Modules term 2

Wound Documentation

• Amount and color of drainage on old dressing • Length, width, diameter, and depth of wound • Sinus tracts and their length • Color of wound • Appearance of surrounding skin • Type of dressing applied • Type of drain if present • Red hazardoug bag • Pain and tolerance to dressing change • Picture of wound to compare • Treatment performed • Cleanse the wound with wet sterile gauze from the center of the wound outward. • Medication given prior or medication for healing • Types of wound cleanser used

Prevent infection

• Apply topical antimicrobials. • silver sulfadiazine • Correct Shave body hair around wounds. • Correct Administer a tetanus toxoid booster. • Correct Cover the wounds with a sterile dressing. • Correct Have all visitors wash hands upon entering the room.

2. Fibroblast

• Last 2-4wks • Granulation tissue & scar forms

Mental Health Concerns

•Depression •Grief •Isolation •Suicide

Eczema interventions

•Entry for infections •Take temperature •Prevent secondary infection

Interventions 1-12 months

•Supine position for sleep •Choking hazard (Popcorn, grapes, hotdogs, Toys) •Avoid microwaving formula •Iron deficiency •Baby-proof home •Falling •Protect from stairs •Do not leave unattended in the bath even if a couple of inches •Protect from stairs •Protect from burns (Uses back burner on the stove) •Cover electrical outlets •Remove chemicals, medication & poisons out of reach •Never shake a baby shaken baby syndrome- closed head injury

The basic rules for first aid treatment of wounds

1. Stop the bleeding. 2. Treat shock. 3. Prevent infection.

Which individuals is least likely at risk for the development of psoriasis?

A 32-year-old African American

melain

A pigment that gives the skin its color

Risk for contamination in a clean surgical wound

Less than 5%

Urine Culture & Sensitivity

•Culture to determine the presence of microorganisms •Clean catch/Midstream sample •Cleanse with bacteriostatic solution

Which finding indicates that a patient is experiencing chronic hypoxia? O Fatigue O Cyanosis O Dysrhythmias O Digital clubbing

O Digital clubbing Rationale Digital clubbing of the fingers is a sign of chronic hypoxia. Fatigue, cyanosis, and dysrhythmiasare signs of acute hypoxia.

Evisceration

Protrusion of an internal organ through a wound or surgical incision

Curling ulcer

Severe burn leads to acute gastritis due to decreased blood supply secondary to hypovolemia. Decreased blood supply inhibits ability to carry away excess acid from stomach.

Which behaviors are common with mental illness? Select all that apply. O Shock O Anger O Denial O Excitement O Vargaining

Shock Anger Denial

anxiety

The condition of feeling uneasy or worried about what may happen

Types of Wound Drainage Purulent

Thick, yellow, green, tan, or brown

The mother of a teenage girl says that the girl is always trying to dress like her favorite pop star and is not willing to dress normally. Which concept would explain this behavior?

Threat to self-concept

Cachexia

a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS

ulcer stage 2

a deeper loss of epidermis and dermis; may bleed and scar

Body Mass Index (BMI)

a measure of body weight relative to height

5. Which social group form is typical during the teenage years? a. Cliques b. Same-sex peers c. Heterosexual peers d. Parallel groups

a. Cliques

3. Which method of contraception, if used properly, can prevent the transmission of sexually transmitted diseases? a. Condoms b. Birth control pills c. Intrauterine devices d. Spermicides

a. Condoms

verruca

an epidermal tumor caused by a papilloma virus, also called a wart

Crede maneuver

applying manual pressure over the lower abdomen to express urine from the bladder at regular intervals.

4. A women's fertile period occurs: a. 14 days after the last menstruation. b. 14 days before the beginning of the next menstruation. c. midway between menstrual periods. d. right after menstruation ceases.

b. 14 days before the beginning of the next menstruation.

2. A 1-year-old who regards all toys in relation to his or her own body is exhibiting which type of behavior? a. Dysfunctional b. Selfish C. Sexual d. Egocentric

b. Selfish

Ecchymosis

bruising

total incontinence

complete loss of bladder control

Purulent

containing pus

The older adult patient complains to the nurse about nocturia. This problem is most likely related to: O loss of bladder tone O decrease in testosterone O decease in bladder capacity. O intake of caffeine

decease in bladder capacity.

Isotonicity:

equal osmotic pressure • Clinical applications: loss of isotonicity through vomiting or prolonged diarrhea

What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors? O guarded O poor O good O repeatable

good

keratin

hard protein material found in the epidermis, hair, and nails

burn shock

hypotension, decreased urinary output, tachycardia, tachypnea & restlessness.

defense mechanisms

in psychoanalytic theory, the ego's protective methods of reducing anxiety by unconsciously distorting reality

functional incontinence

mental and physical

Anions:

negative charge • Chloride [Cl−], bicarbonate [HCO3−], phosphate [PO43−], and sulfate [SO42−])

energy-yielding

nutrient nutrients that break down to yield energy within the body, including carbohydrates, fat, and protein.

What is age-related to patient changes caused by the loss of elasticity of the lens called O Nystagmus O Cataracs O presbyopia O blepharitis

presbyopia

Marsmus

progressive emaciation caused by lack of protein and calories

Dietary Reference Intakes (DRIS)

reference values for the nutrient intake needs of healthy individuals for each gender and age group.

tinea corporis

ringworm of the body

pruitus

severe itching

pustulant vesicles

small, circumscribed elevations of the skin that contain pus

nevi

small, dark skin growths that develop from melanocytes in the skin; also known as moles

elective surgery

surgery that is recommended but can be omitted or delayed without catastrophe

-ectomy

surgical removal

fatty acids

the major structural components of fats.

dietetics

the management of the diet and the use of food; the science concerned with nutrition planning and the preparation of foods.

3. Maturation

• Begins 3wks to 1 year

Pseudoparkinsonism

(D) Tremor and rigid posture

Dietary Reference Intake Panels of the Institute of Medicine of the National Academy of Sciences

1. Calcium, vitamin D, phosphorus, magnesium, and fluoride 2. Folate and other B vitamins 3. Antioxidants 4. Macronutrients 5. Trace elements 6. Electrolytes and water

15. The nurse is assessing a patient who is displaying early signs of hypoxia. What signs and symptoms will the nurse observe? (Select all that apply.) 1. Restlessness 2. Increased pulse rate 3. Decreased blood pressure 4. Irregular apical pulse 5. Dyspnea

1. Restlessness 2. Increased pulse rate 3. Decreased blood pressure 4. Irregular apical pulse 5. Dyspnea

7. The nurse encourages the patient to drink an adequate amount of fluids to help with dry mucous membranes and to liquefy secretions. What fluids should the nurse include in this teaching? (Select all that apply.) 1. Coffee 2. Milk 3. Water 4. Juice 5. Tea

3. Water 4. Juice

A client who has been hospitalized with schizophrenia tells the nurse my heart has stopped and my veins have turned to class which behavior is a client experiencing 1. Echolalia 2. Hypochondriasis 3. somatic delusions 4. Depersonalization

3. somatic delusions

Abscess

Cavity that contains pus and is surrounded by inflamed tissue, formed as a result of suppuration in a localized infection

Which areas are affected only minimally by age? O Ego integrity Physical activity O Ego integrity Productivity O Ego integrity Cognition O Ego integrity Sexuality

Cognition

A woman discovers that her spouse is having an affair and starts to experience sudden blindness with no medical cause. The nurse understands this to be an example of which defense mechanism?

Conversion

The nurse defines ageism most accurately as: A. The undervaluing of individuals based on their age. B. Perception of a person's worth based on productivity C. Biases directed towards individuals considered aged D. Discrimination based on an individual's increasing age

D. Discrimination based on an individual's increasing age

Which nurse is credited as developing mental hospitals throughout the United States in the 19th century?

Dorothea Dix

While caring for a patient, a nurse learns that the patient lives in the same house as the patient's grandparents. Which type of family is this considered? O Nuclear O Blended O Extended O Homosexual

Extended An extended family consists of a nuclear family plus some additional family members living in the same household. A blended family arises when adults remarry and bring together their children from previous marriages. A nuclear family is a unit consisting of biological parents and their offspring. A homosexual family is a family group that includes a same-sex couple:

Indicate whether the following statement is true or false: Nearly 25% of people 70 years of age and older report falls each year. True False

False

DIGESTION OF FATS Small Intestine

Fat digestion largely occurs in the small intestine where the major enzymes that are necessary for the chemical changes are present. These digestive agents come from three major sources: an emulsification agent from the gallbladder and two specific enzymes from the pancreas and the small intestine itself.

At mealtime, the older adult seems to be eating less food than would be adequate Compared to the younger adult, what is a requirement for the older adult? O More fluids O Less calcium O Fewer calories O Mare vitamins

Fewer calories

A mother is ordering a food tray for a 10-month-old infant in a pediatric hospital. Which food item would the nurse remove from the tray to increase patient safety? O Grapes O Jell-O O Crackers O Yogurt

Grapes

Indispensable amino acids

Histidine, lysine, and phenylalanine

Which statement by a client prescribed paroxetine indicates to the nurse that more medication education is needed? O "I'll be a little drowsy in the morning O im expecting to fo feel somewhat better but I may need other therapy O I've been on the medication for 8 days now, and I don't feel any better O I know that ill probably have to take this for several months

I've been on the medication for 8 days now, and i don't feel any better

What instruction should the nurse give to an elderly patient diagnosed with presbyopia? O Avoid exposure to direct sunlight O Keep bright-colored objects in your home. O Drink 1000 mL of liquids per day O Eat five protein-rich meals er day

Keep bright-colored objects in your home.

Duodenum

The first section of the intestines

What is a sinus tract?

a narrow, elongated channel in the body that allows the escape of fluid

vegan

a person who does not eat food from any animal source

Carbohydrates

maintain the body's reserve store of quick energy as glycogen. should provide approximately 45% to 65% of the total kilocalories. •Primary & preferred source of energy. •Maintain glycogen reserve •Spare protein •Glucose circulates the blood •Ex: grains, milk, fruits, vegetables

Anorexia Nervosa:

• Associated w/ stressful life event • Distorted body image • Overachiever & perfectionist • Can be life-threatening • Starvation, suicide, cardiomyopathy, electrolyte imbalance

Third intention

• Delayed closure for irrigation or removal of debris & exudates Heals from the inside out

Dystonias

(A) Aberrant posturing

Dyskinesia

(B) Involuntary movements

Which defense mechanism has a positive influence on the person's behavior?

