Final review

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior?

"Agitated and pacing. Exhibiting grandiosity. Mood labile."

After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?

"Are you currently thinking about harming yourself?"

A Nurse has taught a women about the physical signs that accompany ovulation. Which statement by the patient indicates that the teaching has been effective?

"I can still conceive for up to 48 hrs after ovulation."

Which of the following statements would indicate family teaching about schizophrenia had been effective?

"It's a relief to find out that we did not cause our son's schizophrenia."

A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing response is most appropriate? Select all that apply.

"Tell me why you want to make this change." "This may not be the best time for you to make such an important decision."

A client at the mental health clinic tells the case manager, "I can't think about living another day, but don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which case manager response is most appropriate?

"The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care."

A client diagnosed recently with Alzheimer's disease (AD) is prescribed donepezil (Aricept). The client's spouse inquires, "How does this work? Will this cure him?" Which response by the nurse is appropriate?

"This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease."

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately a month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?

"Weight gain is a common, but troubling, side effect."

An adolescent diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which response should the nurse make?

"Your child has a chemical imbalance of the brain, which leads to altered perceptions."

Mother is going going into preterm labor, the order is for brethine (terbutaline sulfate) 0.25 mg subcutaneous every30 minutes for 2 hours. The label on the terbutaline reads 1 mg/mL how many milliters will you adminster?

0.25 mL

he order is Alprozolam 0.5 mg PO t.i.d. The concentrate contains 1 mg per mL. How many mL of this antianxiety drug will you administer to your patient?

0.5

The order is Thorazine (chlorpromazine hydrochloride) 40 mg IM q6h prn for agitation. The vial is labeled 25 mg/mL. How many milliliters will you administer?

1.6

A vial of Celexa (citalopram) contains 120 mL and the concentration is 10 mg/5 mL. The order is Citalopram 20 mg PO daily. How many doses will this container supply?

12

IV fluid order D5/RL 1000 mL q8h. What is your IV rate?

125 mL/hr

The prenatal clinic nurse is providing information to a pregnant woman who is at 15 weeks' gestation. The patient asks when she should expect to feel fetal movement. Which of the following is the most appropriate answer by the nurse?

18 to 20 weeks

Which of the following tasks should the psychiatric nurse not assign to a nursing assistant? Select all that apply.

Administering ziprasidone PO Performing the admission assessment

During preconception counseling, the nurse explains that the fetus is most vulnerable to the effects of teratogens during which time period?

2 to 8 weeks

Provider orders Carbamepazine 17 mg/kg/day PO to be given in 2 divided doses. Your patient weighs 29.4 kg. The pharmacy supplies you with Carbamepazine 100 mg tablets. Each dose will consist of how many tablets? You may split the tablets in half if needed.

2.5

The perinatal nurse is caring for a patient with preeclampsia. What intervention does the nurse include on the patient's care plan?

Adminster magnesium sulfate per agency policy

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 2 weeks and a 7- pound weight loss during that time. Which should be this client's priority nursing diagnosis?

Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

A couple wishes to determine the chances of having a blue-eyed baby. Both parents have brown eyes, but have heterozygous gene pairs for eye color. Calculate the odds of having a child with blue eyes.

25%

A patient diagnosed with pancreatic cancer is prescribed strict intake and output. During the last shift, the patient received 1 liter of 0.9% normal saline; two 50-milliliter doses of morphine sulfate in 0.9% normal saline; 3 ounces water. What should the nurse calculate this patient's total intake for the previous shift to be?

Correct Answer: 1,190 Rationale: To calculate the patient's total intake, 1 liter of 0.9% normal saline is 1,000 mL. Add this to 100 mL for the two doses of morphine sulfate to equal 1,100 mL. The oral intake of 3 ounces is converted to 90 mL (1 ounce = 30 mL). The patient's total intake for the previous shift was 1,190 mL.

Magnesium sulfate 30 grams is mixed in 500 mL lactated Ringers. Order: Infuse a maintenance dose of magnesium sulfate @ 4 grams /hour. What is the IV rate?

66.67 mL/hour

A nurse assesses a new born as follows: heartrate is 112 beats/min; respiratory effort; slow, irregular with weakcry;muscle tone; some flexion of the extremities; reflex irritability: grimace; Color: pink. What apgar score does thenurse give the infant?

7

Which situation on an inpatient psychiatric unit would require priority intervention by a nurse?

A client exhibiting aggressive behavior toward another client.

The nurse is caring for a woman who is undergoing an induction with oxytocin (Pitocin). The nurse explains to the nursing student that contrindications to labor inductions include which of the following? (Select all that apply)

Active herpes infection Breech presentation Placenta abruption Vasa previa or complete placenta previa

A nurse assessing a fetal heart rate notes minimal baseline variability not associated with a fetal sleep cycle. There is no change after fetal scalp stimulation. What action by the nurse is most important?

Administer oxygen 8-10 L/min by face mask

A patient in the high risk OB unit has suffered a seizure and is now postictal. She is on oxygen at 2L/min. Which assessment by the nurse warrants immediate intervention?

Fetal heart rate of 98 beats/min

The woman in labor is complaining of severe back pain(back labor). What action should the nurse suggest to the birth partner?

Apply counterpressure

A woman complains of perineal pain. The nurse assesses swelling, but sees no other abnormalities. The woman does not wish pharmacological treatment. What suggestion by the nurse is most appropriate?

Applying a covered ice pack to the perineum every 2-4 hrs for 20 minutes

A woman asks the perinatal nurse about gestational diabetes becasue she has been reading about it. The nurse should inform the patient that screening for this condition is usually done at what time?

Around 24 to 28 weeks' gestation

A Women in the third trimester of her first pregancy complains of excessive fatigue. Her Hemoglobin is 11.2 g/dL. What action by the nurse is best?

Asess woman's diet for adequate iron and protein

A woman has just given birth to an infant whose 1 minute Apgar score is 9. Meconium stained amniotic fluid was noted upon rupture of membranes. What action by the nurse is most appropriate?

Assess and document the infant's 5-minute Apgar score

A pregnant woman in her second trimester arrives at the labor unit traige station with complaints of lower abdominal cramping and urinary frequency. Appropriate nursing actions include which of the following? (select all that apply)

Assess fetal heart rate Assess patients pulse rate Obtain a urine sample for culture and sensitivity Palpate the patients abdomen for contractions

A woman in labor receives a dose of hydromorphone hydrochloride (Dilaudid) at 11:30 am. She gives birth at 12:45 pm. What action by the nurse takes priority?

Assess the neonate frequently for respiratory depression

What important nursing action occurs right after the thrid stage of labor?

