawal? (Select all that apply.) A. Anxiety B. Tremors C. Seizures D. Delirium E. Drowsiness F. Hypertension
A, B, C, D Withdrawal from sedative-hypnotics can be life threatening. The manifestations and treatment are similar to AWS. Early, the patient may have tremors, anxiety, insomnia, fever, orthostatic hypotension, and disorientation. Later, the patient may experience delirium, seizures, and respiratory and cardiac arrest. Drowsiness would be an effect of taking alprazolam, not withdrawing from it.
Symptoms associated with Wernicke's encephalopathy include: SATA A-Loss of muscle coordination/ altered gait B-Vision changes C-Appear drunk D-Extreme confusion E-Loss of mental activity/ vestibular dysfunction F-Memory Loss G-Confabulation H-Hallucinations
A, B, C, D, E Vision changes associated with Wernicke's encephalopathy include: nystagmus, orbital palsy, gaze palsy, sluggish rxn to light, anisocoria. Wernicke's encephalopathy may be reversible if treated promptly. F, G & H are associated with Korsakoff syndrome or psychosis. Korsakoff's syndrome may be irreversible. Wernicke-Korsakoff Syndrome is the combination of two conditions in the brain caused by thiamine, or vitamin B1, deficiency
An intensive care unit is receiving a patient from the psychiatric hospital with suspected neuroleptic malignant syndrome. The nurse expects the patient to exhibit the following signs and symptoms? (select all that apply) a.Ataxia b.Pyrexia c.Hypotension d.Tachycardia e.Flaccid muscles
A, B, D Typical/First-generation Antipsychotics: treat positive symptoms *SD FX: Prolonged QT interval, Parkinsonian symptoms -Neuroleptic Malignant Syndrome: *High fever, muscle rigidity, tachycardia, tachypnea, hypertension, confusion, coma *Fever (can be as high as 107F) *Sweating, pale, excessive salivation *Arrhythmias *Change in LOC *Severe EPS *Elevated WBC's, Liver function studies, Creatine kinase/myoglobin *Rare, but can be fatal -Atypical/Second-generation Antipsychotics: treat positive and negative symptoms *Prolonged QT interval *Liver function tests *Metabolic syndrome *Agranulocytotsis - which specific medication? CLOZAPINE
The stroke (STK) core measures were developed in partnership with the American Stroke Association (ASA) for use by primary stroke centers. These measures include: SATA A. Stroke Education B. Assessment for rehabilitation C. ACE Inhibitor prescription on d/c D. Enoxaparin prescription on d/c E. Statin prescription on d/c
A, B, D, E STK-1 Venous thromboembolism (VTE) prophylaxis STK-2 Discharged on antithrombotic therapy STK-3 Anticoagulation therapy for atrial fibrillation/flutter STK-4 Thrombolytic therapy STK-5 Antithrombotic therapy by end of hospital day 2 STK-6 Discharged on statin medication STK-8 Stroke education STK-10 Assessed for rehabilitation
In which of the following cases is it mandatory that a nurse report a suspected sexual assault of their patient in New Mexico? SATA a. When a child under the age of 13 is assaulted by an adult b. When an elderly patient is assaulted by a caregiver c. When a 14 year old is assaulted by a 19 year old stranger d. When a 14 year old is assaulted by their sister's boyfriend, who lives in their home with them. e. An adult patient with severe autism spectrum disorder is assaulted by another adult
A, B, D, E NM is not a mandatory reporting state for sexual assault on adults, Intimate-partner violence, or domestic abuse. ¤e.g., Do not report statutory rape-- Only report if patient request help to do so. -It is mandatory reporting if you suspect child abuse/sexual abuse, for age 12 and under in NM. (age of censent in NM is 13) -If the person is one in authority, and the person is under 18 (13-17), then it is mandatory. Authority could mean many things: busdriver, parent, priest, police, coach, teacher, trafficking situation, etc. -It is mandatory to report elder abuse (this is when an elderly person requires care for ADLs, has a caregiver, and in some other situations) -It is mandatory to report when a person with an intellectual disability is assaulted.
Drugs most commonly used for Alzheimers disease include: SATA a. Donepezil (Aricept) b. Diazepam (Valium) c. Risperidone (Risperidal) d. Galantamine (Razadyne) e. Rivastigmine (Exelon) f. Memantine (Namenda, Namenda XR)
A, D, E, F Cholinesterase inhibitors such as Donepezil, Galantamine, and Rivastigmine slow the destruction of acetylcholine. Memantine is a Glutamate-blocking agent.
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) a week ago. You find him sitting stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply. a. Hold his medication and contact his prescriber stat. b. Wipe him with a washcloth that has been wetted with cold water or alcohol. c. Administer an "as needed" medication such as benztropine intramuscularly to correct his dystonic reaction. d. Reassure him that no treatment is needed and that this reaction will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today.
A, b Pt is experiencing NMS, a serious adverse effect that can occur from antipsychotics. his requires immediate intervention and the provider should be notified immediately. Benztropine is an anticholinergic/antiparkinsonian, used for treatment of EPS
While caring for a patient who is experiencing alcohol withdrawal, the nurse should (select all that apply) a. monitor neurologic status on a routine basis. b. provide a quiet, nonstimulating, dimly lit environment. c. pad the side rails and place suction equipment at the bedside. d. orient the patient to environment and person with each contact. e. give antiseizure drugs and sedatives to relieve withdrawal symptoms.
A, c, d, e (all but b) Rationale: For patients in withdrawal, nursing management includes monitoring neurologic status and vital signs and giving drugs to prevent the progression of symptoms and increase patient comfort. Maintaining a well-lit environment that reduces sharp contrasts and shadows is important to reduce external stimuli. To prevent injury associated with seizure activity, nurses should keep suction equipment, an Ambu bag, and an oral or nasopharyngeal airway at the patient's bedside and use padded side rails.
The nurse administers the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because: A. delirium can be reversed by treating the underlying cause B. depression in a common cause of dementia in older adults C. nursing care should be based on the cause of cognitive impairments D. drug therapy with antipsychotics is indicated in the treatment of dementia
A. delirium can be reversible the CAM is used to diagnose delirium
The nurse is providing care for a patient admitted with alcohol withdrawal delirium. Which intervention should be the first priority for the nurse? A. Applying physical restraints B. Reorienting the patient frequently C. Asking the patient about his last alcohol intake D. Scoring the patient using a symptom assessment tool
C Management begins with identifying at-risk people. Use a symptom assessment tool, such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). Physical restraints are rarely necessary if drugs administered during withdrawal are appropriately used. Information about treatment for alcohol dependency is not appropriate at this acute stage.
The nurse caring for a client diagnosed with Alzheimer's disease can anticipate that the family will need information about which medication therapy? A. Immunosuppressants B. Antihypertensives C. Acetylcholinesterase inhibitors D. Benzodiazepines
C Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.
Which of the following symptoms would alert a healthcare provider to a possible diagnosis of schizophrenia in a 22-year-old male client? A. Withdrawal from college because of failing grades B. Chaotic and dysfunctional relationships with his family and peers C. Hearing voices telling him to hurt his roommate D. Excessive sleeping with disturbing dreams
C People diagnosed with schizophrenia all have at least one psychotic symptom such as hallucinations, delusional thinking, or disorganized speech. The other options do not describe schizophrenia but could be caused by a number of problems.
A student nurse is working with an 82-year-old patient diagnosed with dementia. The student is frustrated at times by not knowing how best to care for or communicate with the client. Which of the statement by the student best illustrates best care practice? A. Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." B. Lighthearted banter: "You look great today in your new sweater, you handsome devil!" C. Positive regard: "I am glad to be here caring for you today. Let's talk about our plans for the day." D. Limit setting: "You cannot yell out in your room. You are upsetting other patients."
C Positive regard implies respect. It is the ability to view another person as being worthy of caring about and as someone who has strengths. The attitude of unconditional positive regard is the nurse's single most effective tool in caring for people with dementia. It induces people to cooperate with care and increases family members' satisfaction with care. Although the patient may not be able to verbalize plans for his day, this response conveys belief that the patient has something to offer and treats him with respect. It also shows that the nurse wants to care for the patient and conveys commitment to the relationship. Limit-setting may be necessary at times; however, it is not the most effective care tool. The other responses are nontherapeutic.
Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his "nice" mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect
C Resilience refers to developing and using certain characteristics that help a child to handle the stresses of a difficult childhood without developing mental problems. Resilient children can adapt to changes in the environment, form nurturing relationships with adults other than their parents, distance themselves from the emotional chaos of the family, and have social intelligence and the ability to use problem-solving skills.
The primary healthcare provider mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess for which nightly behavior? A. Depression B. Lethargy C. Agitation D. Mania
C Sundowning involves increased disorientation and agitation occurring at night. None of the other options are associated with sundowning.
Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-yr-old female patient. The home care nurse plans a visit to evaluate the patient's cognitive function. Which assessment would be most appropriate? A. Glasgow Coma Scale (GCS) B. Confusion Assessment Method (CAM) C. Mini-Mental State Examination (MMSE) D. National Institutes of Health Stroke Scale (NIHSS)
C The MMSE is often used to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
A patient is diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing intervention is most appropriate for the nurse use with the patient? A. Communicate using a letter or picture board. B. Treat disruptive behavior with antipsychotic drugs. C. Use a calendar and family pictures as memory aids. D. Apply a wander guard mechanism to keep the patient in the area.