Sublimation

Sanguineous

bloody

Alopecia

hair loss

Physiologic buffer systems

• Respiratory control: carbon dioxide leaves the body • Acidosis/alkalosis

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 am."

The nurse is caring for a patient who is in crisis because of the death of a spouse. Which statement by the patient indicates the final phase of the crisis?

"I plan to find a job so I can take care of my child."

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client?

"The exact cause of acne is not known."

Which statement by the nurse about alcohol withdrawal syndrome indicates effective learning?

"Tremors are seen in a patient who abruptly quits drinking."

National health goals

"society in which all people live long, healthy lives". encouragement of healthy choices in diet, promotion of weight control, and education about other risk factors for disease, especially in the report's specific nutrition objectives.

Identify the three most common wound complications.

1. Infection 2. Bleeding 3. Dehiscense

three basic functions within the body

1. Provide energy 2. Build tissue 3. Regulate metabolic processes

Types of Wound Drainage Serous

Clear, watery plasma

Which is an important instruction to increase alcohol abstinence in a patient?

Referring to Alcoholics Anonymous (AA)

Normal Mole Color:

Symmetrical borders are even one color smaller than 1/4 inch

FOOD LABEL INFORMATION

The FDA food-labeling regulations for nutrition facts panel content provide the following mandatory and voluntary (italicized below) information relating to dietary fat in food products (Figure 3-7): • Total fat • Saturated fat • Trans fat Polyunsaturated fat • Monounsaturated fal • Cholesterol

According to Freud, the superego is responsible for which concept? O The reality factor O Reducing tension O Immediate gratification O The parental or societal value system

The parental or societal value system

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

2. A major developmental task of middle childhood includes: a. developing positive self-esteem and a positive self-image. b. eruption of permanent teeth. c. ability to play video games. d. prevention of injury.

a. developing positive self-esteem and a positive self-image.

5. In early childhood the best disciplinary technique includes: a. rewarding good behavior. b. punishing bad behavior. c. setting rigid, structured rules. d. posting rules on the refrigerator door.

a. rewarding good behavior. b. punishing bad behavior.

emulsifier

an agent that breaks down large fat globules into smaller, uniformly distributed particles; the action is chiefly accomplished in the intestine by bile acids, which lower the surface tension of the fat particles, thereby breaking the fat into many smaller droplets and facilitating contact with the fat-digesting enzymes.

macules

flat spots on the skin, such as freckles

urtica

nettle, burn

Ulcer stage 1

nonblanching erythema

gastric lavage

often used in cases of poisoning or to stop GI bleeding. it involves instilling room-temperature medications or solutions into the stomach and then suctioning it back out 500mL

Vitamin B12 (Cobalamin):

required for hemoglobin synthesis, important for iron levels, hemoglobin tests for levels to see if working, used for anemia not listed as cobalamin Food Source: soy milk, meat liver, intrinsic factor necessary for absorption, if there is no intrinsic factor you will be on IM for life. Deficiency: Pernicious Anemia • IM injection monthly • lifetime • will have activity intolerance, pale appearance

tinea capitis

ringworm of the scalp

-plasty

surgical repair

lipids

the chemical group name for organic substances of a fatty nature: the lipids include fats, oils, waxes, and other fat-related compounds such as cholesterol.

Stage 1 care of burns

the emergent phase, onset of injury until the patient stabilizes. Hypovolemic shock is the major concern for up to 48hrs after a major burn resuscitate with IV to keep hydrated. How do we know its working UO will be at least 30 ml/hr

Water intoxication

• Infants • Psychiatric patients (psychogenic polydipsia) • Patients on psychotropic drugs • Endurance athletes who are not replacing electrolytes

1. Inflammatory

• Last 3-5 days • Local edema, pain, redness & warmth

Neuroleptic Malignant Syndrome (NMS)

•Rare but Potentially fatal •toxicity •Mostly occur after initiation of therapy, changing medication & increase in medications Symptoms: •>HR, >P, >RR, <>BP, Fever, muscle rigidity, SZ, diaphoresis difficulty swallowing, dyskinesia

Which individuals are at greatest risk for abusing their children? Select all that apply. O Abused as a child O Mature O Very strict O No self-control O High self-esteem

Very strict No self-control Abused as a child

Which assessment helps determine a patient's level of anxiety?

Vital signs

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it."

Common catheter sizes:

(1) Infant: 6-Fr to 8-Fr (2) Children: 10-Fr to 12-Fr (3) Adults: 12-Fr to 14-Fr

Match each phase of wound healing with its correct description. Hemostasis (A) New cells are produced to fill the wound. This process closes the wound and aids in prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition?

White skin that is insensitive to touch

percutaneous endoscopic gastrostomy (PEG)

a feeding tube inserted endoscopically into the stomach less chance of aspiration

nonessential nutrient

a nutrient that can be manufactured in the body by means of other nutrients. Thus, it is not essential to consume this nutrient regularly in the diet.

registered dietitian (RD)

a professional dietitian accredited with an academic degree from an undergraduate or graduate study program who has passed required registration examinations administered by the Commission on Dietetic Registration (CDR).

1. Tasks to be mastered during early childhood include: a. walking. b. bowel control. c. abstract thinking. d. visual maturity.

a. walking. b. bowel control. d. visual maturity.

Erickson: Initiative vs Guilt

- early childhood - favorable relationships with family members result in an ability to set goals and devise and carry out plans without infringing on the rights of others

Erickson: Industry vs. Inferiority

- school age - most important influences are people in the neighborhood and school - child must master certain social and academic skills

Erickson: Autonomy vs. Shame and Doubt

- toddlerhood - a sense of self develops out of positive interactions with one's parents and other caregivers

digestive enzymes

-Amylase (saliva): starch -Protease/hydrochloric acid (gastric): proteins -Protease/lipase/amylase (pancreas): sugar -Bile salts (liver): fats

Which lab value would represent the therapeutic index for lithium maintenance?

0.6 to 1.2 mEq/L

Which lab value would represent the therapeutic index for lithium maintenance? O 1 to l.5 mEq/L O 0.6 to l.2mEq/L O 2.2 to 2.6mEq/L O 3.5 to 5.1mEq/L

0.6 to l.2mEq/L Rationale The therapeutic index for lithium is 0.6 to 1.2 mEq/L. Because lithium has a narrow therapeutic range, patients need to be monitored closely for safety. range of to l.5 is the normal loading range, not the therapeutic maintenance range. A range of2.2to 2.6 is too high; the patient would experience lithium toxicity in this range. The Range of 3.5 to 5.1 is much too high to be the therapeutic index.

Which drugs does the nurse list while informing a group of adolescents about different hallucinogenic drugs? Select all that apply. 1 Phencyclidine (PCP) 2 Amantadine (Symmetrel) 3 Gamma-hydroxybutyrate (GHB) 4 Lysergic acid diethylamide (LSD) 5 3,4-Methylenedioxymethamphetamine (MDMA)

1 Phencyclidine (PCP) 4 Lysergic acid diethylamide (LSD) 5 3,4-Methylenedioxymethamphetamine (MDMA)

Factors Determining a Major, Moderate or Minor burns

1. % of TBSA burned 2. Victims age 3. Specific location 4. Cause of the burn 5. Other disease present 6. Depth of burn 7. Injuries sustained during burn Medical Management • Evolves through three phases • Emergent phase • Acute phase • Rehabilitation phase

Which conditions are seen in a patient who has been taking methylphenidate (Ritalin) for a long time? Select all that apply. 1 Sinusitis 2 Paranoia 3 Weight loss 4 Hallucinations 5 Severe depression

2 Paranoia 3 Weight loss 4 Hallucinations

A 59-year-old homeless man is admitted with diagnoses of hypothermia and pneumonia. The nurse notes that the patient is malnourished and has multiple ecchymotic areas on his arms and legs. The nurse also notes the odor of alcohol coming from the patient. In addition to being alert to the consequences of hypothermia and pneumonia, to which other signs and symptoms should the nurse be alert during her shift? 1 Rebound hyperthermia and burn injuries to skin 2 Decreasing level of consciousness and bradypnea 3 Tremors, diaphoresis, disorientation, and restlessness 4 Dyspnea, hypotension, bounding pulse, and urinary retention

3 Tremors, diaphoresis, disorientation, and restlessness

Calcium:

9.5- 10.5 normal range bone formation, muscle & nerve action • Food Sources: dairy, collard greens, kale, tofu, rhubarb, sardines, yogurt, fortified food • Deficiency: osteoporosis, cramps, tetany, +Chvostek's (tap the cheek) or Trousseau's sign (blood pressure on the arm and contracts/spasm) Vitamin D aids with absorption of vitamin C • Toxicity: muscle weakness, constipation, bone pain, much calcium will result in stones in the urine

Kwashiorkor

A disease of chronic malnutrition during childhood, in which a protein deficiency makes the child more vulnerable to other diseases, such as measles, diarrhea, and influenza.

Which antidote would be appropriate to reverse oral methamphetamine (Desoxyn) intoxication? O Diazepam (Valium) O Haloperidol (Haldo) O Methadone (Dolophine) O Activated charcoal (Charcoal Plus DS)

Activated charcoal (Charcoal Plus DS) Rationale 10 methamphetamine (Desoxyn) has been taken orally, activated charcoal (Charcoal Plus DS) should be administered to reverse intoxication. Diazepam (Valium) is used to sedate a patient with severe agitation. Haloperidol (Haldol) may lower the seizure threshold in patients who are risk for seizures Methadone (Dolophine) is used to reduce severe withdrawal symptoms in patients with opioid toxicity.

An older patient comes to the clinic for a routine visit. During the taking of the health history, the patient admits to engaging in daily exercise and attending field trips at the local adult day care center. Which life theory best explains the patient's lifestyle behavior?

Activity theory- also known as the implicit theory of aging, normal theory of aging, and lay theory of aging, proposes that successful ageing occurs when older adults stay active and maintain social interactions

Which processes does the nurse teach a patient with anxiety due to depression to encourage positive emotional growth? Select all that apply.

Adaptive mechanisms to deal with stress Using coping mechanisms to deal with anxiety

Which term best describes the external manifestation of inner feelings or emotions that is often reflected by one's facial expressions?