Assess the placenta for complete expulsion

A woman is having a infertility workup and has been told she has scarring in the fallopian tubes. What action by the nurse is best?

Assess the woman for previous vaginal infections and their treatment

A college nurse offers screening programs for students. At what age hould the nurse encourage women to have their first PAP test?

At age 21

The perinatal nurse teaches the student nurse that deep breathing exercises following cesearean birth are critical to the prevention of what complications? (select all that apply)

Atelectasis AND Pneumonia

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle?

Autonomy

A nurse student asks the faculty member to define "lanugo." Which description is best?

Fine, downy hair on the fetus

A nurse on an inpatient unit helps a client understand the significance of treatments, and provides the client with copies of all documents related to the plan of care. This nurse is employing which tenet of the recovery model?

Be Transparent

medications most commonly used to treat alcohol withdrawal are:

Benzodiazapines

What is the most commonly used group of anxiolytics?

Benzodiazepines

A woman is being started on oral contraceptive pills. Which screening assessments should the nurse perform or assist with?

Blood pressure

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority?

Blood pressure of 180/100 mm Hg

The nurse prepares to offer health screening and promotion activities for women 40-60. Which activity does the nurse plan to include as a priority foe this group?

Breast cancer screeening

A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness?

Schizophrenia spectrum disorder

woman is being treated for infrequent ovulation. The nurse should prepare to educate her about what medication?

Clomiphene citrate (Clomid)

The clinic nurse knows that the part if the uterine cycle that occurs during the period of time between ovulation and the onset of menses is known as which of the following?

Secretory Phase

An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?

Continue professional attempts to establish a positive working relationship with the client.

A patient tells the nurse, "I dread going on after the divorce is final. I have no idea how I am going to manage financially or emotionally." The nurse realizes this patient is demonstrating which aspect of Caplan's stress and loss theory? 1. living without the assets and guidance 2. psychic pain 3. reduced problem-solving ability 4. emotional turmoil

Correct Answer: 1 Global Rationale: According to Caplan's theory of stress and loss, there are three factors that influence a person's ability to deal with a loss. This patient is demonstrating the factor of "living without the assets and guidance of the lost person or resource." Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. The patient is not demonstrating an inability to handle her problems according to the data provided. Emotional turmoil is not a specific factor cited in Caplan's theory.

A patient who is a recent widow states, "I wanted to ask him for a divorce and then he died." What should the nurse realize this patient is at risk for developing? 1. an accelerated grief reaction 2. a dysfunctional grief reaction 3. a typical grief reaction process 4. psychosomatic disorders

Correct Answer: 1 Global Rationale: Factors that can interfere with a successful grieving reaction include ambivalent relationships prior to the loss. This statement does not necessarily indicate a dysfunctional grief reaction or the likelihood of a psychosomatic disorder. The patient's intentions may prevent a typical grief reaction.

A dying patient tells the nurse, "Don't let my family leave me." What should the nurse realize this patient is demonstrating? 1. fear of dying alone 2. the anticipation of improving in health 3. the need for the family to see the patient improve 4. the desire to prolong life

Correct Answer: 1 Global Rationale: Family members are often afraid to be present at the time of death, yet dying alone is the greatest fear expressed by patients. There is no information provided to indicate there will be a recovery or improvement in the patient's condition. While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone.

A patient who had a below-the-knee amputation 2 months ago is seen walking with a new limb prosthesis and returning to work. What does the nurse realize about this patient? 1. The patient has completed the work of mourning the loss of the leg. 2. The patient is having difficulty with grief. 3. The patient is in denial. 4. The patient is forgetting about the disease that caused the loss of the limb.

Correct Answer: 1 Global Rationale: In one theory of the process of loss, the person gradually withdraws attachment to the lost object or person. The period of mourning, or work of mourning, ends and the person reaches a state of completion. This is the time when the patient may be ready to move on and make a change such as using a prosthesis or return to activities they were involved in before the loss. The patient's actions indicate a positive adaptation, not an inability to manage grief. Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. There is inadequate information provided to infer the patient has forgotten about the disease which caused the loss of the limb. Further, forgetting an event of this magnitude is extremely unlikely.

A terminally ill patient and the family agree that the physician will write a do-not-resuscitate order for the patient. The nurse understands that what should be implemented when following this order? 1. Do not call a code if the patient stops breathing or the heart stops beating. 2. Call a code only if the patient stops breathing. 3. Call a code only if the patient's heart stops beating. 4. Withhold food and fluids but provide pain medication.

Correct Answer: 1 Rationale 1: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. Global Rationale: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. Withholding food and fluids but providing pain medication would be elements of a comfort-measures-only order.

Which of the 4 classes of medications used for panic disorder is considered the safest because of low incidence of side effects and lack of physiological dependence?

Selective Serotonin Reuptake Inhibitors (SSRIs)

A patient tells the nurse that since his wife died he has not been able to sleep and sees no reason to continue living. According to Freud's theory on grief and loss, what should the nurse realize this patient is experiencing? 1. depression 2. grieving 3. emancipation 4. denial

Correct Answer: 1 Rationale 1: According to Freud's theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Global Rationale: According to Freud's theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Grieving is the inner labor of mourning a loss. The patient is not grieving. Emancipation and denial are not elements of Freud's theory of grief and loss.

After an unsuccessful resuscitation attempt, a patient dies. What should the nurse do first? 1. Document the time of death. 2. Notify the funeral home. 3. Contact the physician. 4. Contact the orderly for transport to the morgue. Correct Answer: 1

Correct Answer: 1 Rationale 1: After death, the time must be recorded in the patient's record. Global Rationale: After death, the time must be recorded in the patient's record. After documentation is completed, the attending physician will require notification. Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family's wishes. The body can be transported to the morgue after family members have been notified and allowed to see their loved one.

An older client has recently moved to a nursing home. The client has a sad affect, trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication would the nurse most likely administer to the client?

Sertraline (Zoloft)

A 30-year-old terminally ill patient is concerned about how her 7-year-old child will perceive her death. What advice from the nurse would be most beneficial? 1. Children this age recognize that death is permanent. 2. Children this age emotionally distance themselves from the death. 3. Because the child fears separation the patient can prepare the child by explaining that death is permanent. 4. Children this age think death is sleeping.

Correct Answer: 1 Rationale 1: Age is a great determinant of beliefs about death. Children this age understand the finality of death. Global Rationale: Age is a great determinant of beliefs about death. Children this age understand the finality of death. At the age of 7, children do not have the emotional maturity to distance themselves from death. The ability to understand separation has been mastered by the age of 7. Children this age do not think that death is sleeping.