C The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.
A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A. Adolescents attending summer camps B. Older female adults who are overweight C. Older male adults with diabetes D. Young adults living in school dormitories
C The primary risk factor for cognitive impairment is advancing age; males with a history of stroke or diabetes are at significant risk. Older females with a history of poor health, insomnia, and lack of social support are at risk for cognitive impairment, not those who are overweight. Risk factors for young adults include substance abuse and high-risk behaviors, not crowded living conditions. Adolescents who attend summer camp are not necessarily at risk for cognitive problems; adolescents who participate in high-risk behaviors would be at risk.
A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. Which response should the nurse provide to this client statement? A. "You are safe here in the hospital; nothing bad will happen to you." B. "The voices are wrong about the hospital food. It is not contaminated." C. "I understand that the voices are very real to you, but I do not hear them." D. "Other people are eating the food, and nothing is happening to them."
C This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing. This is the only option that provides such support.
When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," what would be an appropriate response for the nurse to make? A. "I do not believe I understand the word volmers. Tell me more about them." B. "Why do you think someone, or something is going to harm you?" C. "It must be frightening to think something is going to harm you." D. "You are safe here. This is a locked unit, and no one can get in."
C This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option A gives global reassurance. Option B encourages elaboration about the delusion. Option C asks for information that the client will likely be unable to answer.
Which nursing intervention is most appropriate when caring for patients with dementia? A. Avoid direct eye contact. B. Lovingly call the patient "honey" or "sweetie." C. Give simple directions, focusing on one thing at a time. D. Treat the patient according to their age-related behavior.
C When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not show respect.
Substance use problems in older adults are usually related to a. use of drugs and alcohol as a social activity. b. continuing the use of illegal drugs started during middle age. c. misuse of prescribed and over-the-counter medications and alcohol. d. a pattern of binge drinking for weeks or months with periods of sobriety.
C Rationale: HCPs are much less likely to recognize substance use in older adults than in younger adults. Older adults may misuse prescription and over-the-counter medications and alcohol
Select all of the following statements that are true about Dexmedetomidine as it applies to alcohol withdrawal: A. May cause respiratory depression B. Should not be given to someone with EtOh toxicity C. May cause bradycardia and hypotension D. Titrated med only administered in the intensive care unit E. Should be given to someone with EtOh toxicity to lessen the severity of withdrawal F. Administered PO/IV to manage EtOh withdrawal based on CIWA-a score
C, D Dexmedetomidine (Precedix) is an alpha2 agonist used for sedation and to control hyperactivity in patients suffering from alcohol withdrawal. Its mechanism of action including the inhibition of norepi, thus causing vasodilation, which leads to the side effects of hypotension and bradycardia. It is only administered in the ICU. It does NOT cause respiratory depression like benzodiazepines do.
Benzodiazepines are indicated in the treatment of delirium caused by which condition? A. Polypharmacy B. Cerebral hypoxia C. Alcohol withdrawal D. Electrolyte imbalances
C. Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.
The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response. a. "Hormone therapy will reverse the condition." b. "Vitamin C and zinc will reverse the condition." c. "There is no treatment to reverse dementia." d. "Dementia can be reversed with diet, exercise, ad medications."
C. Dementia is irreversible. Delirium is reversible.
A female patient presents to the emergency department reporting the most severe headache of her life. Which type of stroke should the nurse anticipate? 1. TIA 2. Embolic stroke 3. Thrombotic stroke 4. Subarachnoid hemorrhage
Correct Answer: Subarachnoid hemorrhage Rationale: Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.
Treatment modalities for the management of cardiogenic shock include (select all that apply) a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.
Correct answer: a, c Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.
A patient admitted for scheduled surgery has a positive brief screening test result for an alcohol use disorder. Which initial action is most appropriate? a. Notify the health care provider. b. Complete a detailed alcohol use assessment. c. Initiate a referral to a specialty treatment center. d. Provide patient teaching on postoperative health risks.
Correct answer: b Rationale: Patients with a positive brief screening test result need to undergo a more detailed assessment, including the substance used, dose taken, method of intake, and length of time of substance use. After the assessment is complete, alert the HCP as the patient who uses substances will need specialized care.
Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.
Correct answer: c Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain cause a decrease in blood supply.
Which patient is most at risk for developing delirium? a. A 50-yr-old woman with cholecystitis b. A 19-yr-old man with a fractured femur c. A 42-yr-old woman having an elective total hysterectomy d. A 78-yr-old man admitted to the medical unit with complications of heart failure
Correct answer: d Rationale: Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium (Table 59-16).
The clinical diagnosis of dementia is based on a. CT or MRS. b. brain biopsy. c. electroencephalogram. d. patient history and cognitive assessment.
Correct answer: d Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical assessment is done to rule out other potential medical conditions. Cognitive testing (e.g., MiniMental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions on neuroimaging, and the exclusion of other causes of dementia. Structural neuroimaging with CT scan or MRI is used to evaluate patients with dementia but does not provide a definitive diagnosis. A psychologic evaluation is needed to determine the presence of depression.
Which statement(s) accurately describe(s) mild cognitive impairment? (select all that apply) a. Cannot be detected by screening tests b. The person may appear normal to the casual observer c. Family members may see changes in the patient's abilities d. Problems that the person is experiencing interfere with daily activities e. The person is usually aware that there is a problem with his or her memory
Correct answers: b, c, e Rationale: The patient with mild cognitive impairment has problems that are severe enough to be noticed by the person having them and to others and can be found on screening tests. Family members may see changes in the person's abilities. To the casual observer, the person with MCI may seem normal. Because the problems do not interfere with daily activities, the patient does not meet the criteria for being diagnosed with dementia.
The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply.) Select all that apply. a. Decreased urinary output and irritability b. Transient headache and +1 proteinuria c. Ankle clonus and epigastric pain d. Platelet count of less than 100,000/mm3 and visual problems e. Seizure activity and hypotension
Correct: A, C, D Rationale: Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of severe eclampsia.
A patient reports that "the voices are really bad today." Helpful nursing responses would include a. Giving an additional "as needed" dosage of his antipsychotic medication. b. Telling him that the voices are not real and that he should ignore them. c. Directing him to return to his room and try not to think about the voices. d. Encouraging the patient to use competing auditory stimuli, such as humming or listening to music.
D A person who hears voices struggles wo understand the experience, sometimes developing related delusions to explain the voices. For example, a person may believe that the voices are from God or from a device implanted by the CIA. Patients may try to cope by drowning our auditory hallucinations with loud music or by talking loudly, humming, or singing Such competing auditory stimuli, may in fact, reduce hallucinations and serve as a recommended intervention. (Halter, 2022, p. 196)
A 62-year-old patient who is recovering from a urinary tract infection that has required hospitalized for delirium. Based on research regarding possible post delirium complications, what are important areas for the provider to assess regularly after discharge? A. Sexual functioning B. Sleeping habits C. Symptoms of posttraumatic stress D. Depression and level of cognition
D Although delirium is usually a short-term condition, it may have long-term consequences. In patients with preexisting cognitive impairment, there is an acceleration of cognitive decline. Although there are reports of long-term cognitive impairment (in the absence of preexisting cognitive impairment) and functional decline following delirium, results of studies have been inconsistent. An association also exists with depression after delirium. Although a holistic examination would assess sleep, this is not the area that research has found to be problematic. A holistic examination would include sexual functioning, but it is not the priority at this time. Posttraumatic stress symptoms have been seen in younger patients who experienced delirium while hospitalized.
The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease (AD)? A. A 65-yr-old male patient does not recognize his family members and close friends B. A 59-yr-old female patient misplaces her purse and jokes about having memory loss C. A 79-yr-old male patient is incontinent and not able to perform hygiene independently. D. A 72-yr-old female patient is unable to locate the address where she has lived for 10 years.
D An early warning sign of AD is disorientation to time and place such as geographic disorientation. [Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of AD. ] Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a manifestation of middle or moderate dementia (or AD). Incontinence and inability to perform self-care activities occur with severe or late dementia (or AD).
What initial intervention should the nurse suggest to the family members of a client diagnosed with Alzheimer's disease who has become incontinence of urine? A. Provide toileting on an as-needed basis. B. Apply disposable diapers. C. Encourage hourly toileting. D. Label the bathroom door with a picture.
D Labeling doors and various items with pictures can be helpful for a client who has forgotten where things are and what certain items are. The remaining options may need to be implemented eventually when such prompting is no longer effective
A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her child faces for extrapyramidal side effects (EPSs)? A. All antipsychotic medications have an equal chance of producing EPSs. B. Advise the mother to ask the provider to change the medication to clozapine instead of risperidone. C. Newer antipsychotic medications have a higher risk for EPSs. D. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics.
D Risperidone is a newer, atypical antipsychotic. All newer antipsychotic medications have a lower incidence of EPSs than older, traditional antipsychotics. The other responses are untrue. There is no reason to advise a medication change at this time.