Affect

Factors That Impair Wound Healing

Age malnutrition obesity impaired oxygenation smoking drugs diabetes mellitus radiation wound stress

The clinical tests of a patient indicate elevated levels of liver enzymes, hypoglycemia, and abnormal blood protein levels. The patient does not have any chronic diseases. For which condition does the nurse assess? O Pneumonitis O Alcohol addiction O Delirium tremens O Altered perception

Alcohol addiction

A patient says that he drinks alcohol on a regular basis. During his discussion with the nurse, the patient admits to "having a problem." To which support group would the nurse refer the patient?

Alcoholics Anonymous

After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

Ambulation three times daily

The nurse is preparing a client for skin grafting and identifies that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which source?

Another species

12. A patient is unresponsive to normal verbal stimuli and not breathing. How does the nurse assess for a carotid pulse? (394) 1. Assess the location of the pulse for a maximum of 5 seconds. 2. Check the strength of the pulse for 5 seconds and then compare it to the opposite side. 3. Assess the pulse rate for 10 seconds and then check for a 3-second capillary refill. 4. Check the rate, rhythm, and strength of the pulse for a maximum of 10 seconds.

Answer 4: Health care professionals, including nurses, should check for a carotid pulse, but spend no longer than 10 seconds.

Vitamin E (Tocopherol):

antioxidant, Food Source: vegetable oils, green leafy vegetables, cereals, apricots, apples, peaches Toxicity: interfere vitamin K

Benztropine is often prescribed in conjunction with which type of drug? O Anxiolytics O Barbiturates O Antipsychotics O Antidepressants

Antipsychotics Rationale Benztropine is used to treat extrapyramidal symptoms that often develop as a side effect of antipsychotic medication. Barbiturates, antidepressants and anxiolytics do not have extrapyramidal side effects.

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?

Appearance

Prevention, relief, reduction, or soothing of symptoms of a disease state describes which type of care? A) Physical B) Palliative C) Preventive D) Precautionary

B) Palliative

Adhesion

Band of scar tissue that binds two anatomic surfaces normally separated; most commonly found in the abdomen

Alcohol Abuse Medications

Benzodiazepine: chlordiazepoxide (Librium), lorazepam (Ativan), diazepam (Valium), oxazepam (Serax) •anxiety reducing, sedative-hypnotic, muscle relaxing & anticonvulsant actions S/E: sedation, dizziness, HA, hypotension Naltrexone (Revia) •Blocks "high" or opiate effect S/E: tiredness, N/V

how can you tell if a mole is cancerous ?

Biopsy

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair

Hip surgery restrictions

Cannot bend more than 90 degress, cross legs, cannot sit low, bent foward, roatate foot legs,

Basic nutrion percentage break down

Carbohydrates: 45 -65% Fat: 20 -35% Protein: 10 -35%

A nurse is caring for an 88-year-old patient with extremely fragile skin. What interventions would the nurse place on the nursing care plan to provide the best protection for the skin? O Wash with mild soap O Change positions frequently O Apply lotion once daily O Provide adequate clothing for protection

Change positions frequently

Which drug is a low-potency antipsychotic drug? Trifuoperazine Haloperidol Fluphenazine Chlorpromazine

Chlorpromazine Rationale Chlorpromazine is a low-potency antipsychotic drug Trifluoperazine, haloperidol, and fluphenazine are high-potency antipsychotic drugs.

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? Select all that apply.

Clean with mild soap and water. Encourage adequate nutritional intake. Apply a dressing that allows oxygen to pass through.

Wich condition is electroconvulsive therapy primarily used to treat? O Ego integrity Clinical depression O Ego integrity Substance abuse disorders antisocial O Ego integrity personality disorders O Ego integrity schizophrenia psychosis

Clincal depression

Which drugs can be prescribed to a patient with an alcohol-related disorder who is seeking treatment for withdrawal symptoms? O Naltrexone O Disulfiram O Clorazepate O Acamprosate

Clorazepate Rationale Clorazepate is a benzodiazepine that is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Naltrexone is an opioid antagonist that is prescribed to block pharmacologic effects associated with opioids and alcohol. Disulfiram reduces the desire for alcohol by inducing nausea and vomiting. Acamprosate helps patients maintain abstinence from alcohol.

When communicating with an older adult patient the nurse becomes aware of the fact that the patient is well satisfied with his aging accomplishments over a lifetime and has no regrets concerning Which Erikson's developmental stage has the patient believed? O Acceptance O Windirawal O Ego integrity O interaction

Ego integrity

Eicosanoids.

Eicosanoids are signaling hormones that exert control over multiple functions in the body (e.g., the inflammatory response, immunity), and they are messengers for the central nervous system)

nasogastric tube gastric lavage

Ewald tube: single lumen

A 17-year-old female high school student presents to the emergency room and speaks to the nurse stating that she can't remember anything about a party she attended last night, including whether she was engaged in sexual activity. The nurse asks if the young woman consumed any drinks prepared by someone else at the party. The young woman states that she did. The primary care provider recommends a SANE (Sexual Assault Nurse Examiner) exam. For which medication will the young woman be screened during the exam?

Gamma-hydroxybutyrate (GHB)

What should not be present in urinalysis?

Gucouse Bilirubin Hemonglobin Ketones Bacteria Casts

Who developed the humoral theory of mental illness? O Erik Erikson O Hippocrates O Philippe Pinel O Sigmund Freud

Hippocrates Rationale Hippocrates viewed mental illness as an imbalance of humors pertaining to body fluids. Pinel is the incorrect answer, he classified mental illness on the basis of behaviors. Freud is the incorrect answer, he theorized that personality has three parts-the id, the ego, and the superego. Erikson is the incorrect answer; he provided the framework for understanding personality development in terms of task mastery.

Dietary fiber.

Humans lack the necessary enzymes to digest dietary fiber; therefore, these polysaccharides do not have a direct energy value like other carbohy drates. However, their inability to be digested makes them an important dietary asset. The beneficial rela tionship between a diet high in fiber and disease pre vention and/or management (eg, cardiovascular disease, gastrointestinal problems, diabetes)

A change of aging related to the circulatory system includes decreased blood vessel elasticity. For what should the nurse assess? O Canfursion O Tachycardia O Hypertension O Retained secretions

Hypertension

which phrase accurately defines substance abuse? O Use of illegal drugs or alcohol O Regular ingestion of mind-altering chemicals O Dependence on drugs caused by repeated use O Impairment caused by the periodic, purposeful use of chemical substances

Impairment caused by periodic, purposeful use of chemical substances Rationale Substance abuse is best defined as the periodic, purposeful use of a substance that leads to clinically significant impairment. Substance abuse is not limited to illegal drugs or alcohol. Dependence (commonly known as addiction) can develop as a result of repeated substance abuse. Regular ingestion of mind-altering chemicals may not lead to clinically significant impairment, which is a characteristic of substance abuse.

Energy

In addition to carbohydrates, fats serve as a fuel for energy production. Excess caloric intake from any macronutrient source is converted into stored fat throughout the body. Fat is a much more concen trated form of fuel, yielding 9 kcal/g when burned by the body as compared with carbohydrate's yield of 4 kcal/g

How do you prevent granulation?

In an overgranulated wound, the use of a dressing that promotes granulation should be stopped and changed to one that provides a warm moist environment, reduces overgranulation and promotes epithelialisation, such as a foam dressing.

Which clinical signs of are associated with severe anxiety? Select all that apply.

Increased pulse rate Increased respiration Increased perspiration Increased blood pressure

A patient on disulfiram (Antabuse) therapy has altered mental status. Which medication could be responsible for this condition? O Phenytoin (Dilantin) O Isoniazid (Nydrazid) O Estazolam (ProSam) O Metronidazole (Flagyl)

Isoniazid (Nydrazid) Rationale Disulfiram (Antabuse) inhibits the metabolism of isoniazid (Nydrazid), which results in alterations in mental status: Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychotic episodes and confusion. Disulfiram (Antabuse) inhibits the metabolism of phenytoin (Dilantin), resulting in nystagmus, sedation, and lethargy. Disulfiram (Antabuse) inhibits the metabolism of benzodiazepines such as estazolam (Flagyl), resulting in benzodiazepine toxicity.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which describes a characteristic of this type of a lesion?

It is highly metastatic.

Nasotracheal suctioning:

Length of insertion: (a) Adults: 20 to 24 cm (b) Older children: 14 to 20 cm (c) Young children and infants: 8 to 14 cm

Benzodiazepines

Lorazepam (Ativan) Diazepam (Valium) Clonazepam (Klonopin) Alpraxolam (Xanax) •Depress the CNS, anxiolytic, sedative-hypnotic, muscle relaxant, & anticonvulsant S/E: sedation, ataxia, dizziness, HA, hypotension Interventions: •Monitor renal & liver function test •Safety precaution •Avoid other CNS depressant •Taper •SZ

Debridement

Mechanical • Wet to dry Enzymatic • Topical enzymes (Santyl) • Digest necrotic tissue Surgical- doctor goes and removes dead tissue Must clear so granulation can happen. The new skin that is forming.

A nurse is instructing a wife about giving heparin injections to her husband. The wife is unable to focus and frequently asks the nurse to repeat instructions. Which degree of anxiety is the wife experiencing? O Mild O Panic O Severe O Moderate

Moderate

fraction of inspired oxygen (FiO2)

Nasal cannula 1-6 L/min = 24%-44% O2 Simple face mask 5-8 L/min = 35%-55% O2 Venturi mask 4-10 L/min = 24%-55% O2 Partial rebreather mask 6-12 L/min = 60%-90% O2 Nonrebreather mask 6-15 L/min = 70%-100% O2

Which signs and symptoms are associated with anxiety? Select all that apply.

Nausea Tremors Increased heart rate

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage?

Neurological deficits

A patient asks if an antiseptic or ointment can be applied to her third-degree full-thickness burns. Which advice would the nurse give to the patient? O "Use sprays or creams instead of antiseptics and ointments. O "Only oil-based antiseptics and ointments should be applied O "Antiseptics or ointments may interfere with medical treatment." O "Anything that will cause the child to be more comfortable can be applied."

O "Antiseptics or ointments may interfere with medical treatment." Rationale It is not appropriate to apply antiseptics, ointments, sprays, or creams to the burn because they may potentially interfere with medical treatment and cause complications. Loose sterile dressings can be applied to the burn area.

When orders are written to remove sutures in 22 days, which type of sutures does the nurse suspect the patient has been given? O Blanket O Separate O Retention O Continuous

O Retention Rationale Retention sutures are used to close abdominal incisions that are made during abdominal surgery. These sutures can be left in place for 22 days or more. Blanket sutures, separate sutures, and continuous sutures are generally removed in 7 to 10 days to ensure optimal healing

Which inference could the nurse make from a post appendectomy incision site that has bright red gauze? O Sutures have ruptured. O Normal wound healing is occurring O Sutures have become infected. O Serum is oozing from the sutures.