A patient tells the nurse that her estranged husband died a little over a year ago and states, "I am not sure why this is so difficult. I really couldn't stand him near the end." Which response by the nurse is most appropriate? 1. "Sometimes a rocky relationship with someone at the time of their death can affect your ability to grieve." 2. "You seem angry." 3. "You should contact a therapist." 4. "You are just entering the grief process. Things will get better."

Correct Answer: 1 Rationale 1: An ambivalent relationship prior to the loss can affect a person's ability to grieve Global Rationale: An ambivalent relationship prior to the loss can affect a person's ability to grieve. The patient does not seem angry. It is inappropriate for the nurse to refer the patient to a therapist. As the death occurred over a year ago, the patient is experiencing impaired grieving.

The brother of a terminally ill patient states, "I'll donate a million dollars to the hospital if they cure my brother." The nurse realizes this statement indicates which phase of Kübler-Ross's stages of loss? 1. bargaining 2. denial 3. anger 4. acceptance

Correct Answer: 1 Rationale 1: Bargaining is an attempt to postpone or in some way affect the reality of the loss Global Rationale: Bargaining is an attempt to postpone or in some way affect the reality of the loss. The brother is not expressing denial or acceptance and does not appear to be angry.

A terminally ill patient is demonstrating signs of spiritual distress. Which should the nurse do first to assist this patient? 1. Use the FICA assessment. 2. Help the patient with guided imagery. 3. Offer to pray with the patient. 4. Leave the patient alone with her thoughts.

Correct Answer: 1 Rationale 1: Because the nurse often feels uncertain about implementing interventions that would be helpful to the patient responding to a loss, the FICA assessment can be used to assess a patient's spiritual or religious practices. Global Rationale: Because the nurse often feels uncertain about implementing interventions that would be helpful to the patient responding to a loss, the FICA assessment can be used to assess a patient's spiritual or religious practices. The nurse should use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts.

A patient has decided to join a support group for surviving spouses of victims of violent crime. According to Engel's theory of grief and loss, the nurse identifies that this patient is in which stage? 1. restitution 2. acute grief 3. shock and disbelief 4. denial

Correct Answer: 1 Rationale 1: During restitution the mourner continues to feel a painful void, is preoccupied with thoughts of the loss, and may join a support group or seek other social support for coping with the loss. Global Rationale: During restitution the mourner continues to feel a painful void, is preoccupied with thoughts of the loss, and may join a support group or seek other social support for coping with the loss. The patient who is joining a support group is in the stage of restitution. Acute grief is initiated by shock and disbelief, which may manifest as denial.

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?

Social isolation R/T poor self-esteem AEB secluding self in room

While preparing for the discharge of a terminally ill older adult patient, the family asks for information concerning the most appropriate time to become involved with a hospice agency. Which action by the nurse is most correct? 1. Assist the family with making contact with a hospice agency at this time. 2. Determine the patient's life expectancy to gauge when the contact should be made. 3. Encourage the family to "hold off" making the contact until death is very close. 4. Determine what expectations the family has of the hospice agency.

Correct Answer: 1 Rationale 1: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. Global Rationale: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. It is inappropriate to try to determine life expectancy. This is an inaccurate measurement of the degree of services needed. Waiting until the time of death nears does not leave much time for the hospice agency to assist the family. Determining the family's expectations concerning hospice is an inappropriate action for the nurse.

A patient asks the nurse what it means to have hospice care at home. What should the nurse respond to this patient? 1. "Hospice makes sure that you are comfortable at home." 2. "Hospice care helps cure your illness." 3. "Hospice care is for patients who will be sick for longer than a year." 4. "Hospice care means your physical needs will be met."

Correct Answer: 1 Rationale 1: Hospice care focuses on comfort care versus curative care. Global Rationale: Hospice care focuses on comfort care versus curative care. It is care for patients with limited life expectancy. The care plan includes both the patient and family/caregiver as the unit of care, and the care plan is written to meet their values and goals. Patients receiving hospice care are generally defined as those who have a prognosis of 6 months or less if their terminal disease runs a normal course.

A patient with a chronic illness asks the nurse if the new medication is going to cure the disease. Which is the nurse's best response? 1. "It will help you be more comfortable. I don't think it's going to cure the disease." 2. "Of course it's going to cure the disease." 3. "If you believe it will cure the disease, then it will." 4. "I don't think it's going to help or hurt at this time."

Correct Answer: 1 Rationale 1: In palliative care, the nurse needs to be honest with the patient and explain that the medication will help with comfort, but will not cure the chronic illness. Global Rationale: In palliative care, the nurse needs to be honest with the patient and explain that the medication will help with comfort, but will not cure the chronic illness. The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. The nurse has no way of knowing whether the medication will help or hurt the patient.

A patient tells the nurse that her husband passed away a year ago and she is now beginning to realize that he is truly gone. The patient is planning to begin a new job and possibly move to a new community. The nurse realizes that this patient is in which stage of Bowlby's theory of attachment? 1. detachment 2. protest 3. despair 4. anger

Correct Answer: 1 Rationale 1: In the stage of detachment the person realizes the permanence of the loss and expresses readiness to move forward. This is what the patient is doing when planning to begin a new job and move to a new community. Global Rationale: In the stage of detachment the person realizes the permanence of the loss and expresses readiness to move forward. This is what the patient is doing when planning to begin a new job and move to a new community. The protest phase is marked by a lack of acceptance of the loss. In despair, the person's behavior becomes disorganized. Anger is not a stage in Bowlby's theory of attachment.

A terminally ill patient is experiencing dyspnea and tells the nurse that he feels like he is suffocating. What can the nurse do to assist this patient? 1. Keep the room cool with a slight breeze. 2. Increase the heat in the room. 3. Provide additional intravenous fluids. 4. Assist the patient to a sitting position out of bed.

Correct Answer: 1 Rationale 1: Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. Global Rationale: Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. Raising the temperature in the room will not reduce the feeling of suffocation. Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation. The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed.

At the time of admission, a patient with a terminal illness tells the nurse that her daughter will be allowed to make health-related decisions if she becomes incapacitated. What should the nurse realize this patient is specifically describing? 1. healthcare surrogate 2. living will 3. durable power of attorney 4. advance directive

Correct Answer: 1 Rationale 1: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. Global Rationale: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. The living will provides written directions about life-prolonging decisions. The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual's behalf. Advance directives are legal documents that allow a person to plan for healthcare and/or financial affairs in the event of incapacity. They include living wills, healthcare surrogates, and durable power of attorney.