A 10-year-old who is frequently disruptive in the classroom begins to fidget in her chair and then moves on to disruptive behavior. What is the most appropriate initial technique for managing this sort of disruptive behavior? A. Therapeutic holding B. Quiet room C. Seclusion D. Touch control
D The appropriate adult can move closer to the child and place a hand on her arm or an arm around her shoulder for a calming effect when the fidgeting is first noted. The closeness signals the child to use self-control. It is the least restrictive treatment approach and should be tried initially.
Which nursing diagnosis should be considered for a child with attention deficit hyperactivity disorder ADHD? A. defensive coping B. impaired verbal communication C. Anxiety D. risk for injury
D The child's marked hyperactivity puts him or her at risk for injury from falls, bumping into objects, impulsively operating equipment, pulling heavy objects off shelves, and so forth.
A patient is receiving lorazepam to prevent the occurrence of delirium tremens. Which manifestation would the nurse recognize as indicative of an overdose of this medication? A. Bradycardia B. Hyperreflexia C. Warm, flushed skin D. Shallow respirations
D. Clinical manifestations of benzodiazepine overdose include shallow respirations, hypotension; weak, rapid pulse; slow reflexes; impaired motor function; coma; and possible death.
To provide effective care for the patient who is taking a second-generation antipsychotic, the nurse should frequently assess for a. Alcohol use disorder b. Major depressive disorder c. Stomach cancer d. Polydipsia e. Metabolic syndrome
E Metabolic syndrome is a common side effect of second gen antipsychotics
True or false: False reports of sexual assaults are very common.
FALSE -False reports of sexual assault are rare. They are usually figured out by simple police investigation. -Lives are not "ruined" by false reports. Main types of false reports: ¨Teens who are trying to get out of trouble: their parents most likely are behind pressing charges. ¨Mentally ill people: history of assaults, psychosis, rarely blame a single person. ¨Criminals, with a history of other criminal behavior.
True or False: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is used to identify drug and alcohol addicts
False The primary goal of SBIRT is to: Identify and effectively intervene with those who are at risky or high risk for psychosocial or health care problems related to their substance use. SBIRT is not meant to seek out addicts Screening, Brief Intervention, and Referral to Treatment (SBIRT) 1.Screening for problems using standardized screening tools -AUDIT for alcohol use -DAST for illicit drug use 2.Brief intervention or teaching about consequences of use and abuse -Motivational Interviewing (MI) 3.Referral for further treatment
Stages of Alzheimers Disease:
MILD: • Forgetfulness beyond what is seen in a normal patient • Short-term memory impairment, especially for new learning • Loss of initiative and interests • May forget recent events or the names of people or things • Impatient • May no longer be able to solve simple math problems • Slowly loses the ability to plan and organize MODERATE: • Memory loss and confusion become more obvious • Has more trouble organizing, planning, and following directions • May need help getting dressed • May start having episodes of incontinence • Trouble recognizing family members and friends • Agitation, restlessness • May lack judgment and begin to wander, gets lost • May have trouble sleeping • Delusions, hallucinations, paranoia • Behavioral problems SEVERE: • Severe impairment of all cognitive functions • Little memory, unable to process new information • Unable to perform self-care activities • Often needs help with daily needs • May not be able to talk • Cannot understand words • May have problems eating, swallowing • May not be able to walk or sit up without help • Immobility • Incontinence
True or False: Procalcitonin is a frequently-used diagnostic measure for septic shock
TRUE. Procalcitonin (PCT) is a peptide precursor of the hormone calcitonin and its primary trigger is infection. PCT is identified as part of the complex pro-inflammatory response of the innate immune system. PCT is widely reported as a useful biochemical marker to differentiate sepsis from other non-infectious causes
You're caring for a patient with cardiogenic shock. Which finding below suggests the patient's condition is worsening? Select all that apply: A. Blood pressure 95/68 B. Urinary output 20 mL/hr C. Cardiac Index 3.2 L/min/m2 D. Pulmonary artery wedge pressure 30 mmHg
The answer is B and D. When answering this question look for values that are abnormal and that point to worsening tissue perfusion (urinary output should be 30 mL/hr or greater....if it's lower than this it show the kidneys are not being perfused) and worsening cardiac output (the blood pressure and cardiac index are within normal limits BUT pulmonary artery wedge pressure is NOT). A pulmonary artery wedge pressure (also called pulmonary capillary wedge pressure) is the pressure reading of the filling pressure in the left atrium. A normal PAWP is 4-12 mmHg and if it's >18 mmHg this indicates cardiogenic shock. If it reads high, that means there is back-flowing of blood into the heart and lungs (hence the left ventricle is failing to pump efficiently and increasing the pressure in the left atrium).
Which statement below is INCORRECT about Alzheimer's disease? A. It's the 5th leading cause of death for adults over 65. B. Alzheimer's disease is more likely to develop in men rather than women. C. Most patients typically start showing signs and symptoms of this disease after the age of 60. D. Hispanics and African Americans are at higher risk for developing Alzheimer's disease.
The answer is B. Alzheimer's disease is more likely to develop in WOMEN (not men) because they tend to live longer. All the other statements are true regarding AD.
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells
The answer is B. The first treatment in regards to helping maintain tissue perfusion is fluid replacement with either crystalloid or colloid solutions. THEN vasopressors like Norepinephrine are ordered if the fluids don't help.
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hour
The answer is B. This is the only correct option. Option A is wrong because fluids are administered first, and if they don't work vasopressors (Norepinephrine) is administered. Option C is wrong because although blood glucose levels should be measured, it does not take precedence over other treatments. Option D is wrong because Drotrecogin alpha should be given within 24-48 hours of septic shock to be the most effective
A patient taking a cholinesterase inhibitor is experiencing nausea and diarrhea. These side effects can be decreased by doing which of the following? A. Administering the medication on an empty stomach B. Administering the medication with meals C. Administering the medication two hours before a meal D. Administering the medication at bedtime
The answer is B. This medication group can lead to GI upset. If this occurs, administering the med with meals can help decrease this side effect.
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."
The answer is B. This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.
A patient with Alzheimer's disease is having trouble performing the movements needed to use their toothbrush for mouth care. This is described as? A. Aphasia B. Apraxia C. Anomia D. Agnosia
The answer is B: Apraxia Definition. Apraxia (called "dyspraxia" if mild) is a neurological disorder characterized by loss of the ability to execute or carry out skilled movements and gestures, despite having the desire and the physical ability to perform them
They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse would make it priority to monitor for? A. Rebound hypertension B. Ringing in the ears C. Worsening hypotension D. Severe headache
The answer is C. Dobutamine increases contractility and cardiac output, BUT causes vasodilation due to the way it acts on receptors and this may make hypotension WORSE. The patient may be started on norepinephrine or dopamine if worsening of hypotension occurs.
You're helping a patient with hygiene. The patient is having trouble asking you for a particular bathing item. The patient wants the soap bar but makes up a name for the item. This is known as what? A. Amnesia B. Agnosia C. Anomia D. Aphasia
The answer is C: Anomia Anomia is defined as a language specific disturbance arising after brain damage whose main symptom is the inability of retrieving known words.
You're helping a patient with hygiene. The patient is having trouble asking you for a particular bathing item. The patient wants the soap bar but makes up a name for the item. This is known as what? A. Amnesia B. Agnosia C. Anomia D. Aphasia
The answer is C: Anomia Anomia is defined as a language specific disturbance arising after brain damage whose main symptom is the inability of retrieving known words.
A patient with Alzheimer's disease is prescribed a cholinesterase inhibitor. Which of the following medications below is NOT this type of medication? A. Galantamine B. Rivastigmine C. Memantine D. Donepezil
The answer is C: Memantine. This is a NMDA antagonist (glutamate receptor antagonist). Memantine (Namenda) is also used for AD; it has been shown to delay functional decline in moderate to severe disease. The Cholinesterase Inhibitors have been shown to help maintain memory, thinking, and speaking skills for a few months to a few years in some patients with mild to moderate AD; and donepezil is also used in severe AD.
Neurofibrillary tangles found in Alzheimer's disease are made up of a protein called ________. What is the role of these proteins? A. Beta-amyloid; delivers nutrients to the neuron B. Amyloid precursor protein; promotes neurotransmitter released at the synaptic junction C. Tau; provides structural strength to microtubules in the neuron D. Microglia; removes debris from outside the neuron
The answer is C: Neurofibrillary tangles found in Alzheimer's disease are made up of a protein called Tau. Tau proteins provide structural strength to microtubules in the neuron.
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine
The answer is D. Cultures are drawn, antibiotics are administered, and then Fluids are ordered in septic shock to try to increase MAP. If this is unsuccessful, then vasopressors are ordered NEXT. Norepinephrine is used as a first-line agent. Dobutamine may sometimes be used but for its inotropic effects on the heart.
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg
The answers are A, B, C, and E. When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.