O Sutures have ruptured. Rationale The presence of bright red gauze during an assessment indicates that the patient has bleeding, which may be due to the rupture of sutures. The presence of blood is not indicative of normal wound healing. The gauze could be pale red if serum oozed from the sutures. Infected sutures are characterized by the presence of pus, and the gauze would appear yellow in color.

A graduate nurse receives a patient with frostbite to the big toe. Which action requires immediate correction by the preceptor? O The nurse is rubbing the toe. O The toe is wrapped inside warm towels. O The toe is placed in a whirlpool bathtub. O Several blankets are applied to warm the area.

O The nurse is rubbing the toe. Rationale The nurse should refrain from rubbing the part because friction can bruise and damage underlying tissue. Wrapping the frostbitten part in the warm towels, placing it in a whirlpool of water, and applying several blankets are appropriate interventions for the nurse to implement

The nurse observes a loss of appetite in a patient being treated for addiction. Which prescription would most likely be prescribed by the health care provider? O Phenytoin O Propranolol O Thiamine O Chlordiazepoxide

O Thiamine Rationale The administration of thiamine helps improve the patient's nutritional state. Phenytoin is an anticonvulsant medication used to treat seizures in an addicted patient. Propranolol is useful in treating cardiorespiratory distress. Chlordiazepoxide is used to treat tremors and nervousness in an addicted patient.

Which dressing is the nurse likely to place on the reddened skin on an elderly patient? O Transparent dressing O Wet-to-dry dressing O Foam dressing O Binders

O Transparent dressing Rationale A transparent dressing is placed over the reddened area in the elderly patient to prevent skin breakdown. Wet-to-dry dressings are used on infected ulcers to help slough of necrotic tissue through mechanical débridement. Foam dressings are used for stage || ulcers to avoid bacterial contamination. Binders are used to hold dressings in place.

Why does transtracheal oxygen not require a humidification water chamber? O The oxygen is already humidified when delivered. O The method only administers oxygen during inhalation. O Transtracheal oxygen delivery bypasses the nasopharynx. O Oxygen via the transtracheal route is delivered in smaller volumes, so humidification is not needed

O Transtracheal oxygen delivery bypasses the nasopharynx. Rationale Humidification is required during oxygen delivery via nasal or oral routes because of the tendency of the nasopharynx to become dried out during oxygen delivery. Transtracheal oxygen bypasses the nasopharynx and therefore does not require humidification. Transtracheal oxygen is not humidified when delivered. Oxygen delivered via this route is administered throughout the respiratory cycle, not just during inhalation. A patient receiving transtracheal oxygen will require smaller volumes because of the continuous flow, but this does not influence the need for humidification.

Which nursing action could interfere with the ostomy appliance's ability to adhere to the skin? O Changing the ostomy appliance every 3 days O Washing the peristomal skin with soap and water O Applying the protective skin barrier around the stoma O Pressing ostomy appliance against the skin for 1 to 2 minutes

O Washing the peristomal skin with soap and water Rationale The peristomal skin should only be cleansed with warm water and patted dry. Soap can leave a residue that will affect the pouch's ability to properly adhere to the skin. Changing the ostomy appliance every 3 days, applying to protect skin barrier around the stoma, and pressing the ostomy appliance against the skin for 1 to 2 minutes are accurate steps to promote ostomy appliance adherence to the skin

which side effect will the nurse monitor for in an elderly client prescribed selective serotonin reuptake inhibitor for depression? O Ego integrity Reflex tachycardia O Ego integrity Excessive salivation O Ego integrity Orthostatic hypotension O Ego integrity postprandial blood glucose

Orthostatic hypotension

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Types of Wound Drainage Serosanguineous

Pale, red, watery: mixture of serous and sanguineous

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis

Peristalisis

Periodic muscle contraction and relaxation, or rhythmic waves, which mix food mass and move it forward

lacto-ovo-vegetarian

Person who consumes all vegan items plus dairy products and eggs.

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine (Nardil) Tranylcypromine (Parnate) S/E: orthostatic hypotension, restlessness & insomnia Interventions: •Monitor BP •Monitor for hypertensive crisis •HA, occipital HA, neck stiffness, sweating, N/V •Administer w/ food •Tapered •Avoid food that requires bacteria or mold for preparation & tyramine

Which intervention does the nurse expect the health care provider to prescribe for a patient with a critically elevated serum potassium level? O Soap suds enema O Rectal tube insertion O Nasogastric tube insertion O Polystyrene sulfonate (Kayexalate) enema

Polystyrene sulfonate (Kayexalate) enema Rationale A critically elevated potassium level can lead to life-threatening cardiac dysrhythmias. The health care provider will prescribe a polystyrene sulfonate (Kayexalate) enema to lower the potassium level. A soap suds enema is used to alleviate constipation. A rectal tube prevents skin breakdown from uncontrolled diarrhea. A nasogastric tube alleviates gastric distention caused by bowel obstruction.

Which typical antipsychotic medication is available as a suppository? Loxapine Fluphenazine Prochlorperazine Chlorpromazine

Prochlorperazine Rationale Prochlorperazine is the only typical antipsychotic agent available as a suppository. Loxapine, fluphenazine, and chlorpromazine are not available as suppositories.

Exploratory

Provides further data/diagnosis

What second-generation antipsychotic agent is available as extended-release tablets? Lurasidone loperidone Ziprasidone Quetiapine

Quetiapine Rationale Quetiapine is available as extended-release tablets. Lurasidone and iloperidone are also available as tablets, but notextended-release tablets. Ziprasidone is available in capsule and injection forms.

Tinea cruris (jock itch)

Rash, scaling small papules in groin and medial thigh area

The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection?

Red, shiny skin around the nail bed

The parents of a 10-year-old child report that the child wets the bed when tests are scheduled at school. Which defense mechanisms does the nurse suspect the child is using?

Regression

The nurse observes that one of the team members is often absent from the unit. The team member also exhibits excessive discrepancies in documenting procedures that are related to controlled substances. Which action should the nurse take?

Report the behavior to the supervisor.

Debriding agents (Santyl)

SANTYL® Ointment is a biologic treatment that is appropriate for both initial debridement, as well as maintenance debridement of necrotic tissue.

Which symptoms are associated with alcohol withdrawal? Select all that apply. O Seizures O Hyperactivity O Hypersomnia O Hallucinations O Increased appetite

Seizures Hyperactivity Hallucinations Rationale Alcohol withdrawal symptoms can begin within a few hours of discontinuation of drinking and may continue for 3 to 10 days. Withdrawal symptoms include visual and auditory hallucinations, seizures, and hyperactivity. Hypersomnia and increased appetite are withdrawal symptoms of cocaine.

An elderly patient is lying in the room crying. When questioned, the patient admits to being frustrated about having to live alone, the loss of a spouse, and not being able to see the grandchildren. This patient is experiencing which stage of development? O Senescence stage O Parenthood stage O committed stage O establishment stage

Senescence stage

During shift change, the evening nurse reports that a patient displays pseudoparkinsonism. Which assessment findings would the nurse document in the patient record to support this nursing report?

Shuffling gait, tremor, rigidity

excoriation

Skin sore or abrasion produced by scratching or scraping

What are ways to assess and document a patient's emotional status? Select all that apply.

Speech pattern Content of thought Insight and judgment

During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of which stage of pressure ulcer?

Stage 2 pressure ulcer

A nurse on a pediatric unit is rounding on assigned patients. What interaction, if witnessed by the nurse during rounds, would be of great concern? O A rocking chair is used to put an infant to sleep O A baby's bottle is propped on a pillow during feeding O The baby's bottle is propped on a pillow during feeding. O A father is gently massaging his infant's scalp

The baby's bottle is propped on a pillow during feeding.

Which factor does the success of a patient going through a substance abuse treatment program depend on?

The motivation of the user

tetanus toxoid

The patient should receive the tetanus vaccine every 10 years to maintain immunity.

Which goals are associated with crisis intervention? Select all that apply. O The victim will have a positive self-image. O The victim's emotional stress will be decreased. O The victim will deny having any suicidal or homicidal ideation. O The nurse will help the victim organize and mobilize resources: O The victim will be educated on relaxation techniques.

The victim's emotional stress will be decreased. The nurse will help the victim organize and mobilize resources: Rationale The goals of crisis intervention include that the victim's emotional stress will be decreased and the nurse will protect the victim; the nurse will help the victim organize and mobilize resources; and the victim will return to precrisis status. Educating the victim on relaxation techniques is not a goal but can be used to achieve the goal of decreasing emotional stress. Suicidal or homicidal ideation is not a goal for crisis intervention. Having a positive self-image is not one of the core goals of crisis intervention.

Which medication can be prescribed to treat Wernicke's encephalopathy? O Haloperidol Haldol) O Naltrexone (ReVia) O Thiamine (Thiamilate). O Carbamazepine (Tegretol)

Thiamine (Thiamilate) Rationale Thiamine (Thiamilate) is used to treat Wernicke's encephalopathy. Haloperidol (Haldol) is prescribed to treat hallucinations and delirium. Naltrexone (ReVia) is an opioid antagonist that is prescribed to block the pharmacologic effects associated with opioids and alcohol. Carbamazepine (Tegretol) is prescribed to prevent or treat seizures

Which antipsychotic medication is the most potent alpha-l blocker? Thioridazine Trifluoperazine Haloperidol Fluphenazine

Thioridazine Rationale Thioridazine, along with chlorpromazine, is the most potent alpha-l blocker Trifluoperazine and fluphenazine are not as potent as thioridazine. Haloperidol has almost no effect on alpha-l receptors.

A nurse is assessing a patient with schizophrenia who says, "You all know the thoughts I've been having today." Which type of delusion would the nurse document the patient as having? O Somatic delusions O ideas of reference O Delusions of grandeur O Thought broadcasting

Thought broadcasting Rationale Thought broadcasting is when patients believe that others know their ideas without action on their part to convey the thoughts. A delusion of grandeur includes believing oneselfto be someone with great power. An idea of reference is a belief thatan event has special personal meaning. Somatic delusions are false beliefs pertaining to body function.