A mother brings her 8 year old daughter to the clinic for the third time in 2 months. The mother states her daughter is very active and often falls down. The mother states that her daughter eats well but weight falls below the 10th percentile. The clinic record shows the child had multiple bruises on her arms at the last two visits. Today the nurse notes that the child has areas of ecchymosis on her left leg and ankle. Which action by the nurse is best?

Speak with the child alone, asking if she feels safe a home

A terminally ill patient is experiencing secretions pooling in the back of the throat. What can the nurse do to help this patient feel more comfortable? 1. Raise the head of the bed. 2. Gently massage the patient. 3. Provide frequent small sips of fluids. 4. Provide oral care. Correct Answer: 1

Correct Answer: 1 Rationale 1: The nurse should reposition the patient and raise the head of the bed if fluids accumulate in the upper airways and back of the throat. Global Rationale: The nurse should reposition the patient and raise the head of the bed if fluids accumulate in the upper airways and back of the throat. Gentle massage helps with accumulating edema of the extremities. Small sips of fluids and oral care help with the discomfort of drying oral mucous membranes.

A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided. The family members are not supportive of this directive. Which action by the nurse is the most appropriate? 1. Place the document on the chart. 2. Contact the Social Services department. 3. Notify the hospital attorney. 4. Explain to the patient that the conflict could invalidate the document.

Correct Answer: 1 Rationale 1: The patient is competent, and the wishes of the patient must take priority. The document should first be placed on the chart and the physician notified. Global Rationale: The patient is competent, and the wishes of the patient must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department, hospital attorney, or unit supervisor will need to be contacted. A lack of support by the family does not invalidate the document.

A terminally ill patient is receiving palliative care. What does the nurse understand the purpose of this type of care to be? 1. alleviating suffering and enhancing quality of life 2. reducing pain and preventing medical complications 3. controlling side effects of illness while postponing death 4. withdrawing all medical care to allow natural death

Correct Answer: 1 Rationale 1: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Global Rationale: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Medical complications can be controlled but not prevented. The purpose is not specifically to postpone death. Withdrawing all medical care would be inappropriate as it would cause more suffering.

A patient of Native American descent is expected to die. The family arrives at the hospital and wants to observe their religious and cultural traditions. Which intervention by the nursing staff would be most appropriate? 1. Offer the family a private room to sit together. 2. Discourage the family from sitting with their loved one prior to death. 3. Discuss the possibility of transferring the patient home for the death. 4. Encourage the family to consider a DNR order.

Correct Answer: 1 Rationale 1: Traditional Native Americans prefer to mourn in private, away from the dying patient. Global Rationale: Traditional Native Americans prefer to mourn in private, away from the dying patient. It is not appropriate for the nurse to discourage the family from spending time with the patient at this critical point. The severity of the patient's condition does not allow for transfer at this time. Some tribes prefer not to openly discuss DNR decisions.

A terminally ill patient who does not have an advance directive or do-not-resuscitate order in place stops breathing. What should the nurse do to assist this patient? 1. Call a code. 2. Initiate a slow code. 3. Contact the physician to assess the patient for death. 4. Contact the nursing supervisor.

Correct Answer: 1 Rationale 1: Without an advance directive or do-not-resuscitate order, the nurse is legally responsible for calling a code on the terminally ill patient who has stopped breathing. Global Rationale: Without an advance directive or do-not-resuscitate order, the nurse is legally responsible to call a code on the terminally ill patient who has stopped breathing. To initiate a slow code would be malpractice. The nurse needs to call a code, not call the physician or the nursing supervisor.

The nurse is caring for a patient who is nearing death from a terminal illness. The patient is experiencing secretions in the back of the throat and dyspnea. Which medications should the nurse provide to assist this patient? Standard Text: Select all that apply. 1. Oxygen 2. Morphine 3. Atropine 4. Scopolamine 5. Demerol

Correct Answer: 1, 2, 3, 4 Global Rationale: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with oxygen, opioids, and medications that reduce secretions, such as atropine and scopolamine. Meperidine (Demerol) is not useful for chronic pain because it has a short half-life and a toxic metabolite that can cause irritability and seizures.

A patient with a terminal illness says that when the pain becomes too unbearable he plans to take an overdose of pain medication and end it all. How should the nurse respond to this patient's plan? Standard Text: Select all that apply. 1. "Do you have a living will?" 2. "Have you assigned durable power of attorney to anyone?" 3. "Have you considered a healthcare surrogate?" 4. "Have you researched methods for self-euthanasia?" 5. "Have you talked with your healthcare provider about orders for life-sustaining treatment?"

Correct Answer: 1, 2, 3, 5 Global Rationale: A living will is a document that provides written directions about life-prolonging procedures to follow when an individual can no longer communicate in a life-threatening situation. Durable power of attorney is a document that can delegate the authority to make healthcare decisions. A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. A physician order for life-sustaining treatment (POLST) is a form for patients with serious, progressive, chronic illnesses that translates their wishes regarding life-sustaining treatment into actionable medical orders. Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient.

A patient who nearing the end of life is irritable and uncomfortable in bed. Which actions should the nurse take to make the patient more comfortable? Standard Text: Select all that apply. 1. Raise the head of the bed. 2. Apply bed pads over the linens. 3. Gently massage the extremities. 4. Reduce the amount of pain medication. 5. Use a draw sheet to turn the patient.

Correct Answer: 1, 2, 3, 5 Global Rationale: Actions to help this patient achieve comfort include raising the head of the bed, applying bed pads over the linens, gently massaging the extremities, and using a draw sheet when turning. Reducing the amount of pain medication can increase this patient's level of pain.

During a home visit the nurse determines that a patient whose spouse died 10 months ago is demonstrating signs of grief resolution. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Not living in the past 2. Breaking ties with the lost person 3. Asking for help to end the pain of the loss 4. Experiencing waves of sadness when looking at a picture 5. Wishing that death had occurred at the same time the spouse died

Correct Answer: 1, 2, 4 Global Rationale: Evidence that grief is resolving includes not living in the past, breaking ties with the lost person, and experiencing waves of sadness when looking at a picture. Asking for help to end the pain of the loss and wishing for death at the same time that the spouse died indicates that grief resolution is not occurring.

A patient whose spouse passed away 5 years ago becomes severely depressed on holidays, anniversaries, and birthdays. What should the nurse do to help this patient? Standard Text: Select all that apply. 1. Encourage the patient to talk with family or spiritual support systems. 2. Explain that these feelings are a sign of chronic depression. 3. Help the patient talk about the loss and hopes for the future. 4. Explain that these feelings will last as long as the patient is alive. 5. Role-play ways for the patient to get through the days when depression is the worst.