The nurse is providing routine care for a patient with Severe Alzheimer's disease (late stage). The patient has no motor activities or language communication abilities. What are some nursing interventions the nurse can implement to promote patient interaction and communication? Select all that apply. A. Limit interaction to verbal communication B. Use touch when appropriate C. Incorporate nonverbal communication D. Have music and imagery available during the day E. Identify yourself to the side of the patient rather than directly in front
The answers are B, C, and D. Communication and interaction is still very essential in the late-stage of Alzheimer's disease. Even though the patient may not be able to speak or move around, communication and interaction are vitally important for providing quality patient care and a loving environment for the patient. The nurse should try to incorporate nonverbal communication as much as possible like facial expression and body gestures. This is because even though the patient may not understand the words spoken, they may understand the nonverbal communication. Touch should be used when needed to reassurance or let the patient know you care along with soft music and other tools to provide a calm, interactive environment.
In early stages of Alzheimer's disease, the hippocampus is affected. This part of the brain is responsible for what function(s)? Select all that apply: A. Learning B. Navigation C. Memory D. Language E. Planning
The answers are: A, B, and C. The hippocampus tends to be affected first in AD. This structure is important for being able to learn new things, recall memories (especially recent ones), and navigation (due to its function with spatial memory). This structure is affected early on, and this is why patients start to have memory problems and can get lost easily (losing function of spatial memory).
True or False: Physostigmine is the antidote to reverse anticholinergic toxicity that may be associated with the use of antipsychotic medications.
True Physostigmine is a cholinesterase inhibitor used to treat glaucoma and anticholinergic toxicity. Anticholinergic toxicity is a potentially life-threatening medical emergency caused by antipsychotics or other anticholinergic medications, including many antiparkinsonian drugs and over-the-counter cold/allergy medicines. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include: ANS instability repetitive motor movements dilated pupils (mydriasis) urinary retention/ constipation hyperpyrexia w/o sweating tachycardia delirium with altered mental status, agitation Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should immediately be evaluated for possible anticholinergic toxicity. Interventions: Hold meds call provider emergency cooling measures urinary catheterization prn benzo or sedation as ordered Physostigmine
1. Natalya, a patient with a history of alcohol use disorder, has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea
a, b, d, e Disulfiram (antiabuse) -Interrupts alcohol metabolism (deterent) -Causes physiological response that may include : *severe headache *nausea and vomiting *Flushing *Hypotension *Tachycardia *Dyspnea *Diaphoresis *chest pain *Palpitations *Dizziness *Confusion -Effects last 14 days after discontinuing (60-120 hour half life)
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is hallucinations? Select all that apply. a. "I know you say you hear voices, but I cannot hear them." b. "Stop listening to the voices, they are NOT real." c. "Tell me more about what you hear." d. "Please tell the voices to leave you alone for now."
a, c
Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy
a, d Clinical manifestations: flulike vDrug craving vDiaphoresis vFever vGI distress vRestlessness vInsomnia vWatery eyes vTremors vMuscle aches vRunny nose vAltered mood vDilated pupils Treatment often requires medications -Low dose of long-acting opioid (methadone, buprenephorine) -α2-adrenergic agonists (clonidine) -GI medications -Acetaminophen -Sedatives
Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present with which assessment characteristic? 1. Vague physical complaints such as insomnia or pain 2. Extreme anger and unpredictable behavior 3. Psychosis and/or mania as a result of long-term abuse 4. Family members described as supportive
1 Patients may present with symptoms that may be vague and can include chronic pain, insomnia, hyperventilation, or gynecological problems. Attention to the interview process and setting is important to facilitate accurate assessment of physical and behavioral indicators of family violence. Presenting with extreme anger is possible but not as common as presenting with vague physical complaints. Having many family members there is unlikely as many victims keep their history of being battered a secret. It is not known that psychosis or mania is a result of physical violence, and this would not be a usual presenting complaint.
Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what? 1. Have sameness and consistency in their environment 2. Relate in a consistent manner to staff 3. Learn that the staff cannot be manipulated 4. Accept controls that are concrete and fairly applied
1. Have sameness and consistency in their environment
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed? 1. Intramuscular injections of thiamine 2. Traditional phenothiazine 3. Judicious use of antipsychotics 4. Oral administration of chlorpromazine
1. Intramuscular injections of thiamine
The ten signs of Alzheimers Disease (Alzheimers Assocition):
1. Memory loss that disrupts daily life 2. Challenge in planning or solving problems 3. Difficulty completing familiar tasks 4. Confusion with time or place 5. Trouble understanding visual images and spatial relationships 6. New problems with words in speaking or writing 7. Misplacing tings and losing ability to retrace steps 8. Decreased or poor judgement 9. Withdrawal from work or social activities 10. Changes in mood and personality (Pathologic changes of AD precede clinical manifestations by 5 to 20 years)
The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what? 1. Safety within the environment 2. Psychological faculties 3. Participation in educational activities 4. Face-to-face contact with other clients
1. Safety within the environment
The nurse is planning care for a school-aged child with autism spectrum disorder (ASD) who has been hospitalized for some tests. Which intervention should the nurse plan to implement? 1. Placing the child in a private room 2. Providing adequate stimulation through play 3. Encouraging staff to visit the child frequently 4. Giving detailed explanations about the upcoming tests
1. The child with ASD should be placed in a private room. Decreasing stimulation by placing the child in a private room may lessen the disruptiveness of hospitalization. Play should be carefully planned; overstimulation can precipitate behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits from staff caregivers kept short whenever possible. Because these children have difficulty organizing their behavior and redirecting their energy, they need to be told directly what to do. Explanations about tests should be at the child's developmental level, brief, and concrete.
Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal? 1. Tremors 2. Seizures 3. Hallucinations 4. Blackouts
1. Tremors are an early sign of alcohol withdrawal. The remaining options are not events considered early signs of alcohol withdrawal.
A health care provider prescribes disulfiram for a client who abuses alcohol. The nurse teaches the client that disulfiram will have which action? a. It decreases alcohol cravings. b. It causes a severe adverse reaction if alcohol is consumed. c. It decreases the effect of alcohol inebriation. d. It allows the client to tolerate only small amounts of alcohol.
b Disulfiram is used for aversion therapy; a person who consumes alcohol while taking disulfiram will experience a severe reaction consisting of nausea, vomiting, hypotension, headache, tachycardia, tachypnea, and flushing. The medication does not decrease alcohol cravings, and it does not decrease inebriant effects. When taking disulfiram, the client cannot tolerate any alcohol.
A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a)An infant who is being fed reconstituted formula b)A toddler living in an older home that is being remodeled c)A preschooler who attends a play group 3 days a week d)A school aged child who rides a bus 5 days a week
b)A toddler living in an older home that is being remodeled Environmental exposures (lead paint); risk of foreign objects in mouth
•Which of the following drugs is helpful in relieving the extrapyramidal side effects that may be caused by antipsychotics? SATA •a. Morphine •b. Hydroxizine (Atarax) •c. Amantadine (Symmetrel) •d. Benztropine (Cogentin)
b, c, d •Hydroxizine is a an antihistamine, and is used to treat extrapyramidal side effects from antipsychotics. Antihistamines are also used to treat agitation, anxiety, and aggression. •Amantadine is a dopaminergic agent. •Benztropine is an anticholinergic, it is an anti-tremor agent and can also treat Parkinson's symptoms. *If too much benztropine is given, it can create mental side effects
Cardinal features of a child who experienced Fetal Alcohol Syndrome include? SATA a. High nasal bridge b. Small palpebral fissures c. Smooth philtrum d. Thin upper lip e. Large head
b, c, d are all cardinal features of FAS Other facial dysmorhpias associated with FAS include: Microcephaly, low nasal bridge, epicanthal folds, minor ear anomalies, microgathia
Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work."
b. "I think the baby cries just to make me angry."
A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. Which is the priority nursing action during the first 48 hours after the client's admission? a. Improve a nutritional status b. Monitor vital signs c. Obtain a foam matress d. Identify a plan to reduce alcohol intake
b. Monitor vital signs The VS, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. ID a plan to reduce alcohol upon dc is important, but not priority at the moment. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes priority after issues of withdrawal period have subsided
What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with older adults.
b. The caregiver was neglected as a child.
An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through: a. A casual authoritative demeanor b. Keeping patients busy c. Brief, frequent, nonthreatening encounters d. Threats of seclusion or punishment
c. Brief, frequent, nonthreatening encounters
7. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that a. The medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill.
d Anosognosia is a cognitive symptom of schizophrenia. Anosognosia (ah-no-sag-NO-zsuh) is the inability to realize one is ill—an inability caused by the illness itself. It is common in severe mental illness. Anosognosia may lead the patient to resist or stop treatment, making care more challenging and frustrating to others. Anosognosia can interfere with requesting or accepting help. (Halter, 2022, p. 197)
The nurse is caring for a patient in cardiogenic shock after an acute myocardial infarction. Which assessment findings would be most concerning? A. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds B. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL C. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin D. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding
d Severe hypoxemia, lactic acidosis, and bleeding are manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are manifestations of the progressive stage of shock.