Thermal burns

caused by contact with open flames, hot liquids or surfaces, or other sources of high heat Treat by removing victim from source, cool burn with water, check for bleeding and shock, seek medical attention

Atelectasis

collapsed lung; incomplete expansion of alveoli sound you will hear on collapsed lung: diminished lung sound or abscence of sound.

ostomy

create an opening

4. Between 12 and 24 months of age, the child's speech normally includes: a. only vowel sounds. b. both vowels and consonants. c. frequent babbling. d. three- to four-word sentences.

d. three- to four-word sentences.

separation anxiety

emotional distress seen in many infants when they are separated from people with whom they have formed an attachment

Vitamin A (Retinol):

enable eye to adjust to the light, tissue growth, reproduction, immune function Food Source: carrots, sweet potato, liver, egg yolk, whole milk, green or orange vegetables, fruits Deficiency: night blindness, xerosis (dry skin) Toxicity: birth defect, hair loss, bone, liver damage

exudate

fluid, such as pus, that leaks out of an infected wound

HeType1 (HSV-1)

he cause of the cold sore (fever blisters) on mouth lips or nose Characterized by vesicle rupture & encrust •Symptoms of general malaise & fatigue •Typically occur after an acute illness or infection •Tingling, burning, Pain

Vitamin B2 (Riboflavin):

helps the body convert food into fuel Food Source: milk, lean milk, fish, grains Deficiency: cracked lips, red tongue

End-Of-Life (EOL) Care:

involves ethical and legal issues and religious and cultural responsibilities that need to be addressed by the health-car team. Common Fears •Fear of pain •Fear of being a burden to the family •Fear of Loneliness and •Abandonment •Fear of being Meaningless

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

An important consideration in the rehabilitation of a geriatric patient to prevent loss of function from inactivity and immobility is: O Using assistive devices such as walkers and canes O teaching good nutrition to prevent loss of muscle mass O performing active exercises daily O assessing for a safe environment

performing active exercises daily

A patient believes in self be the President of the United States and that terrorist are trying to kidnap him the nurse records this observation of which type of behavior O absent behavior O positive behavior O negative behavior. O False Behavior

positive behavior

Cations:

positive charge • Sodium [Na+], potassium [K+], calcium [Ca2+], and magnesium [Mg2+]

Proteins

protein is tissue building Amino acids are the building blocks of protein that are necessary for constructing and repairing body tissues (e.g., organs, muscles, cells, blood proteins).

Hallucinogens

psychedelic ("mind-manifesting") drugs, such as LSD, that distort perceptions and evoke sensory images in the absence of sensory input

Suspected Deep-Tissue Injury

purple or maroon or blood-filled blister

Because of changes in the blood vessels which become narrow with fatty deposits the geriatric elder is at risk for. O hypotension O stroke O increased heart muscle tone O rapid response to anxiety

stroke

simple carbohydrates

sugars with a simple structure of one or two single-sugar (saccharide) units; a monosaccharide is composed of one sugar unit, and an disaccharide is composed of two sugar units.

-orrhaphy

suturing or repair

Recommended Dietary Allowances (RDAs)

the average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a group.

nutrition science

the body of science, developed through controlled research, that relates to the processes involved in nutrition internationally, clinically, and in the community.

nutrition

the sum of the processes involved with the intake of nutrients as well as assimilating and using them to maintain body tissue and provide energy, a foundation for life and health.

A patient with advanced cancer wishes to have a natural death without much medical intervention. How can this patient execute this wish when unable to express it during the dying process? O Write a diary to mention the wish. O Get a court order for this wish. O use an advance directive to convey the wish. O Keep the family members informed about the wish.

use an advance directive to convey the wish.\\Rationale Advance directives are helpful to spell wishes for health care at the time. when they are unable to indicate their choices. A diary is not a legal document, whereas an advance directive is. Getting a court order is not a practical approach; rather an advance directive would be useful. Rather than informing family members, the patient may appoint any person to carry out the wish as expressed in the advance directive through the durable power of attorney for health care.

Dehydration

• >2% total body weight loss results in symptoms • Monitor infants & older adults for fluid imbalance

Renin-Angiotensin-Aldosterone System (RASS)

• Aldosterone regulate the amount of sodium reabsorbed by the kidney

Second Intention

• Great tissue loss w/ Irregular edges heals from the inside out • Ex: Pressre injury

Buffer Systems

• Human body has many buffer systems • Relatively narrow pH range (7.35 to 7.45) is compatible with life • pH < than 7 are acidic, pH > 7 are alkaline

First intention

• Wound edges are approximated w/ little tissue loss • Ex: Surgical incision

Serum Blood Urea Nitrogen (BUN)

•Determine the kidney's ability to rid the blood of non-protein nitrogenous waste and urea, w/c result from protein breakdown (catabolism) •Monitor progression of disease or effectiveness of therapy •Normal 10 -20mg/dL •NPO 8 hours •Increase fluid intake•protect patient from disorientation or SZ< overhydrated, liver disease, malnutrition

School Age: 6 -12 years

•Growth is gradual & subtle ("Growing pains") •Being to lose deciduous teeth by age 6 •Concrete Operational Phase: (Capable of understanding the views of others, Support learning environment) •Obesity to this age correlates to obesity at a later age •Physical activity •Gun safety •FON pg717 Safety Alert

Etanercept (Enbrel)

•Used to treat psoriasis •< T-cells- decreases t cell high risk for infection •Take temperature

Creatinine Clearance Test

Creatinine Clearance Test •Evaluates how the kidneys remove creatinine from the blood •24 hour urine•8-12 hour urine •Provides the best est. of the Glomerular Filtration Rate (GFR) •Normal 125mL/minute •Age 65 GFR is 65ml/minute •Blood sample & urine specimen

A person has an argument at the office and then comes home and yells at family members. Which defense mechanism is this person using? O Denial O Displacement O Projection O Rationalization

Displacement

A 9-year-old tells a story, while smiling and joking, about witnessing a house burning down across the street. The nurse recognizes this as an example of which defense mechanism?

Dissociation

A patient is having trouble abstaining from alcohol. Which drug is often prescribed to encourage abstinence?

Disulfiram

A patient who is on disulfiram (Antabuse) presents with ecchymoses, nosebleeds, and bleeding gums. Which medication administered concurrently might have caused these effects? O Phenytoin (Dilantin) O Isoniazid (Nydrazid) O Metronidazole (Flagyl) O Disulfiram (Antabuse)

Disulfiram (Antabuse) Rationale Disulfiram (Antabuse) may enhance the anticoagulant effects of warfarin (Coumadin) and result in ecchymosis, nosebleeds, and bleeding gums. The concurrent use of disulfiram (Antabuse) and phenytoin (Dilantin) will not produce these side effects. Disulfiram (Antabuse) may cause reduced alertness and coordination when used concomitantly with isoniazid (Nydrazid). Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychosis and confusion.

Which statement is true regarding disulfiram (Antabuse)? O Disulfiram (Antabuse) helps reduce the desire for alcohol O Disulfiram (Antabuse) helps in maintaining abstinence from alcohol. O Disulfiram (Antabuse) enhances gamma-aminobutyric acid (GABA) activity. O Disulfiram (Antabuse) blocks pharmacologic effects associated with alcohol.

Disulfiram (Antabuse) helps in maintaining abstinence from alcohol. Rationale Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting after ingesting alcohol. Acamprosate (Campral) helps patients maintain abstinence from alcohol. Diazepam (Valium) enhances GABA activity that has been suppressed by chronic alcohol ingestion. Naltrexone (ReVia) is an opioid antagonist prescribed to block pharmacologic effects associated with opioids and alcohol.

A patient is prescribed doxepin. At which time does the nurse instruct the patient to take doxepin? With the morning meal At breakfast and lunch to decrease insomnia One hour before or 2 hours after a meal to increase absorption During the evening hours

During the evening hours Rationale Doxepin should be taken in the evening because increased sedation is a known side effect of this medication, especially during the onset of therapy. Doxepin causes increased sedation and should not be taken at the beginning of the day. Doxepin does not cause insomnia. Taking doxepin with meals does not affect its absorption.

While teaching a group of older adults at the senior center, the nurse encourages which health-promoting behaviors? Select all that apply. O Maintain a sedentary lifestyle O Use herbal remedies to prevent Alzheimer's diease O Eat a low-cholesterol diet O Have regular medical checkups O Take medications as prescribed by the primary health care provider

Eat a low-cholesterol diet Have regular medical checkups Take medications as prescribed by the primary health care provider

The nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg in which position?

Elevated and immobilized

The nurse is caring for a patient who reports having an illness every time his child leaves town to go on vacation. Which defense mechanism is the patient displaying? O Emotional conflict O Threat to self-concept O Frustration due to stress O Moderate level of anxiety

Emotional conflict Rationale The sick role often produces secondary gains as well as personal attention. A patient who becomes very ill every time the child plans a trip out of town, or a person who obtains renewal of disability benefits because the injury flares up when reevaluation is scheduled, are examples of patients seeking secondary gains. Secondary gains are sometimes used as a ploy to manipulate and cope with various emotional conflicts. Threats to self-concept, frustration due to stress, and moderate anxiety do not produce secondary gains

A young parent brings a toddler to the clinic for a routine checkup. While the nurse is taking the health history, the mother inquires about methods to promote healthy sleeping patterns. What is the best advice the nurse can give the mother? O Enjoy quiet activities such as a story and establish a bedtime ritual. O Allow the toddler to play until exhausted and then prepare for bed O Avoiding daytime naps will cause the toddler to sleep through the night O engage in mommy baby exercises immediately before preparing for bed.

Enjoy quiet activities such as a story and establish a bedtime ritual.

Role Of The Health-Care Worker In End-Of-Life Care

Ensure education of the patient and family concerning the diagnosis •Ensure that informed consent is provided with a clear offer of all available options of care •Ensure that the patient's and family's cultural and personal wishes are respected •Communicate with the multidisciplinary healthcare team when death is imminent or has occurred

A student nurse is participating in data collection from newly pregnant patients who are starting routine prenatal visits. The student nurse becomes concerned when the patient makes which reply?

"I enjoy a nice wine, but I limit myself to two glasses with dinner."

Which statement by a patient indicates the need for further teaching regarding ways to reduce anxiety?

"I should play baseball when I am anxious."

A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. Which is the most appropriate response to the client?

"It is skin from another species."