Correct Answer: 1, 3, 4, 5 Global Rationale: For the patient with chronic sorrow the nurse should encourage the patient to talk with family or others in the patient's spiritual support system, help the patient talk about the loss and hopes for the future, explain that these feelings will last as long as the patient is alive, and role-play ways for the patient to get through the days when the depression is the worst. These feelings are not a sign of chronic depression.

What are the best communication strategies that a nurse can use to encourage patients to share personal and sensitive information? (Select all that apply.)

Start an interview by asking very broad questions and then proceed to more specific questions. Be aware of your own biases and personal opinions with regard to the patient's information.

The sibling of a patient who is nearing death has insisted on intravenous fluids because "My brother wants to live." Which findings should the nurse expect when assessing this patient? Standard Text: Select all that apply. 1. The nurse notes the presence of inspiratory and expiratory crackles in all lung fields. 2. The nurse notes that there is increasing edema in the patient's ankles and feet bilaterally. 3. The patient has developed ascites. 4. The patient has lost 6 pounds from last week. 5. The nurse learns during shift report that the patient vomited three times during the night shift.

Correct Answer: 1,2,3,5 Global Rationale: Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs, peripheral edema, ascites, and vomiting. The patient is much less likely to lose weight at this time.

A patient diagnosed with terminal cancer tells the nurse that she knows everything about a living will. Upon assessment, the nurse realizes the patient needs additional instruction on this type of advance directive when the patient makes which statements? Standard Text: Select all that apply. 1. "A living will is a document in which I designate someone to make healthcare-related decisions for me in the event I become unconscious." 2. "A living will is a document in which I designate someone to make healthcare and legal decisions for me in the event I become unconscious." 3. "A living will is a document in which I designate my personal wishes and which directions to follow in the event I become unconscious." 4. "A living will is a document in which I designate which directions to follow in the event I become unconscious, but the directions can be modified by my family." 5. "A living will is a document in which my family designates someone to make decisions for me in the event I become unconscious."

Correct Answer: 1,2,4,5 Global Rationale: A living will is a document in which the patient designates those wishes and directions to follow in the event of terminal illness or permanent unconsciousness. A healthcare surrogate is an individual that the patient designates to make healthcare decisions for the patient in the event the patient is unable to do so. Durable power of attorney is a document that delegates the authority to make legal, healthcare, and financial decisions for the patient in the event the patient is unable to do so because of a change in health status. A living will is not created by the patient's family and cannot be modified by the family. A living will is not created for another person; therefore, the family cannot make a living will for a patient.

A patient of Mexican American descent is dying. Which statements by the patient's only son are expected? Standard Text: Select all that apply. 1. "We have already notified our priest about Dad's condition." 2. "When the time of death gets closer, we would like him transferred to the inpatient hospice unit at the hospital." 3. "My sister is pregnant, so she really can't help with his care." 4. "My family members will be here at the house a lot right now." 5. "We don't want to worry him, so if there is any change in his condition, please talk to me about it."

Correct Answer: 1,3,4,5 Global Rationale: It is important that the patient's priest be notified. Pregnant women do not care for dying persons or attend funerals. Extended family members are obligated to pay respects to the sick and dying. Based on the belief that worry may make health worse, the family may want to protect the patient from the seriousness of illness. The information is often handled by an older daughter or son. It would be unusual for the family of this patient to express the wish to transfer the patient from home to a hospital. Mexican American families often prefer that the patient die at home.

The nurse suspects a patient is in the final stages of the dying process. What manifestations did the nurse assess in this patient? Standard Text: Select all that apply. 1. change in level of consciousness 2. sudden increase in taste and smell 3. urinary incontinence 4. increased blood pressure 5. irregular heart rate

Correct Answer: 1,3,5 Global Rationale: Assessment findings consistent with the late stages of the dying process include a change in level of consciousness, incontinence of bowel and bladder, and an irregular heart rate. There is a decrease, not an increase, in taste and smell. Blood pressure will decrease.

The patient states, "My husband is the person you should talk with if I am not able to make decisions about my care." What should the nurse realize the spouse has been designated to be? 1. the person who has the patient's living will 2. the healthcare surrogate 3. the person with the durable power of attorney 4. nothing more than the spouse

Correct Answer: 2 Global Rationale: A healthcare surrogate is the person selected by the patient to make medical decisions when the patient is no longer able to make them for him- or herself. The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for health care. Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney.

The spouse of a former patient tells the nurse that he has joined a support group to help with the loss of his wife. The nurse realizes this patient is in which phase of Engel's grief process? 1. acute 2. restitution 3. long-term 4. resolution

Correct Answer: 2 Global Rationale: According to Engel, there are three phases of the grief process: acute, restitution, and long-term. It is during restitution that the surviving spouse might join a support group to help cope with the loss. The acute phase is initiated by shock and disbelief, manifested by denial. During the long-term phase, the individual begins to come to terms with the loss and renew activities. Resolution is associated with the acceptance of the loss but is not one of the phases in Engel's grief process.

The nurse is assessing a dying patient's spiritual beliefs about death. Which acronym represents topics the nurse can use to help with this assessment process? 1. ABC 2. FICA 3. DABDA 4. RACE

Correct Answer: 2 Global Rationale: Faith, influence, community, and address form the acronym FICA. These topics can help the nurse move through the spiritual assessment process with a patient. ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient's spiritual beliefs about death. DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross's stages of grieving. RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation.

The family of a dying patient wants to help relieve the patient's progressive dyspnea. What should the nurse instruct the family to do for the patient? 1. Lower the head of the bed. 2. Raise the head of the bed. 3. Suction the patient as much as possible. 4. Perform chest physiotherapy.

Correct Answer: 2 Global Rationale: Nursing care to improve respirations includes raising, not lowering, the head of the bed. Suctioning and chest physiotherapy would be considered advanced care measures and are not indicated in the scenario.

A patient with a terminal illness is experiencing severe nausea and vomiting. Which medications should the nurse consider appropriate for the patient at this time? Standard Text: Select all that apply. 1. Furosemide (Lasix) 2. Ondansetron (Zofran) 3. Meperidine (Demerol) 4. Morphine sulfate (Morphine) 5. Prochlorperazine (Compazine)

Correct Answer: 2, 5 Global Rationale: Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. Furosemide (Lasix) is a diuretic. Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. Morphine sulfate (Morphine) is an analgesic, which could be causing this patient's nausea and vomiting.

A 22 year-old woman presents to the emergency department with abdominal pain and vaginal bleeding. Her blood pressure is 90/58 mm Hg, her pulse 120 beats/min, and she complains of dizziness. which action by the nurse takes priority?