A client with a history of cocaine abuse has been admitted to a health care facility with a sinus disorder. Which action would the nurse take? a. Educate the client about his or her correct body mechanics and promote stress management. b. Teach the client about safe medication storage and the danger of polypharmacy. c. Assist with adequate personal hygiene, nutrition, and hydration, and provide emotional support to the family. d. Assess the client's drug intake and ensure that the individual does not prematurely leave the health care facility.
d. Assess the client's drug intake and ensure that the individual does not prematurely leave the health care facility. When dealing with a client with a substance abuse issues, the nurse would assess the client's drug intake in terms of amount, frequency, and type of use to obtain useful information. Clients with substance abuse problems tend to avoid health care facilities for fear of judgemental attitudes and worries over being arrested. In this case, the nurse would ensure the client doesn't prematurely leave the facility. When dealing with a client with medication use and abuse issues, the nurse would provide proper education about safe med storage and polypharmacy. When dealing with a client with arthritis, the nurse would educate the client about correct body mechanics and promote stress management. When dealing with a client in a confused state, the nurse would assist them with adequate personal hygiene, nutrition, and hydration and provide emotional support to families.
Positive symptoms of Schizophrenia--> Alterations in speech, definitions (continued):
• Circumstantiality: Including unnecessary and often tedious details in conversation but eventually reaching the point. • Tangentiality: Wandering off topic or going off on tangents and never reaching the point. • Cognitive retardation: Generalized slowing of thinking, which is represented by delays in responding to questions or difficulty finishing thoughts. • Pressured speech: Urgent or intense speech; reluctance to allow comments from others. • Flight of ideas: Moving rapidly from one thought to the next, often making it difficult for others to follow the conversation. • Symbolic speech: Using words based on what they symbolize, not what they mean. For example, a patient reports "demons are sticking needles in me" when what he means is that he is experiencing a sharp pain (symbolized by needles). • Thought blocking: A reduction or stoppage of thought. Cognitive disorganization or interruption of thought by hallucinations can cause this. • Thought insertion: The often uncomfortable belief that someone else has inserted thoughts into the patient's brain. • Thought deletion: A belief that thoughts have been taken or are missing.
Statistics about sexual assault:
-1 in 4 women will be victim of rape or attempted rape in their lifetime -1 in 6 men will be victim of rape or attempted rape in their lifetime -734,630 ppl raped in US in 2018 -1 in 3 women and 1 in 7 men will be victims of domestic violence in their lifetime -Over 50% of women in IPV situations are also being sexually assaulted by their partner -The number of rapes reported to law enforcement is estimated to be only 1/5 of the rapes occurring in the state. -75-80% of victims know their offender
A 78-year-old patient diagnosed with Alzheimer's disease picks up a glass from the bedside table but does not recognize the purpose of the object. This inability is associated with which characteristic of the disorder? A. Agnosia B. Aphasia C. Apraxia D. Agraphia
A Agnosia is the loss of sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.
A patient arrives to the emergency department with a reported overdose of diazepam (Valium). Which medication would the nurse prepare to administer as an antidote? A. Naloxone B. Flumazenil C. Phytonadione D. Protamine sulfate
B. Flumazenil reverses the effects of benzodiazepines, such as diazepam, by acting as a competitive antagonist at gamma-aminobutyric acid (GABA)-benzodiazepine receptor sites. Protamine sulfate reverses the anticoagulant effects of heparin. Naloxone is an opioid antagonist and used with opioid overdose. Phytonadione is vitamin K and is used for hypoprothrombinemia caused by anticoagulants such as warfarin.
A patient diagnosed with schizophrenia approaches the nurse and says, "I'm cold. Ice cream is cold. Freezers keep ice cream cold." This speech pattern can be assessed as: a.Hyperverbosity b.Circumstantiality c.Loose associations d.Expressing delusions
c •Loose associations reflect a disturbance in thinking in which speech shifts from topic to topic in a random, seemingly unrelated manner. When severe, it results in incoherence. •Circumstantiality is when one provides excessive detail and there is a delay in reaching the point they wish to make
Cognitive Symptoms of Schizophrenia, definitions:
-Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. -Memory impairment primarily affects short-term memory and the ability to learn. Repetition and verbal or visual reminders (cues) may help the patient to learn and recall information. For example, a picture of a toothbrush in the bathroom may serve as a reminder to brush teeth. -Impaired information processing: can lead to problems such as delayed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in their peripheral vision, leading to overstimulation. Reducing stimulation can be helpful. -Impaired executive functioning: difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipating and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations. -Anosognosia: inability to realize one is ill—an inability caused by the illness itself.
Positive symptoms of Schizophrenia--> Alterations in perspective, definitions:
-Hallucinations, including: • Auditory: Hearing voices or sounds • Visual: Seeing people or things • Olfactory: Smelling odors • Gustatory: Experiencing tastes • Tactile: Feeling bodily sensations (e.g., feeling an insect crawling on one's skin) -Illusions: Misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it to be a bear. -Depersonalization: A feeling of being unreal or having lost an element of one's person or identity. For example, body parts do not belong, or the body has drastically changed (e.g., a patient may see her fingers as being smaller than they actually are or not as hers). -Derealization: A feeling that the environment has changed (e.g., that one is detached from the environment, that everything seems bigger or smaller, or that familiar surroundings seem somehow strange and unfamiliar).
The risk of elder abuse in a home is best determined by conducting which assessment? 1. The vulnerability of the elder and the stress of the caregiver 2. The amount of disruption the elder causes in the home 3. The financial contribution of the elder and the caregiver's early life experience with abuse 4. How much actual physical assistance the elder needs on a daily basis
1 Abuse occurs across all segments of society and is reinforced by the society and the culture. The actual occurrence of violence requires (1) a perpetrator, (2) someone who by age or situation is vulnerable (e.g., children, women, men, the elderly, mentally ill persons, and physically challenged persons), and (3) a crisis situation. None of the other options presents the greatest risk for elder abuse.
When the nurse believes the cycle of abuse is escalating and that a woman may be in severe physical danger, what should the priority nursing intervention be? 1. Assisting her in developing a plan to go to a shelter in case of a crisis 2. Teaching her to counter verbal abuse with assertive replies 3. Advising her to enter counseling at the mental health center 4. Suggesting that she leave the abuser immediately and go to a trusted friend's home
1 Every victim of abuse should have an escape plan, but one is particularly important when the nurse believes the client is in severe danger. None of the remaining options are as directly involved in client safety.
Which of the following persons has the highest risk factors for physical abuse? 1. Rose, a 77-year-old woman living with her daughter and son-in-law 2. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder 3. Roland, a 53-year-old man with cardiovascular disease living with his son 4. Emma, a 7-month-old baby who has colic and doesn't sleep through the night
1 Older women dependent on family members for care are at higher risk for abuse. The other options do not describe specific characteristics that put them at higher risk for abuse.
An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). 1. Mood swings 2. Poor school performance 3. Impulsive behaviors 4. Easily intimidated 5. Low frustration tolerance
1, 2, 3, 5 Individuals with ADHD show an inappropriate degree of inattention, impulsiveness, and hyperactivity. Attention problems and hyperactivity contribute to low frustration tolerance, temper outbursts, labile moods, poor school performance, peer rejection, and low self-esteem. ADHD is not generally characterized by meekness or by being easily intimidated.
The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness
1, 2, 4, 6-Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base in the body fluids. This occurs in conditions that cause over stimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.
A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which intervention(s)? (Select all that apply.) 1. Observing for stress reaction 2. Observing for delirium tremens 3. Converting narcotic use from an illicit to a legally controlled drug 4. Encouraging involvement in Narcotics Anonymous 5. A motivational interview
1, 4, 5. The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.
While watching television, a patient appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which nursing interventions would be appropriate in dealing with this patient? (Select all that apply.) 1. In a firm voice, tell the patient to stop this behavior. 2. Reassure the patient that he is not in any danger. 3. Instruct other team members to ignore the patient's behavior. 4. Give simple commands in a calm voice. 5. Acknowledge the presence of the hallucinations.
2, 4, 5 Using a calm voice and giving simple commands, the nurse should reassure the patient that he is not in any danger. It is not appropriate to tell the patient to stop the behavior, and ignoring the behavior will not reduce his agitation.
A client is admitted with a diagnosis of renal failure. What arterial blood gas (ABG) result should the nurse expect to see with this client? 1. pH 7.49; PaCO2 36; HCO3 30 2. pH 7.30; PaCO2 35; HCO3 18 3. pH 7.31; PaCO2 50; HCO3 23 4. pH 7.43; PaCO2 48; HCO3 30
2. pH 7.30; PaCO2 35; HCO3 18 Rationale: Clients with renal failure have difficulty synthesizing HCO3 - in the renal tubules secondary to the renal failure. These clients also retain K+ and subsequently develop metabolic acidosis. The ABG with the pH of 7.30 reflects uncompensated metabolic acidosis. The ABG with the pH of 7.49 is incorrect because it reflects metabolic alkalosis (increased pH and HCO3 -) and normal PaCO2. The ABG with the pH of 7.31 is incorrect because it reflects respiratory acidosis (decreased pH, increased PaCO2) and normal HCO3 -. The ABG with the pH of 7.43 is incorrect because it reflects a mixed acid-base imbalance metabolic alkalosis with a respiratory acidosis (normal pH and increased PaCO2 and HCO3 -)
Which child is at lowest risk for abuse? 1. A 3-month-old who has colic and teenaged parents 2. A 4-Year-Old who has cerebral palsy and cognitively challenged parents 3. A 5-year-old who has ADHD and a father who was abused as a child 4. A 2-year-old who has leukemia and two working parents
4 Although the child in option 4 has a serious physical disorder, she is at lower risk than the child in option 1, whose inconsolable crying can be frustrating; the child in option 2, who will not be as independent as other children his age and who has parents who may not understand his needs; or the child in option 3, whose hyperactivity can be annoying, especially to a parent who himself has been abused.