What does the nurse teach the parents of a 7-month-old infant about good oral hygiene to prevent tooth decay in the infant? Select all that apply. O Add milk to the infant's nighttime feeding bottle O Add a moderate quantity of sugar to the formula milk O "Massage the infant's gums and wipe them slowly." O "Use fluoride toothpaste if the water contains no fluorine." O "Start brushing as soon as the child's teeth start to appear."

"Massage the infant's gums and wipe them slowly." "Use fluoride toothpaste if the water contains no fluorine." "Start brushing as soon as the child's teeth start to appear."

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? O "It is caused by oily skin." O "The exact cause of acne is not known." O "It occurs as a result of exposure to heat and humidity." O "Acne is caused by eating chocolate, nuts, and fatty foods."

"The exact cause of acne is not known."

Free-floating anxiety

(E) Feelings of dread that cannot be identified

1. The patient has just returned from the postanesthesia care (PAC) unit. During report, the nurse is told that the patient has a Penrose drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate? 1. "The drain allows for the postoperative instillation of wound irrigation fluid." 2. "The drain is used to reduce infection in the postoperative period." 3. "Penrose drains are used to drain body fluids from the area surrounding the wound by suction." 4. "Gravity is used to drain fluid from the area around the wound with the Penrose drain."

4. "Gravity is used to drain fluid from the area around the wound with the Penrose drain."

Which instruction will the nurse give to the unlicensed assistive personnel (UAP) about catheter care for the patient? (368) 1. Maintain continuous tension on the external catheter tubing. 2. Empty the drainage bag once a day or sooner if necessary. 3. Attach the drainage bag to the side rails, below the level of the bladder. 4. Clean the urinary meatus and 2 inches down the catheter.

4. Clean the urinary meatus and 2 inches down the catheter.

Which clients are at risk for developing skin breakdown? Select all that apply.

A client who is underweight A client diagnosed with heart failure A client diagnosed with spinal cord injury

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status

A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand?

A white color of the skin, which is insensitive to touch

The enzyme amylase begins the conversion of which of the following? A. Starches to sugars B. Sugars to starches C. Proteins to amino acids D. Fatty acids and glycerol to fats

A. Starches to sugars

Side effects of Halperidol

ACUTE DYSTONIA 'Acute' means 'early' -occurs 1-5 days after drug initiation Uncontrolled muscle spasms mostly over face, tongue, neck PARKINSONISM Occurs 1-4 weeks after drug initiation Parkinsonian features - rigidity, bradykinesia, tremor AKATHESIA Occurs 5-60 days after drug initiation Restlessness, irresistible desire to move around

The clinical tests of a patient indicate elevated levels of liver enzymes, hypoglycemia, and abnormal blood protein levels. The patient does not have any chronic diseases. For which condition does the nurse assess?

Alcohol addiction

Hydrofiber (Aquacel)

Alginate and hydrofiber dressings may help with infection control by holding bacteria in absorbed wound fluid, thereby reducing overall bacterial load within the wound and minimizing airborne bacteria during dressing changes.

Which integumentary system changes are associated with aging? Select all that apply. An increase in the production of sebum An increase in bruising and susceptibility to trauma Reduction in perspiration Decreased wound healing time Increased susceptibility to infection

An increase in bruising and susceptibility to trauma Reduction in perspiration Increased susceptibility to infection

23. The patient has a T-tube in place following an abdominal cholecystectomy. What is the expected output of bile in the first 24 hours? (635) 1. 30 mL per hour 2. 250-500 mL 3. 10-50 mL 4. 1-2 L

Answer 2: An expected output ranges from 250-500 mL.

23. The nurse is performing CPR on an infant. What is the most common event that could occur? (399) 1. Fracture of the rib 2. Gastric distention 3. Aspiration of emesis 4. Laceration of spleen

Answer 2: For infants, gastric distention is common because an excessive amount of air is delivered during rescue breathing. To prevent this, the amount of air that is held in the nurse's cheeks is given during each rescue breath.

6. Which patient has a condition that could resemble brain death? (396) 1. The patient has a blood alcohol level of 80 mg/dL. 2. The patient has a core temperature below 30° C (86° F). 3. The patient has oliguria secondary to hypovolemic shock. 4. The patient fainted and was unconscious for 5 minutes.

Answer 2: Hypothermia, anesthesia, poisoning, or drug intoxication can resemble brain death. A core temperature below 30° C (86° F) results in lowered metabolic rate and patients may appear dead but should be slowly warmed and cardiopulmonary resuscitation may be needed.

25. The nurse is assessing a trauma patient who was treated for shock in the emergency department. Oliguria (production of abnormally small amounts of urine) is noted and immediately reported to the provider. Which complication is most related to this finding? (402) 1. Right-sided heart failure 2. Kidney failure 3. Paralytic ileus 4. Electrolyte imbalance

Answer 2: Oliguria is urine output less than 500 mL in 24 hours. During shock, blood flow to the kidneys is decreased. This can result in damage to the kidneys. Paralytic ileus is decreased or absent motility of the bowel, which can also occur with shock; however, the appropriate assessment would be bowel sounds, abdominal pain, or failure to pass gas or stool. Shock can also produce electrolyte imbalance, but assessment of laboratory values would be more appropriate than observing amount of urine output. Heart failure is the least likely complication of shock. Right-sided heart failure is more associated with long-term respiratory or circulation problems.

26. The nurse is assessing the amount of drainage that the patient has from a surgical wound and finds that 650 mL has drained from 9:00 am until now, 11:40 pm. What should the nurse do first? (628, 629) 1. Record the amount and appearance of the drainage and continue to observe. 2. Take the patient's vital signs, assess for other symptoms, and inform the surgeon. 3. Make sure that the patient's linens are clean and dry and empty the drainage receptacle. 4. Apply a pressure dressing and place the patient in a supine position.

Answer 2: The amount of drainage is excessive, so the nurse would take vital signs and assess for other symptoms of hemorrhage or shock and inform the surgeon. Documenting is always necessary and comfort measures are always welcome once the immediate problem is addressed. The nurse should not apply a pressure dressing, but the supine position would be appropriate if the nurse determines that the patient is hypovolemic.

12. The patient had an uneventful hip surgery several days ago and will soon be transferred to a rehabilitation unit. The patient says to the nurse, "I feel silly complaining about this, but I feel a little short of breath and I feel a little anxious and fuzzy-headed." The patient has no known history of respiratory or cardiac problems. What should the nurse do first? (342) 1. Reassure the patient that she is not being silly, and that anxiety is normal. 2. Take the vital signs, apply a pulse oximeter, and listen to breathe sounds. 3. Ask the patient to describe what she is feeling and what she thinks is going on. 4. Apply oxygen per nasal cannula, notify the charge nurse, and call the provider.

Answer 2: The nurse must assess this patient first, because the symptoms are vague and the patient is not in acute distress. There are many things that could be causing the patient's subjective symptoms, but surgical patients always have some risk to for pulmonary embolism (symptoms can be severe, or the patient can be asymptomatic). The nurse first takes vital signs and pulse oximeter readings. Breath sounds are ausculated if the patient is not in severe distress and then the nurse would ask the patient to describe the symptoms in more detail (talking interferes with breathing, so the nurse would check a pulse oximeter reading, before asking the patient to answer questions). Based on assessment, the nurse might decide to apply oxygen and notify the charge nurse and the provider. It is also possible the patient may just feel anxious and needs to talk about the transfer to rehab and other future plans.

17. Which patient is most likely to benefit from the application of a triangular binder? (639) 1. Has a chronic pressure injury on the sacral area 2. Has a possible fracture in the forearm 3. Has venous stasis ulcer on left ankle 4. Has a surgical wound on the lateral chest area

Answer 2: The triangular binder (sling) will provide support for the possible fractured forearm.

9. The nurse is caring for a patient who may have a cervical spine injury. The patient is lying flat and begins to vomit. What should the nurse do? (416) 1. Immediately use an oral suction catheter to remove vomitus and direct the patient to hold breath during suctioning. 2. Direct the patient to look straight ahead and not move his neck, then sit him up-right using the bed mechanism. 3. Direct several people, acting together as one unit, to help logroll the victim onto his side to allow drainage. 4. Immediately report vomiting to the provider and ask if cervical spine injuries have been ruled out.

Answer 3: Several people acting together should logroll the patient. A nurse or provider should control and maintain the position of the head and neck during the roll.

10. The nurse is applying a dressing over the insertion site of a peripheral intravenous catheter. Which dressing is the best choice? (625) 1. Sterile tape with dry gauze 2. Steri-Strips and transparent dressing 3. Transparent dressing 4. Sterile pad with chevron taping

Answer 3: The transparent dressing is currently the dressing of choice.

13. The patient has no contraindications for fluid intake. Over a 24-hour period, he drank 16 ounces of decaffeinated coffee, 10 ounces of juice, 6 ounces of milk, and a half a liter of soda. What instructions does the nurse give the patient about fluid intake to promote wound healing? (617) 1. Instructs the patient to continue drinking the same amount as he drank today 2. Tells the patient that tomorrow he should try to drink twice as much as today 3. Advises the patient that drinking excessive fluid is likely to decrease appetite for food 4. Suggests that he drink 2-3 additional 8-ounce servings of his favorite fluid every day

Answer 4: The goal for the patient (assuming no fluid contraindications) is 2000-2400 mL. He drank a total of 1460 mL, so he if he drinks two or three additional 8-ounce servings, he will be closer to the recommended amount. 16 ounces = 480 mL 10 ounces = 300 mL 6 ounces= 180 mL Half a liter =500 mL Total intake =1460 mL

5. Which dressing requires that the nurse place tape strips on all sides of the dressing? (621) 1. wet-to-dry dressing 2. Dry dressing 3. Transparent dressing 4. Occlusive dressing

Answer 4: The purpose of an occlusive dressing is to prevent air or oxygen from reaching the wound site, so the nurse would use tape to seal the edges of the dressing.

Which are treatment options for posttraumatic stress disorder (PTSD)? Select all that apply. O Antipsychotics O Antidepressants O Cognitive therapy O Behavioral therapy O Electroconvulsive therapy

Antidepressants Cognitive therapy Behavioral therapy Rationale Treatment for PTSD includes antidepressant or antiseizure medications; cognitive therapy, which focuses on breaking negative thought patterns; and behavioral therapy, which aims to break off a conditioned response that has become automatic. Electroconvulsive therapy (ECT) is used for patients with major depression, schizoaffective disorder, or mania when medications are ineffective or contraindicated. Antipsychotics are used for patients with schizophrenia.

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?

Apply cold compresses to the affected area.