Start two large-bore IVs for fluid replacement

A patient who has just lost her spouse asks the nurse how long it will be until she feels like living again. The nurse realizes this patient has to work through which phases of the grieving process according to Bowlby? Standard Text: Select all that apply. 1. denial 2. despair 3. detachment 4. protest 5. restitution

Correct Answer: 2,3,4 Global Rationale: The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate she has acknowledged the event. Denial is associated with feelings of disbelief. Restitution is a stage in Engel's theory of loss.

The nurse is instructing others on the use of hospice care. Which statements would indicate to the nurse that the teaching session has been effective? Standard Text: Select all that apply. 1. "Hospice care is designed for individuals with a terminal prognosis who cannot stay at the hospital." 2. "Hospice care is designed for individuals with a terminal prognosis who decide to spend their final days at home with their families." 3. "Hospice care is designed for individuals with a terminal prognosis who decide to stay in the hospital for symptom management." 4. "Hospice care is designed for individuals with a terminal prognosis who have to go into a hospice center for proper symptom management." 5. "Hospice care is designed for individuals with a terminal prognosis who decide to receive treatment for their symptoms at home, the hospital, or the hospice center."

Correct Answer: 2,3,5 Global Rationale: Hospice care is a philosophy of care designed for the individual with a terminal prognosis and the individual's family members. Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient.

A young adult male patient diagnosed with terminal pancreatic cancer tells the nurse that if he lets his hair grow, God will cure him. What should the nurse realize this patient is demonstrating? Standard Text: Select all that apply. 1. The patient is having delusions and is using religious beliefs to block his loss. 2. The patient is bargaining and is postponing his loss. 3. The patient is in denial, and his religious beliefs block his loss. 4. The patient is normal; bargaining with God for physical healing reflects a stage of grieving. 5. The patient is feeling anger and is using his religious beliefs to project his loss

Correct Answer: 2,4 Global Rationale: Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. The patient is not delusional or in denial and is not using religious beliefs to block the loss. Bargaining with God is not a demonstration of anger.

A patient is explaining her experiences after the sudden death of her daughter a few years ago. If Elizabeth Kübler-Ross's sequence is applied, in which order did the patient experience the stages of death and dying? Rank the patient's statements in the order they would have been made. Standard Text: Click and drag the options below to move them up or down. Choice 1. "I have to admit I tried to make a deal with God to bring her back to me." Choice 2. "I'm going to try to use my experience with her illness to help other parents." Choice 3. "I cannot get my mind around it. I still keep waiting for her to come home from school." Choice 4. "I can hardly get out of bed because I just want to sleep." Choice 5. "I just feel so mad at her for leaving me!"

Correct Answer: 3,5,1,4,2 Global Rationale: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. The stages are denial, anger, bargaining, depression, and finally acceptance.

A nurse is counseling a couple whose child has been diagnosed with cystic fibrosis. They understand that this is an inherited disease, but don't know how the child got it, neither of them is affected. What is the response by the nurse?

This is a recessive disorder, meaning that each of you is just a carrier."

A preoperative patient says to the nurse, "I hope I wake up after surgery. I don't know what my family would do if I didn't." The nurse realizes this patient is demonstrating which potential problem? 1. coping 2. chronic sorrow 3. anticipatory grieving 4. death anxiety

Correct Answer: 3 Global Rationale: Anticipatory grieving is a combination of intellectual and emotional responses and behavior by which people adjust their self-concept in the face of a potential loss. This patient is expressing a feeling, not demonstrating coping. This patient is not demonstrating chronic sorrow, which is a "cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced in response to continual loss, throughout the trajectory of an illness or disability." This patient is not experiencing death anxiety, which is worry or fear related to death or dying. It may be present in patients who have an acute life-threatening illness, who have a terminal illness, who have experienced the death of a family member or friend, or who have experienced multiple deaths in the same family.

The family of a dying patient states, "She has to be in pain, because all she does is moan." What should the nurse realize this family is doing? 1. overreacting 2. asking for more pain medication for the patient 3. not understanding that moaning can be agitation in the patient 4. considering moaning to be a sign the patient is recovering

Correct Answer: 3 Global Rationale: Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. The family thinks she is in pain, which would not indicate an improvement in status. The responses by the family are typical and do not reflect excessive concern. There in no indication that the family is requesting pain medication.

A patient tells the nurse, "My husband left me to be with God." What should the nurse realize this patient is demonstrating? 1. coping 2. denial 3. a regional difference in the way death is expressed 4. a cultural rite related to death

Correct Answer: 3 Global Rationale: Regional differences in the way death is expressed in the United States include "passed away," "went to be with God," and "passed from this life." This statement does not reflect coping, denial, or a cultural rite.

A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis?

This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

The nurse who provided care to a terminally ill patient does not want to spend any time with the grieving family and begins to provide care to another patient. What is this nurse demonstrating? 1. empathy 2. apathy 3. overemotionality 4. blunting

Correct Answer: 4 Global Rationale: Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle his or her emotions appropriately right after the death, and this is a coping mechanism. Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. Apathy is an emotion characterized by a lack of concern and involvement. Overemotionality is not a recognized term.

A patient who has recently loss his spouse states, "I just can't cry." What should the nurse realize this patient is at risk for developing? 1. psychological issues 2. depression 3. overemotionality 4. somatic symptoms

Correct Answer: 4 Global Rationale: The inability to express grief can lead to the onset of somatic, or physical, symptoms. Crying is considered a typical and expected part of the grief reaction in most grief theories. There is no indication this patient will face an increased risk for the development of psychological issues or depression.

A patient diagnosed with testicular cancer tells the nurse that he does not believe he has cancer. The nurse realizes that the patient may be progressing through the stages of grief. Place in order the stages of grief. Standard Text: Click and drag the options below to move them up or down. Choice 1. depression Choice 2. acceptance Choice 3. anger Choice 4. denial Choice 5. bargaining

Correct Answer: 4,3,5,1,2 Global Rationale: The patient is currently in the stage of denial by refusing to accept the diagnosis. Kübler-Ross's stages of grieving begin with denial. The second stage is anger, when the patient demonstrates anger over the situation. The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. The fourth stage, depression, occurs when the patient realizes the full impact of the loss. The final stage is acceptance and occurs when the patient accepts the conditions of the illness and begins to plan or hope for the future. A patient may or may not experience all of the stages in this process.

A patient being treated for terminal cancer is prescribed morphine sulfate through a continuous intravenous infusion. The pharmacy is requesting the patient's current weight in kilograms. During the last measurement, the patient's weight was documented as 128 lbs. What should the nurse calculate this patient's weight in kg to be?