An elderly client pays the bills because she fears that her family will make her live elsewhere if she doesn't "help out." The nurse assesses for suggestions that the client may be at risk for what form of abuse? 1. Psychological 2. Neglect 3. Physical violence 4. Financial maltreatment
4 Financial maltreatment occurs when the perpetrator takes financial advantage of the elderly person, often through the use of subtle threats of what unpleasant or frightening outcome will occur if the elder does not supply funds. None of the remaining options is as directly associated with money as is the correct option.
When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? 1. "It makes sense that rape is a crime of violence, not a crime of sex." 2. "I always thought rapes happened at night, but now I know that isn't true." 3. "Who would have guessed that most rape victims know the rapist?" 4. "So if you dress conservatively, your risk of being raped is small."
4 Rapes have little to do with whether the victim dresses seductively because rape is a crime of violence rather than a crime of sex. The other options represent accurate information regarding the act of rape.
The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease? (Select all that apply.) A. Urinalysis B. Chest x-ray C. MRI of the head D. Liver function tests E. Neuropsychologic testing F. Blood urea nitrogen and serum creatinine
A, C, D, E, F (all but B) Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function. A chest x-ray examination is not used to investigate an alternate cause of memory or language problems.
A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." What is the nurse's best response? A. "I will get you a prn medication for agitation." B. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?" C. "You are having problems with your speech. You need to try harder to be clear." D. "You are confused. I will take you to your room to rest a while."
B The guidelines that are useful in communicating with a patient with disorganized or bizarre speech are to place the difficulty in understanding on yourself, not the patient, and look for themes that may be helpful in interpreting what the patient wants to say. Telling the patient, he needs to try harder to be clearer is unrealistic since the patient would be unable do this. The other options are not useful in communicating with this patient and attempting to find common themes.
The family of a child diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. What is the focus of child's evaluation? (Select all that apply.) A. Physical growth B. Activities of daily living C. Personal perception D. Academic performance E. Social relationships
B, C, D, E For the family and child with ADHD, evaluation will focus on the symptom patterns and severity. For those with ADHD, inattentive type, the focus of evaluation will be academic performance, activities of daily living, social relationships, and personal perception. For those with ADHD, hyperactive-impulsive type or combined type, the focus will be on both academic and behavioral responses.
Which of the following is true? A. SVR is increased in septic shock and increased in cardiogenic shock B. SVR is decreased in septic shock and increased in cardiogenic shock C. SVR is decreased in septic shock and decreased in cardiogenic shock D. SVR is increased in septic shock and decreased in cardiogenic shock
B. In septic and anaphylactic shock, massive amounts of cytokines are dumped into the circulation, which causes vascular dysfunction leading to a pathologic decrease in SVR (systemic vasodilation). The increased SVR present in cardiogenic, hemorrhagic, and obstructive shock is the body's attempt to maintain blood pressure (perfusion pressure) by increasing arteriolar tone.
Which of the following is the best diagnostic procedure for rapid diagnosis of deep venous thrombosis (DVT)? a. D-dimer assay b. Venous duplex ultrasound c. Venography d. Complete blood count
B. Most VTE's diagnosed by ULTRASOUND (non invasive and fast) D-Dimer is not specific. Not CCB. Venography, yes, but not fast enough.
A client has reached the maintenance phase of schizophrenia. What is the appropriate clinical planning focus for this client? A. Safety and crisis intervention B. Acute symptom stabilization C. Social, vocational, and self-care skills D. Stress and vulnerability assessment
C During the maintenance phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community. All the other options should have been handled previously.
A client is brought to the hospital by an adult daughter, who visited this morning and found her parent to be confused and disoriented. When the client is admitted, the daughter states, "I'll take these glasses and hearing aid home, so they don't get lost." What is the nurse's best reply? A. "Don't worry. You can leave them at the bedside. We are insured for losses of this sort." B. "Because we do not have a copy of durable power of attorney, we cannot release them to you." C. "I would like to have your parent wear them. It will help there to be less confusion or retain more orientation." D. "That will be fine. I'll have you sign our hospital release form."
C Clients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids. None of the other options support this client need.
A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with which cognitive disorder? A. Amnesic disorder B. Selective inattention C. Delirium D. Dementia
C Delirium is characterized by a disturbance of consciousness, a change in cognition (such as impaired attention span), and a fluctuating level of consciousness that develop over a short period of time. None of the other options share these characteristics.
A patient is admitted to a long-term care facility and has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to: a. let him know what behavior is socially appropriate b. assist him with self-care to manage self esteem c. maintain familiar routine of sleep, meals, drug administration, and activities d. promote orientation at every encounter with a patient by asking the day, time, and place
C. maintain familiar routine of sleep, meals, drug administration, and activities (We will also use this same intervention in patients w/ ASD)
o Functions of the following Cranial Nerves? CN III IV VI V & VII VII, IX, & X VIII XI X & XII
CN III Oculomotor: looks at the bridge of nose CN IV Trochlear: rotates eye inward and downward CN VI Abducens: abducts the eyes outward CN V (trigeminal) and VII (Facial): Facial Movement Corneal Reflex CN VII, IX (Glossopharyngeal), X: Sense of taste CN VIII: Auditory: Hearing and balance CN XI: Spinal Accessory Nerve assessed with shoulder shrug CN X (Vagus), XII (Hypoglossal): Tongue movement
Compare and contrast clinical manifestations of Alcohol Withdrawal vs Delirium Tremens:
Clinical manifestations of withdrawal peak at 24-96 hours after last drink (usually around 48 hours): •Agitation •Anxiety •↑ Heart rate •↑ BP •Diaphoresis •Nausea •Tremors •Insomnia •Hyperactivity Clinical manifestations of Delirium tremens: •Tachycardia •High blood pressure •Convulsions/seizures •Fever •Visual, tactile, or auditory hallucinations •Disorientation/profound confusion •Anxiety •Head full of sand
Dementia with Lewy bodies (DLB) is characterized by a. remissions and exacerbations over many years. b. memory impairment, muscle jerks, and blindness. c. parkinsonian symptoms, including muscle rigidity. d. increased intracranial pressure from decreased CSF drainage.
Correct answer: c Rationale: Dementia with Lewy bodies (DLB) is characterized by features of dementia and Parkinson's disease. These patients typically have manifestations of Parkinsonism, hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep problems.
Based on the current research, which patient is most likely to develop dementia? A. A worker in a factory where asbestos is found B. An office manager in a high-stress environment C. A bartender in a dark underground club/bar A former boxer and is now a trainer
D Brain injury and trauma are associated with a greater risk of developing Alzheimer's disease and other dementias. People who suffer repeated head trauma, such as boxers and football players, may be at greater risk. The other options do not specifically represent known risk.
True or False: Strangulation and stalking is not linked to homicide.
False. -Prior strangulation during intimate partner violence is associated with homicide and escalation of violence. ¨Strangulation is, in fact, one of the best predictors for the subsequent homicide of victims of domestic violence. One study showed that "the odds of becoming an attempted homicide increased by about seven-fold for women who had been strangled by their partner" (Journal of Emergency Medicine, 2008). -Stalking shows a high amount of danger for sexual assault and deadly assault
The exact cause of Alzheimer's disease is not fully understood. However, what two changes in the brain are found in a patient with this disease? Select all that apply: A. Destruction of the myelin sheath on the neuron B. Development of beta-amyloid plaques in between neurons C. Destruction of dopaminergic neurons D. Creation of neurofibrillary tangles within the neuron
The answers are B and D. Beta-amyloid plaques and neurofibrillary tangles are found in a patient with AD. Option A (destruction of the myelin sheath) happens in multiple sclerosis, and option C (destruction of dopaminergic neurons) occurs in Parkinson's disease.