Type of fat

As discussed earlier, the type of dietary fat matters. An excess of cholesterol and saturated fat in the diet, which comes from animal food sources, has been historically accepted as a specific risk factor for atherosclerosis, the underlying blood vessel disease that contributes to heart disease (see Chapter 19). However, if saturated fats (from food sources also containing dietary cholesterol) and trans fats are re placed with omega-6 polyunsaturated fatty acids, there appear to be no health benefits.15 On the other hand, if saturated and trans fats are replaced with omega-3 polyunsaturated fats, there is a favorable result to lipid profiles and risk for heart disease. 15 Monounsaturated fats are also cardio-protective. A diet rich in monounsaturated fats, such as the Mediterranean diet, increases high-density lipoprotein levels, improves the atherogenic index (ratio of total cholesterol to HDL cholesterol), and reduces vascular inflammation, thereby improving the overall cardio vascular health profile.20-22

Burns Assessment

Assessment • Depth of the burn • Causative agent • Temperature • Duration of contact • Burn thickness • Age & comorbidities • Rule of nines (TBSA) • Pain scale • Respiratory difficulties • Inhalation burn *Rule of nines does not take into account the difference levels of growth & is not accurate for children.

A patient has been prescribed trazodone hydrochloride and is being taken ofa monoamine oxidase inhibitor (MAOl). How soon can the patient start taking the trazodone? Immediately; there is no interaction between these two medications Within 5 days of discontinuing the MAOl Within l0 days of discontinuing the MAOl At least l4 days after discontinuing the MAOl

At least l4 days after discontinuing the MAOl Rationale A period of 14 days (not 5or l0 days) is the minimum amount of time that should lapse between discontinuing an MAOland starting trazodone. Severe reactions can occur, including rigidity, convulsions, hyperpyrexia, and death, when these two medications are taken together or when trazodone is taken too soon after discontinuing an MAOl.

The physical needs of the dying patient should be of utmost importance to the nurse giving care. Which patient situation would require an intervention? A) Lying in bed with side rails up B) Soiled and needs clothing changed C) Eating a high-protein, high-calorie diet D) Being transferred from the bed to the chair with two assistants

B) Soiled and needs clothing changed

Which nursing assessment priority for a patient taking a monoamine oxidase inhibitor (MAOl) and who reports a severe occipital headache, stiff neck, sweating, nausea, and vomiting? White blood cell count Blood pressure Deep tendon reflexes MAOI serum level

Blood pressure Rationale Severe occipital headache, stiff neck, sweating, nausea, and vomiting along with sharply elevated blood pressure are common prodromal symptoms of hypertensive crisis, which is a major potential complication of MAOI therapy. If a patient taking an MAOl experiences these symptoms, blood pressure should be checked immediately. Changes in white blood cells are not seen with the described side effects from MAOls. Assessment of deep tendon reflexes is not indicated by the clinical manifestations expressed by the patient. Measurement of MAOl serum level is not indicated by these clinical manifestations.

Which factor would be assessed before inserting a rectal tube into a patient with diarrhea? O Skin integrity O Peristomalarea O Bowl sounds O Level of orientation

Bowl sounds Rationale The patient's bowel sounds should be assessed before inserting a rectal tube as a baseline assessment before treatment. Skin integrities and level of orientation are parts of a routine physical assessment but are not needed before inserting a rectal tube. A peristomal area is found only in patients with an ostomy.

Transparent film (Tagaderm)

Breathable, Mepore® Pro is a self-adherent dressing that absorbs blood and exudate. The backing film allows showering and protects the wound from water and contamination. Mepore Pro is a skin friendly adhesive that provides secure and gentle fixation.

Which of the following conditions would be expected in an infant less than 2 years of age? A. Retention B. Cystitis C. Incontinence D. Anuria

C. Incontinence

Most of the digestion of carbohydrates takes place in the: A. mouth B. stomach C. small intestine D. large intestine

C. small intestine

Sublimation is a defense mechanism that helps the patient do which action?

Channel unacceptable impulses into socially acceptable ones

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which?

Characteristic of a thrush infection

The nurse is caring for a patient who reports, "I am not feeling well, but I do not want to consult my health care provider because I don't want to hear bad news." Which issue does the nurse suspect in the patient?

Conflict

Central Nervous System

Constant carbohydrate intake and reserves are neces sary for the proper functioning of the central nervous system. The brain has no stored supply of glucose; therefore, it is especially dependent on a minute-to minute supply of glucose from the blood. Sustained and profound shock from low blood sugar may cause brain damage and can result in coma or death.

Because thin skin and tack of subcutaneous fat predispose the older adult to pressure ulcers the nurse alters the care plan to include turning the bed of the patient how often? O Once every shit O Every 4 hours O Each evening O Every 2 hours

Every 2 hours

Which condition is associated with delirium tremens (DTs)?

Excessive alcohol consumption

The patient is concerned about confidentiality and afternoons not to tell anyone what is 10 what is the best response by the nurse? O I am required to report any intent to hurt yourself to others O conversations between patient and yours are confidential O What we say can be secret what I write in the chart is available to the health team O I can't help you unless you trust me

I am required to report any intent to hurt yourself to others

A parent reports to the nurse, "My child gets upset and won't eat his dinner when he loses in school games." Which stage of Erikson's theory would the nurse correlate the child's activity with? O Basic trust versus mistrust O Intimacy versus isolation O Industry versus inferiority O Autonomy versus shame and doubt

Industry versus inferiority

cholestorol

Linked to < risk of CAD/Atherosclerosis •Found in foods of animal origin •Liver main endogenous source •Essential for fat metabolism •Ex: organ meat, egg yolks, butter

The nurse is caring for a patient with bipolar disorder. What should the nurse expect to be prescribed to the patient to manage the mood swings of this disorder?

Lithium carbonate- prescription medicine used to treat the symptoms of Bipolar Disorder

Which disorder currently ranks as the leading cause of disease burden in the United States? O Bipolar disorder O Major depression O Ischemic heart disease O Endocrine abnormalities

Major depression Rationale lschemic heart disease is the leading cause of disease burden (years ived with the disability) in the United States About 0.4%to 1.6%of the adult population in the United States suffers from bipolar disorder. Major depression currently ranks as the second leading cause of disease burden. About 45%to 60% of patients with depression suffer from endocrine abnormalities.

Maltose

Maltose is not usually found as such in food form. It is derived within the body from the intermedi ate digestive breakdown of starch. Starch is made up entirely of glucose units. Therefore, during the break- down of starch, many disaccharide units of maltose are released. Synthetically derived maltose is used in various processed foods.

In addition to psychosocial treatment, which therapy does the nurse anticipate will be ordered for a patient admitted for morphine abuse? O Verapamil (Calan), O Naltrexone (ReVia) O Propranolol (inderal) O Flumazenil (Romazicon)

Naltrexone (ReVia) Rationale Naltrexone (ReVia) is an opioid antagonist prescribed to block the pharmacologic effects of the high associated with alcohol and opioids, such as morphine. Flumazenil (Romazicon) is a benzodiazepine antagonist and is used to treat benzodiazepine overdose. Propranolol (Inderal) is an adrenergic beta blocker and is indicated for treating high blood pressure and tachycardia, which may occur with amphetamine toxicity. Verapamil (Calan) is used for the treatment of cocaine abuse.

Herpes Simplex Medical management

No cure •Infection control & handwashing •Keep it clean and dry •Loose absorbent clothing •acyclovir (Zovirax), valacyclovir (Valtrex), acetaminophen, lidocaine, codeine and aspirin, NSAIDS (ibuprofen) •Assess for HIV •Comfort & vasodilation •10 to 15 minutes •Be cautious for Orthostatic hypotension

keloids

Nodules formed in wound healing due to excessive collagen, increased TGF-Beta activity

A client has a non-infected pressure ulcer on the left heel. The nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure?

Normal saline

The nurse is preparing a teaching plan for a male patient with urinary incontinence. Which instructions would the nurse include in the teaching plan? Select all that apply. O Check for reoccurrence of disease." O "Drink adequate amounts of fluids daily. O Perform Kegel exercises, 5 to 10 times a day." O Avoid the consumption of alcohol and coffee O Initiate voiding by applying pressure to the abdomen.

O "Drink adequate amounts of fluids daily. O Avoid the consumption of alcohol and coffee Rationale Patients with urinary incontinence may reduce their fluid intake to reduce voiding Less fluid intake results in concentrated urine. This concentrated urine irritates the bladder, increasing the urge to void. Therefore, the patient is advised to take in more fluids per day. Alcohol and coffee should be avoided because they may irritate the bladder, increasing the urge to void. Urinary incontinence is not a urinary tract infection, and there is no possibility of recurrence of the disease. Kegel exercise is advised for female patients with urinary incontinence. Applying abdominal pressure to stimulate urination is a part of bladder training program recommended to patients with neurogenic bladder,

A patient has been prescribed methenamine mandelate (Mandelamine) to prevent recurrence of chronic urinary tract infections. Which instruction would the nurse provide to maximize the effectiveness of Mandelamine? O "Take medication on an empty stomach. O O "Drink cranberry juice daily to acidify the urine." O "Drink only a small sip of water while taking the medication"

O "Drink cranberry juice daily to acidify the urine." Rationale The patient should be instructed to eat and drink foods that acidify the urine to maximize the effectiveness of Mandelamine. The medication does not need to be taken on an empty stomach or with only a small sip of water. A diet high in protein and whole grains acidifies, not alkalinizes, urine and is therefore recommended.

Which statement by the nurse about the effects of ambulation in the postoperative period indicates effective learning? O "Early ambulation helps hasten postoperative recovery." O Ambulation is necessary for patients with severe infection O "Patients should get in and out of bed within a month after surgery." O "Early ambulation causes urinary retention and thrombophlebitis.

O "Early ambulation helps hasten postoperative recovery." Rationale Early ambulation after surgery increases circulation and metabolism and therefore, hastens postoperative recovery in the patient. Ambulation is contraindicated in patients with severe infection as the patient may be weak and needs to conserve energy. Patients should get in and out of bed as soon as possible after the surgery to prevent deep vein thrombosis. Early ambulation improves kidney function and prevents urinary retention. There are low chances of thrombophlebitis because early ambulation increases circulation.

Which instruction would be given to a patient receiving transtracheal oxygen who reports the catheter has come out and he or she is unable to replace it? O "Force the catheter back in place." O "Go to the emergency room immediately! O "Administer oxygen at a higher flow rate." O "Clean the catheter site with hydrogen peroxide."