Correct Answer: 58.1 Rationale: To calculate the patient's weight in kilograms, the nurse should divide the weight in pounds by 2.2. This calculation would be 128/2.2 = 58.1 kg.

During prenatal class, the nurse teaches expectant couples about the importance of amniotic fluid and its functions. What functions does the nurse describe? (Select all that apply)

Cushions fetus from mechanical injury Facilitates symmetrical growth of fetal limbs Helps regulate body temperature Prevents amnion from adhering to the fetus

Which would the nurse recognize as signs of alcohol withdrawal?

Tremors Elevated BP Diaphoresis

Pseudo-parkinsonism, akathisia, and dystonia are examples of extrapyramidal effects from antipsychotic medications.

True

Name the FHR pattern seen below. Are any interventions needed? If so what are they?

Variable Decelerations. indicates cord compression, providing oxygen and assisting the mother to change positions or placing her into deep Trendelenburg can decrease the compression

A pregnant woman is admitted to the high risk OB unit and started on an IV of magnesium sulfate. What assessment by the nurse is most important?

Deep tendon reflexes (DTR)

A nurse is working in an urban clinic with a diverse population. What action by the nurse is most important?

Determine patients' definitions of health and desired outcomes of health care.

Give one example of a medication that is commonly prescribed for drug-induced extrapyramidal reactions.

Diphenhydramine

A nurse notes fetal heart rate decelerations that appear to start prior to a uterine contraction with fetal heart rate running normal by the end of the contraction. How does the nurse document this finding?

Early deceleration

A woman is in the early latent phase of labor and is frusterated by the length of time this stage is taking. what action by the nurse is best?

Encourage frequent position changes or walking

The nurse would assess for which characteristics in a client with narcissistic personality disorder?

Entitlement

Delirium is an irreversible condition that has a slow onset.

False

A woman's birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come to the birthing unit?

When contractions are 3 to 5 mins apart

The pediatric nurse explains to the student that production of testosterone by the male embryo causes what to occur?

Formation of the male genital tract

A woman in the infertility clinic is concerned that her religion may object to assisted reproductive technologies. Which process should the nurse explore with the woman as possibly acceptable?

GIFT (gamete intrfallopian transfer)

A terminally ill patient nearing end of life is dehydrated and complains of being thirsty. What can the nurse do to make the patient more comfortable? 1. Provide oral care every 2 hours. 2. Increase intravenous fluids. 3. Raise the head of the bed. 4. Begin enteral feedings. Correct Answer: 1 Rationale 1: Dehydration in the patient nearing death causes discomfort primarily from dry mouth and thirst. The patient should be given oral care at least every 2 hours, and more often if the patient is breathing through the mouth.

Global Rationale: Dehydration in the patient nearing death causes discomfort primarily from dry mouth and thirst. The patient should be given oral care at least every 2 hours, and more often if the patient is breathing through the mouth. Increasing intravenous fluids could cause peripheral and lung edema. Raising the head of the bed helps with dyspnea, not dehydration. Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst.

A patient's cervix is 8 cm dilated and she is 100% effaced. what action by the nurse is most important at this time?

Have the woman avoid pushing at this time

A nursing student wishes to investigate national goals. Where should the student research this information?

Healthy People Initiative

The perinatal nurse describes normal maternal signs and symptoms associated with lightening to the prenatal class attendants. These signs and symptoms include which of the following? (select all that apply)

Increased urinary frequency Increased vaginal secretions Leg cramps

A nurse assess the fetal position in a laboring woman. The fetal position is documented as LSP. What action by the nurse is best?

Inform the provider; prepare for possible cesarean delivery

A patient inquires why ibuprofen (Motrin) and not acetaminophen (Tylenol) is usually prescribed for mentral discomfort. Which response is best?

Inhibits prostagladins

A nurse is assessing a patient in the women's clinic for chadwick's sign. How does the nurse perform this assesment?

Inspects the vulva and vagina for a bluish tint

A jilted college student is admitted to a hospital following a suicide attempt and states, "No one will ever love a loser like me." According to Erikson's theory of personality development, a nurse should recognize that this patient has a deficit in which developmental stage?

Intimacy versus isolation

A nursing instructor is planning to teach students about the process of oogenesis. Which information does the nurse plan to include?

It is regulated by the follicle stimulating hormone (FSH)

A student asks the faculty member to explain why the fetus has such low P02. What explanantion by the faculty member is most accurate?

It keeps the ductus arteriosus open.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle should a nurse determine has been violated based on these actions?

Justice

During the prenatal visit, a nurse teaches a pregnant woman about emergencies for which she needs to be seen immediately. Which situations does the nurse include in this education? (Select all that apply)

Low, dull backache or pelvic pressure Maternal fever over 100.5F Reduction in fetal movements

Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)

Maintain a calm demeanor. Set limits on the behavior Clearly delineate the consequences of the behavior.

A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness?

Major depressive episode

A pregnant woman's last normal menstral period started on June 8, 2013. Calculate her expected date of birth using nagele's rule. What is her due date?

March 15, 2014

A G2T2P0A0L2, patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second degree laceration was needed following the birth. The nurse assesses that the patient's uterus is boggy and a little deviated to the right. The patient's vaginal bleeding has increased. What action by the nurse takes priority?

Massage the uterine fundus with continual lower segment support

A nurse brought a newborn to his mother's room. What action by the nurse takes priority?

Matching the information on mother's and baby's ankle and wrist bands

A nurse is teaching a group of middle school students about the functions of the male reproductive tract. Which information should the nurse include?

Maturing sperm are stored in the epididymis

The most commonly used medications for Medication Assisted Treatment for heroin dependence are: (Select all that apply}

Methadone Buprenorphine

A patient on the post partum floor of the hospital has a body mass index (BMI) of 38 and just gave birth to a healthy baby girl by cesarean section. Which action by the nurse takes highest priority?

Monitoring the incision site and using strict hand-washing technique

The nurse is asked why there seems to be more people diagnosed with neurocognitive disorders (NCD). Which rationale would the nurse offer?

More people now survive into the high-risk period for neurocognitive disorders.

A nurse concludes that a restless, agitated client is manifesting a fight- or-flight response. The nurse should associate this response with which neurotransmitter?

Norepinephrine

A woman who is 26 weeks pregnant has a blood pressure of 158/100 mm Hg. Which action by the nurse is most appropriate?

Obtain urine sample, check for proteinuria, ask about headache or visual disturbances

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy?

On inpatient units, every interaction is an opportunity for therapeutic intervention.

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, grandiosity, agitation, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia?

Paranoid delusions, agitation, neologisms, and grandiosity are positive symptoms of schizophrenia.