True or False: Multiple neurotransmitter abnormalities may be involved in delirium, including: -Cholinergic deficiency -Excess release of dopamine -↑ and ↓ Serotonergic activity
True additionally, an increase in pro-inflammatory cytokines is also associated with delirium AND dementia
True or False? 8 out of the 10 leading causes of death in New Mexico are r/t alcohol
True, and unintentional injuries related to alcohol in NM are 1.7x the national rate
The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions
a. Establish trust and rapport
Which second-generation antipsychotic requires routine absolute neutrophil count monitoring? a. Brexpiprazole b. Clozapine c. Risperidone d. Ziprasidone
b Rarely, clozapine suppresses bone marrow and causes life-threatening neutropenia. This makes patients susceptible to serious infection. Therefore, clozapine is available only through a restricted program. Specific training and regular reporting of the patient's absolute neutrophil count (ANC) are program requirements. Typically, the ANC is monitored once weekly for 6 months, then once every 2 weeks for 6 months, then once every 4 weeks thereafter. The ANC values are reported directly to the clozapine program. (Halter, 2022, p. 59)
Positive symptoms of Schizophrenia--> Alterations in speech, definitions:
-associative looseness, or looseness of association: results from haphazard and illogical thinking where concentration is poor and thoughts are only loosely connected. For example: "My friends talk about French fries but how can you trust the French?" -Word salad: the most extreme form of associative looseness, is a jumble of words that is meaningless to the listener (e.g., "agents want strength of policy on a boat reigning supreme"). -Clang association is choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound ("On the track ... have a Big Mac" -Neologisms are words that have meaning for the patient but a different or nonexistent meaning for others. -Echolalia: the pathological repetition of another's words, occurring perhaps because the patient's thought processes are so impaired that she is unable to generate speech of her own
The nurse caring for a client prescribed risperidone observes the client carefully for which possible side effects? (Select all that apply.) 1. A weight gain 2. Reports of heartburn 3. Daytime sleepiness 4. A rapid heartbeat 5. Sexual dysfunction
1, 3, 5 Risperidone is a D2 antagonist (2nd gen/atypical antipsychotic) that can produce extrapyramidal symptoms and has the potential to produce sedation, weight gain, and sexual dysfunction. None of the other side effects are generally associated with this medication.
A client diagnosed with delirium strikes out at a staff member. The nurse can most correctly hypothesize that this behavior is related to which characteristic symptom of delirium? A. Fear B. Anger C. Unmet social interaction D. Unmet physical need
A Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious clients who are fearful may strike out at others, seemingly without provocation. Anger may develop but it is triggered by fear. Neither of the remaining options are generally associated with the behavior described.
Which side effect of antipsychotic medication is generally nonreversible? A. Pseudoparkinsonism B. Tardive dyskinesia C. Dystonic reaction D. Anticholinergic effects
B Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The other side effects often appear early in therapy and can be minimized with treatment.
Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis
D, tennis (exercise, way to get out energy)
True or false. Toluidine Blue is used in sexual assault female exams.
TRUE This dye Sticks to torn tissues and makes evidence of abuse and damages tissue more visibly apparent.
A patient displays positive symptoms of schizophrenia as evidenced by psychotic disorders of thinking. The nurse can expect the patient to exhibit: a.delusions and hallucinations b.grimacing and mannerisms c.echopraxia and echolalia d.avolition and anhedonia
a. -Positive symptoms of schizophrenia represent an excess or distortion of normal function. -Delusions and hallucinations are considered psychotic disorders of thinking. -The other symptoms listed are noted in schizophrenia, but they are not considered thought disorders.
After talking with her 85-year-old mother, Nancy became concerned enough to drive to her home and check on her. Her mother's appearance was disheveled, her words were nonsensical, she smelled strongly of urine, and there was a stain on her dressing gown. Because she is a nurse, Nancy recognizes that her mother's condition is likely due to a. Early-onset dementia b. A mild cognitive disorder c. A urinary tract infection d. Having skipped breakfast
c. UTI is a common cause of delirium in older adults
Which two of these symptoms meet the diagnostic criteria for schizophrenia? •Delusions •Frequent urination •Tremors •Disorganized Speech •Agitation
delusions and disorganized speech According to the DSM5, one of the criteria for schizophrenia is that Two or more of the following things must be present for a significant portion of the time in a 1-month period: 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (e.g., avolition)
A 21-year-old client asks the nurse, "What's wrong with my brain that's causing me to be so angry and aggressive?" The nurse's response should be grounded on what research-supported basis? 1. The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. 2. The diminishment of stress hormones causes anger and aggression. 3. No abnormalities of the brain have been identified that correlate with anger and aggression. 4. Personality type plays a much greater part in anger and aggression than physical factors.
1 Research has supported the theory that the brain's limbic system and prefrontal cortex as well as some neurotransmitters play a part in anger and aggression. None of the other options are supported by current research.
What are some primary prevention activities a nurse can perform related to substance abuse? (Select all that apply.) 1. Education to prevent substance abuse 2. Focusing on relapse prevention 3. Identification of risk factors for abuse 4. Referral to a self-help group for stress relief and meditation 5. Medical detoxification
1, 3, 4 Primary prevention actions are those taken in order to prevent a problem from occurring. Primary prevention involves reducing stress to prevent addiction. Secondary prevention includes screening and early detection for prompt treatment. Referral to a support group might be considered secondary prevention if a patient has screened positive for substance abuse and has agreed to start attending a group. Tertiary prevention includes rehabilitative strategies.
A patient diagnosed with chronic schizophrenia is placed on an antipsychotic medication, 20 mg twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103 °F (39.4 °C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. What is the most likely cause of these clinical manifestations? 1. Tardive dyskinesia 2. Neuroleptic malignant syndrome 3. Pneumonia 4. Pseudoparkinsonism
2. NMS The symptoms are consistent with neuroleptic malignant syndrome, which is an adverse reaction to antipsychotic medication. While tardive dyskinesia and pseudoparkinsonism may also be side effects of antipsychotic medication, the symptoms presented are not indicative of these conditions. Pneumonia may present with these vital signs; however, the diaphoresis and muscular rigidity are not.
Which statement is true regarding substance addiction and medical comorbidity? 1. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier. 2. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. 3. Most substance abusers do not have medical comorbidities. 4. There has been little research done regarding substance addiction disorders and medical comorbidity.
2. The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.
A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This situation can be an example of which form of abuse? 1. Tough love 2. Physical 3. Emotional 4. Neglect
3 Emotional violence occurs when the child's self-esteem is attacked. It is as devastating to the child as physical abuse. None of the other options are focused on damaging a child's self-esteem. Tough love is a form of parenting that includes consequence but does not involve emotional abuse
When caring for a patient with Alzheimer's disease, which task could be delegated to the LPN/VN on the team? A. Administer enteral feedings via a gastrostomy tube. B. Teach patient and caregivers memory enhancement aids. C. Use bed alarms and frequent monitoring to decrease fall risk. D. Make referrals for community services such as adult day care.
A Administering enteral feedings via a gastrostomy tube is within the scope of practice for the LPN/VN. The RN will be responsible for individualized teaching and patient referrals. The UAP will be able to use bed alarms and frequently monitor the patient.
A child diagnosed with autism will demonstrate impaired development in which area? A. playing with other children B. swallowing and chewing C. Adhering to routines D. eye-hand coordination
A Autism affects the normal development of the brain in social interaction and communication skills. Symptoms associated with autism spectrum disorders include significant deficits in social relatedness, including communication, nonverbal behavior, and age-appropriate interaction. Other behaviors include stereotypical repetitive speech, obsessive focus on specific objects, over adherence to routines or rituals, hyper- or hypo-reactivity to sensory input, and extreme resistance to change. None of the other options are characteristically associated with autism.
Currently what is understood to be the causation of schizophrenia? A. A combination of inherited and nongenetic factors B. Deficient amounts of the neurotransmitter dopamine C. Excessive amounts of the neurotransmitter serotonin D. Stress related and ineffective stress management skills
A Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme nongenetic factors (e.g., viral infection, birth injuries, nutritional factors) that can affect the genes governing the brain or directly injure the brain.
The nurse has administered a dose of risperidone (Risperdal) to a patient with delirium. What finding demonstrates the intended effect of the medication? A. Lying quietly in bed B. Alleviation of depression C. Reduction in blood pressure D. Disappearance of confusion
A Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.
Based on the current understanding of brain physiology, which neurotransmitter would be the expected target of medication prescribed to manage depression? (Select all that apply.) a. Serotonin b. Norepinephrine c. Dopamine d. Acetylcholine e. γ-aminobutyric acid (GABA)
A, B, C Antidepressant medication targets serotonin and norepinephrine. While dopamine is implicated in schizophrenia (increase) and Parkinson's disease (decrease), it is also believed to be a factor in depression. GABA is implicated in anxiety disorders. Acetylcholine is implicated in Alzheimer's disease as well as Huntington's disease and Parkinson's disease.
Nursing assessment of the individual with Down syndrome (DS) is based on the knowledge that which of the following are common chronic conditions for adults with DS? Select all that apply a)Obstructive sleep apnea b)Hypothyroidism c)Liver cancer d)Obesity e)Alzheimer's disease
A, B, D, E Other physical challenges include: •Heart defects. •Gastrointestinal (GI) defects. •Immune disorders: increased risk of developing autoimmune disorders, some forms of cancer, and infectious diseases. •Spinal problems: misalignment of the top two vertebrae in the neck (atlantoaxial instability). .
When admitting a patient to the emergency department who reports chest pain, which assessment findings would alert the nurse to possible cocaine use? (Select all that apply.) A. Tachycardia B. Restlessness C. Hypotension D. Hyperthermia E. Constricted pupils
A, B, D. Pupil dilation and restlessness occur from the nervous system stimulation by the stimulant cocaine. The nurse should suspect stimulant drug use in any patient seeking health care who has tachycardia, hyperactivity, fever, or behavioral abnormalities.
Select all of the following statements that are true about Lorazepan as it applies to alcohol withdrawal: A. May cause respiratory depression B. Should not be given to someone with EtOh toxicity C. May cause bradycardia and hypotension D. Titrated med only administered in the intensive care unit E. Administered PO/IV to manage EtOh withdrawal based on CIWA-a score
A, C, E Lorazepam (Ativan) is a benzo used to treat alcohol withdrawal. It is the benzo of choice used during CIWA protocol. It has a shorter half life than chlordiazepoxide (Librium). Because it is a benzo, it may cause side effects such as respiratory depression, bradycardia, and hypotension.
The nurse can assist a patient to prevent substance abuse relapse by (SATA): a)Rehearsing techniques to handle anticipated stressful situations b)Advising the patient to accept residential treatment if relapse occurs c)Assisting the patient to identify life skills needed for effective coping d)Advising isolating self from significant others until sobriety is established e)Informing the patient of physical changes to expect as the body adapts to functioning without substances
A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.
When caring for a patient with acute intoxication and a history of chronic alcohol use, the nurse will anticipate administering which drug? A. Thiamine B. Naloxone C. Flumazenil D. Morphine sulfate
A. Patients with alcohol intoxication may have hypoglycemia, decreased serum magnesium, and other signs of malnutrition. For this reason, they may be treated with intravenous (IV) glucose, magnesium sulfate, and multivitamins. IV thiamine may be given before or with IV glucose solutions to prevent Wernicke-Korsakoff syndrome, which can cause seizures and brain damage. Flumazenil (Romazicon) is the reversal agent for benzodiazepines, and naloxone is the reversal agent for opioids. The administration of an opioid analgesic (morphine) is not indicated.
The patient describes their needing a larger dose of an illicit drug to get the same effect. How should the nurse document this patient's usage? A. Tolerance B. Addiction C. Substance use D. Substance dependence
A. Tolerance is the need for a larger dose of drug to obtain the original effect. Addiction is compulsive, uncontrollable dependence on a substance such that cessation causes severe emotional, mental, or physiologic reactions. Substance abuse is overindulgence in a substance that has a negative impact on the psychologic, physiologic, or social functioning of the person. Substance dependence is such reliance on a substance that the absence of the substance will cause impairment in function.
Which characteristics suggest a man is experiencing the prodromal phase of schizophrenia? Select all that apply. a. Always afraid that others will steal his belongings. b. Displays unusual interest in numbers and specific topics. c. Has increasingly unusual thoughts and uses words oddly. d. Demonstrates increasing difficulty with concentration.
All of the Above -Schizophrenia is often preceded by a prodromal phase during which milder symptoms of the disorder occur, often months or years before the full disorder becomes manifest. During the prodromal phase, people may experience diminished school performance and cognitive ability. They may become less socially engaged or adept. They may also demonstrate attenuated (mild) psychotic symptoms, such as suspiciousness and/or eccentric or disorganized speech or thought- The prodromal phase is the onset of symptoms of schizophrenia. It includes mild changes in thinking, reality testing, and mood. It can include slight alterations in speech and thought; anxiety, obsessive thoughts and compulsive behaviors start to develop. -Catching signs and symptoms in this phase makes it easier to treat schizophrenia!
Lewy Body Dementia is the third most common form of dementia. It is characterized by formation of balloon-like protein structures inside the neurons. Symptoms may include: SATA 1. Early changes that may occur as long as ten years before dementia occurs 2. fluctuating cognition 3. early changes in attention and executive function 4. sleep disturbance 5. visual hallucinations 6. muscle rigidity 7. other parkinsonian features.
All of the above. Once dementia occurs, symptoms of dementia with lewy bodies (DLB) are similar to those of AD, and parkinsonian s&s are often noted.
When providing community health care teaching about the early warning signs of Alzheimer's disease (AD), which signs should the nurse ask family members to report? (Select all that apply.) A. Misplacing car keys B. Losing sense of time C. Difficulty performing familiar tasks D. Problems with performing basic calculations E. Momentarily forgets an acquaintance's name F. Becoming lost in a usually familiar environment
B, C, D, F Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of AD. Misplacing car keys and momentarily forgetting a name is a normal frustrating event for many people.
A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When the family asks the nurse about the behavior, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A. Alzheimer disease B. Sundowner syndrome C. Delirium D. Dementia
C Delirium, which occurs over hours to a few days, is the most frequent complication of hospitalization in the elderly population. Dementia occurs over a period of months. Alzheimer disease develops over months to years. Sundowner syndrome is most prominent in dementia and becomes worse in the evenings.
Which event would an older client diagnosed with early stage Alzheimer's disease have greatest difficulty remembering? A. His or her high school graduation B. The story of a teenage escapade C. What he or she ate for breakfast D. The births of his or her children
C. What he or she ate for breakfast Initially, recent memory is impaired, and remote memory remains intact.
A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? A. Presence of chest pain B. Blood in the urine or stool C. Tachycardia with hypotension D. Decreased level of consciousness
Correct Answer: Presence of chest pain Rationale: Alteplase is a fibrinolytic agent that is administered to patients who have had a STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? 1. Slow, fearful performance of tasks 2. Overestimation of physical abilities 3. Difficulty judging position and distance 4. Impulsivity and impatience at performing tasks
Correct Answer: Slow, fearful performance of tasks Rationale: Patients with a left-sided stroke (right hemiplegia) are often slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.
Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes a. sensory changes. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.
Correct answer: d Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.
Dementia is defined as a a. syndrome that results only in memory loss. b. disease associated with abrupt changes in behavior. c. disease that is always due to reduced blood flow to the brain. d. syndrome characterized by cognitive dysfunction and loss of memory.
Correct answer: d Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems, such as agitation, delusions, and hallucinations, may occur.
The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of A. cholestatic jaundice. B. acute dystonia. C. pseudoparkinsonism. D. tardive dyskinesia.
D An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia. This tool is not used to assess or monitor any of the other options.
A 7-year-old, who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with which diagnosis? A. Attention deficit disorder B. Conduct disorder C. Autism D. Attention deficit hyperactivity disorder
D The data are most consistent with attention deficit hyperactivity disorder (ADHD) as described in the DSM-5. The other options present with characteristics and behaviors that differ from those in the scenario.
Mnemonic for Causes of Delirium: 'DELIRIUM'
D Dementia, dehydration E Electrolyte imbalances, emotional stress L Lung, liver, heart, kidney, brain I Infection, intensive care unit R Rx drugs I Injury, immobility U Untreated pain, unfamiliar environment M Metabolic disorders
During assessment, a patient has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what they're trying to say. Which speech disturbance are they exhibiting? A.Pressured speech B.Circumstantiality C.Flight of ideas D.Tangentiality
c. Flight of ideas: Moving rapidly from one thought to the next, often making it difficult for others to follow the conversation. Pressured speech: Urgent or intense and resists comments from others. Circumstantiality: Including unnecessary and often tedious details in conversation, but eventually reaching the point. Tangentiality: Wandering off topic or going off on tangents and never reaching the point.
An older patient is admitted to the hospital with a UTI and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? a. "Depression is a common cause of confusion in older adults." b. It is normal for an older person to have cognitive problems while in the hospital." c. "The mental changes are most likely caused by the infection and most often reversible." d. Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."
c. "The mental changes are most likely caused by the infection and most often reversible."
What safety-related responsibility does the nurse have in any situation of suspected abuse? a. Protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties, but especially the patient. d. Report suspected abuse to the proper authorities.
d. Report suspected abuse to the proper authorities.
A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations.
d. She should experience a reduction in hallucinations. • - First-generation antipsychotics treat positive symptoms. Positive symptoms are described as a presence of something that shouldn't be there. -This includes alterations in reality testing- delusions, alterations in speech, inability to think abstractly -Also includes alterations in perception- illusions, depersonalization, derealization, hallucinations
Positive symptoms of Schizophrenia--> Alterations in behavior, with definitions:
• Catatonia: A pronounced increase or decrease in the rate and amount of movement. Excessive motor activity is purposeless. The most common form of catatonia is when the person moves little or not at all. Muscular rigidity, or catalepsy, may be so severe that the limbs remain in whatever position they are placed. Persistent catatonia may contribute to exhaustion, pneumonia, blood clotting, malnutrition, or dehydration. • Motor retardation: A pronounced slowing of movement. • Motor agitation: Excited behavior, such as running or pacing rapidly, often in response to internal or external stimuli. It can put the patient at risk (e.g., from exhaustion, by running into traffic) or put others at risk (e.g., by being knocked down). • Stereotyped behaviors: Repetitive behaviors that do not serve a logical purpose. • Echopraxia: The mimicking of movements of another. • Negativism: A tendency to resist or oppose the requests or wishes of others. • Impaired impulse control: A reduced ability to resist one's impulses. Examples include interrupting others or throwing unwanted food on the floor. It can increase the risk of assault. • Gesturing or posturing: Assuming unusual and illogical expressions (often grimaces), posture, or positions. • Boundary impairment: An impaired ability to sense where one's body or influence ends and another's begins. For example, a patient might stand too close to others or might drink another person's beverage, believing that because the beverage is near, it is the patient's.