A client diagnosed with schizoaffective disorder hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?

Placing the client on one-to-one observation while continuing to monitor suicidal ideation.

A nurse manager is evaluating staff members on their cultural competence. Which action best demonstrates this characteristic?

Plans care with family members within their cultural beliefs

The perinatal nurse explains to the new nurse that the maternal pelvic shape can dertermine the fetal presentation. A fetus in a transverse presentation may be due to which maternal pelvic type?

Platypelloid

A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?

Possessing a feeling of self-fulfillment and realizing full potential.

The perinatal nurse is providing care to a multiparous woman in labor. Upon arrival to the birthing suite, the cervix is 5 cm dilated and the [atient is experiencing contractions every 1 to 2 minutes that she describes as "strong." The patient states she has labored for 1 hour at home and is feeling some rectal pressure. The patient is most likely experiencing what condition?

Precipitous labor

A patient in the emergency department has a positive serum hCG. What can the nurse surmise about this patient?

Pregnant

The nurse explains to the student that the development of the lining is mediated by which hormone?

Progesterone

The perinatal nurse explains the function of Wharton's jelly to a class of expectant parents. What description is the most accurate?

Protects the umbilical cord from compression

The nurse observes that a client with bipolar disorder is pacing in the hall, talking loudly and rapidly, and using elaborate hand gestures. The nurse concludes that the client is demonstrating which?

Psychomotor agitation

A nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate based on gender, age, race, or religion. Which guiding principle of recovery has this nurse employed?

Recovery is based on respect.

Which of the following characteristics describe the obsessional thoughts experienced by clients with Obsessive Compulsive Disorder (OCD)?

Recurrent Intrusive Unwanted Uncontrollable

The nurse is planning discharge teaching for a client taking clozapine (Clozaril). Which teaching is essential to include?

Remind the client to go to the lab to have blood drawn for a white blood cell count.

An instructor is teaching nursing students about neurotransmitters. Which best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron?

Reuptake

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?

Risk for suicide R/T hopelessness

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

Risk for violence: directed toward others

A woman is receiving oxytocin(Pitocin) via infusion. The nurse assesses the following uterine contractions lasting 100 seconds every 1.5 minutes, uterine resting tone is at 36 mm Hg, baseline fetal heart rate is 108 beats/min with absent variability. What action by the nurse takes priority?

Stop the infusion.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment?

Structured programming

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

Symptoms may indicate lithium carbonate toxicity.

A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

Tardive dyskinesia treated by discontinuing antipsychotic medications

The clinic nurse sees a patient and her infant in the clinic for their 2 week follow up visit. The woman appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. Which question would be most appropriate for the nurse to ask?

Tell me about the first few days at home?"

Which of the following are examples of a therapeutic communication response?

Tell me more about our discharge plans. "What might you do the next time you're feeling angry?"

A pregnant woman tells the perinatal nurse that she stopped abusing other drugs when she learned that she was pregnant but has kept using marijuana becasue "it is harmless." What response by the nurse is best?

Tell the mother that marijuana use can effect language and cognitive development

A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize?

Temperature of 100.5°F

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB stating "government agents came in my room at night", and daytime napping. Which is a correctly written and appropriate outcome for this client?

The client will sleep seven uninterrupted hours by day four of hospitalization.

nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors?

The client's behaviors demonstrate no functional impairment, indicating no mental illness.

A student has read that hematopoiesis occurring in the wall of the yolk sac declines after the eighth week of gestation and asks the instructor for clarification. What statement by the faculty member is most accurate?

The fetal liver takes over the function making the blood cells."

A family practice nurse is providing anticipatory guidance to a 11 year old biy. What information about puberty should the nurse plan to include?

The first sign of puberty testicular enlargement

The nursing faculty explains to students that ethnopluralism is an important force shaping the health care today. What concept is most important in understanding this trend?

The increased impact of diverse cultures on health care

A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique?

The nontherapeutic technique of giving reassurance

A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response?

The voices must sound scary, but the devil is not talking to you. This is part of your illness."

Individuals with an addiction to alcohol are given ___________________ to prevent Wernicke's encephalopathy.

Thiamine (Vitamin B1)

The nurse would recognize which drugs as central nervous system depressants?

Whiskey Heroin Phenobarbital Diazepam (Valium

An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?

With staff support, set firm limits on the behavior.

A new nurse is struggling to care for a woman whose baby is stillborn. What advice should the nurse preceptor give the novice?

You can simply say 'I am sorry for your loss.""

A nurse cares for a young adult with depression who has voluntarily sought admission to an inpatient psychiatric facility. The client asks the nurse, "How long do I need to stay there?" What is the nurse's response?

You may leave the facility after the health care provider determines you are safe to leave."

A client was admitted with major depression that was a single episode and moderate. During her stay, she was started on Prozac (fluoxetine) 40 mg orally every day. The nurse's discharge teaching should include all of the following except:

You should avoid foods with tyramine, including beer, beans, processed meats, and red wine.

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response?

Zyprexa is an effective treatment for decreasing delusions and hallucinations."

The person who injects heroin to experience the euphoria it causes is demonstrating:

abuse

The most appropriate nursing intervention for a patient seen at the clinic for increasing shortness of breath but who is not interested in quitting smoking is to :

ask the patient at every clinic visit to identify the rewards, risks, and benefits of quitting and what barriers to quitting are present.

A client on an inpatient unit angrily says to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response?

can see that you are angry. Let's discuss ways to approach Peter with your concerns."

A nurse has assessed baseline fetal heart rate (FHR) by ausculation and documented a baseline heart rate of 158 beats /minute nd a maternal pulse of 94 beats/minute. When the first nurse gives a handoff report to an oncomng nurse, what can the second nurse conclude from this information?

fetal and maternal heart rates are within normal range

The perinatal nurse describes different breech positions to the student nurse. The fetal position with extended legs toward the fetal shoulders is best described as which of the following?

frank breech

The effects of long-term addictive substances on the brain include:

loss of pleasure from experiences that previously resulted in enjoyment.

The nurse has been teaching a caregiver about donepezil (Aricept). The nurse knows that teaching has been effective when the caregiver makes which statement?

medication will slow the progress of Alzheimer disease temporarily."

The nurse assessing a newborn's umbilical stump would document what finding as normal anatomy?

one vein, two arteries

Respiratory depression, pupillary constriction, coma and death are possible results of a(n) __________________ overdose.

opiate, opioid, or heroin

When caring for a patient who is experiencing alcohol withdrawal, the nurse should:

provide a quiet, nonstimulating, dimly lit environment