O "Go to the emergency room immediately! Rationale If the transtracheal catheter is removed and not replaced in a timely manner, the transtracheal opening can close over. If this occurs, the surgical procedure will need to be repeated. Patients should be instructed to go to the emergency room if the catheter comes out. Patients should never be instructed to force the catheter back in place. Patients should consult with the health care provider to determine the required flow rate. Twice daily maintenance of the transtracheal catheter site includes cleaning with hydrogen peroxide.

A nurse is providing discharge education to a patient who has been recently prescribed a potassium-sparing diuretic. Which statement, if made by the patient, indicates a need for further education? O "I should take care to change positions slowly." O "I will need to have my potassium levels checked routinely." O "If notice heart palpitations, I should go to the hospital immediately O "I should reduce my sodium intake by using a potassium chloride salt substitute.

O "I should take care to change positions slowly." Rationale Potassium-containing salt supplements can lead to hyperkalemia in patients taking potassium sparing diuretics and should be avoided. The patient should change positions slowly to prevent orthostatic hypotension, routinely check potassium levels, and understand the importance of going to the hospital if palpitations are felt.

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning? O "Nicotine gum will help decrease nicotine dependence." O CNS stimulants are helpful in treating nicotine addiction." O "The nicotine transdermal patch is the least beneficial option" O Only 10% of people who quit smoking will experience relapse

O "Nicotine gum will help decrease nicotine dependence." Rationale Nicotine gum helps deliver decreasing doses of nicotine and blocks the reinforcing effect of smoking making it an effective treatment option to decrease nicotine dependence. Central nervous system (CNS) stimulants are not effective in treating nicotine dependence; they cause hypertension, diarrhea, and nausea and have other adverse effects. The nicotine transdermal patch works in the same way as nicotine gum and is an effective treatment option. 70% of people who quit smoking will have a relapse within a year,

The nurse is planning care after a right hip replacement in a patient who smokes cigarettes. Which postoperative instruction would be most important to prevent respiratory complications in a patient who smokes cigarettes? O "Drink 8 to 10 glasses of water per day." O "Shift position in bed slightly every 15 minutes." O "Alternate pointing toes up and down 20 times every hour! O "Use the incentive spirometer 10 times every hour while awake.

O "Use the incentive spirometer 10 times every hour while awake. Rationale Patients who smoke and undergo anesthesia for the surgery are at an increased risk for atelectasis and pneumonia. It is important for these patients to diligently perform breathing exercises, such as using the incentive spirometer. The patient should increase fluid intake to prevent constipation, shift position in bed often to prevent pressure sores, and extend and flex the toes often to prevent deep vein thrombosis.

The nurse explains to the parents of a child who has impetigo how to manage the disease at home. Which instructions would be included for the parents? O "Research safety information on the Internet." O "Wash your hands every time you touch your child O "Immediately report if there is honey-colored crust. O "Do not use chemical soaps because they may burn the child's skin

O "Wash your hands every time you touch your child Rationale Impetigo is a highly contagious streptococcal infection, and it could spread if the caregiver or anyone touches the patient. Therefore, the nurse instructs the parents to wash their hands every time they touch the child. Chemical or antiseptic soaps are used to clean the infected area because they prevent the growth of microorganisms. The nurse does not instruct the parents to look for safety information on the Internet because some of the information found there may be inaccurate. The dried exudate from ruptured vesicles is honey colored and can be easily removed. Therefore, it is not important to report it to the health care provider.

The nurse is providing teaching to a patient and his wife regarding postoperative care before a right shoulder replacement. Which comment by the nurse is the best way to facilitate understanding in the patient and his wife? O "Do you have any questions?" O "What questions do you have at this time?" O "Are you concerned about the postoperative period?" O Here is a packet with information on postoperative care. It should answer all of your questions."

O "What questions do you have at this time?" Rationale The nurse should ask open-ended questions to determine the patient and his wife's understanding of the teaching. Asking, "Do you have any questions?" does not facilitate a discussion. Although it is important to determine the patient's concerns, asking if he is concerned about the postoperative concerns requires only a "yes" or "no" answer and does not facilitate discussion. Although a packet may be helpful in facilitating the patient's learning, the nurse should not assume that all questions will be answered by the packet information

The nurse is providing education to a patient with new-onset type 2 herpes simplex genital lesions. Which statement regarding type 2 herpes simplex, if made by the patient, indicates a need for further education? O "I will also be tested for human immunodeficiency virus." O "With medication, I will be able to cure my herpesvirus infection O "I can expect to experience flulike symptoms for several days after the vesicles erupt." O "IF I become pregnant and have active lesions at delivery, I will have to deliver via cesarean section."

O "With medication, I will be able to cure my herpesvirus infection!! Rationale There is no cure for herpesvirus infection. Medical treatment focuses on treating symptoms. It is important to test individuals with herpesvirus for human immunodeficiency virus (HIV) Flulike symptoms often occur with herpes vesicle eruption. Transmission of herpesvirus during childbirth can be fatal to the baby, so cesarean section delivery is vital when active lesions are present.

A patient is scheduled for coronary artery bypass graft surgery (CABG) under general anesthesia. Which information does the nurse include when explaining general anesthesia to the patient? Select all that apply. O "it includes anesthetizing your entire body! O "It includes anesthetizing only the affected part of your body O it is administered through the subcutaneous route." O "It is administered through the intravenous (IV) route or inhalation." O "It involves calculating the drug amount based on your condition and the duration of surgery."

O "it includes anesthetizing your entire body! O "It is administered through the intravenous (IV) route or inhalation." O "It involves calculating the drug amount based on your condition and the duration of surgery." Rationale General anesthesia involves anesthetizing the entire body. This is the preferred method of anesthesia in major surgeries, such as CABG. The route of administration is IV or inhalation The amount of drug required is calculated by the anesthetist and depends on the patient's status, weight, duration of surgery, and so on. Local anesthesia anesthetizes only the affected part of the body, and the common route of drug administration is subcutaneous.

In performing chest compressions on a child, the breastbone is compressed to the depth of how many inches? O 1/2 O 1 1/2 O 2. O 2½

O 1 1/2 Rationale A child's chest is compressed with the heel of one hand at a depth of 1 inches at 100 times per minute inch is not a deep enough compression for a child. Two inches is too deep a compression for a child; 2 inches is too deep a compression for a child.

a patient with a tracheostomy has been assessed and needs suctioning. For how many seconds maximum will the nurse perform suction? O 30 O 20 O 15 O 10

O 10 Rationale Suctioning for longer than 10 seconds depletes the oxygen supply. Anything longer than 10 seconds will compromise patient oxygenation

What amount of pressure would the nurse administer when assisting a closure (VAC) device to a patient's wound? O 5 to 200 mm Hg O 201 to 300 mm Hg O 301 to 400 mm Hg O 401 to 500 mm Hg

O 5 to 200 mm Hg Rationale Administration of intermittent or continuous negative pressure between 5 mm Hg and 200 mm Hg is acceptable according to health care provider prescription or patient comfort. The average is 125. Any value above 200 is inappropriate.v

When performing nasotracheal suctioning in a young child, to which depth (in centimeters) would the nurse insert the catheter to prevent injury? O 7 cm O 9 cm O 12 cm O 16 cm

O 7 cm Rationale The approximate length of insertion for a nasotracheal catheter when suctioning infants and young children ranges from 4 to 8 cm. Suctioning of older children ranges from 8 to 12 cm. For adults, the length of insertion is approximately 16 cm.

When rescue breathing for an adult victim, how many breaths would the nurse provide per minute? O 6 to 8 O 8 to 10 O 10 to 12 O 12 to 14

O 8 to 10 Rationale When providing rescue breathing for an adult victim, 8 to 10 breaths/min would be provided; 6 to 8 breaths/min is too few, 10 to 12 and 12 to 14 rescue breaths are not currently recommended

The nurse is caring for four patients of different age groups and with different health complications. Which patient is at an increased risk of urinary retention? O A 30-year-old man with diabetes O A 65-year-old man with back pain O A 30-year-old woman with cirrhosis O A 65-year-old woman with dementia

O A 65-year-old man with back pain Rationale Urinary retention is predominant in older men as a result of benign prostate hypertrophy (BPH). The disease condition is not always related to urinary retention unless it is related to renal failure, Therefore, a 65-year-old male patient is at a high risk of urinary retention. A 30-year-old male patient with diabetes is less likely to experience urinary retention. Female patients are at a lower risk of developing urinary retention because benign prostate hypertrophy does not occur in women. Thus, a 30-year-old woman is at a lower risk of urinary retention. Older women are at a risk of stress incontinence because of hormonal changes and weakened pelvic musculature

Which technique would the nurse use to alleviate choking in a baby? O Chest thrusts in the prone position O Abdominal thrusts in the supine position O Blind-finger sweep technique O A combination of back blows and chest thrusts

O A combination of back blows and chest thrusts Rationale A chest thrust, if performed alone, is not helpful to remove the aspirated object from the baby's airway (mouth). The nurse should use a combination of back blows and chest thrusts to remove the object stuck in the baby's mouth. Performing chest thrusts with the child in the prone position is not possible. Abdominal thrusts with the child in the supine position can cause severe injury, so this is not a preferred technique in children. If the object is visible, the nurse can use the blind sweep technique. Because the object is not visible in this case, the nurse should not perform this technique.

Which assessment does finding confirm that cardiac arrest has occurred in a drowning victim? O Absence of pulse O Absence of breathing O Loss of consciousness O Lack of response to a painful stimulus

O Absence of pulse Rationale Absence of pulse confirms the occurrence of cardiac arrest. Absence of respirations, loss of consciousness, and lack of response to a painful stimulus do not confirm cardiac arrest.

Which clinical signs would the nurse expect to find in a patient who is in an irreversible coma? Select all that apply. O Absence of heartbeat O Absence of reflex activity O Absence of respiration O Presence of heartbeat O Presence of constricted pupil

O Absence of reflex activity O Absence of respiration O Presence of heartbeat Rationale An irreversible coma is also called brain death. The usual clinical criteria for brain death include the absence of reflex activity, movements, and respirations. The heart continues to beat even if the brain is dead; therefore the absence of a heartbeat does not indicate brain death. The presence of dilated and fixed pupils indicates irreversible coma; therefore the presence of constricted pupils is not an indication of brain death.

A patient arrives at the clinic with edema of the face, anorexia, nocturia, and general malaise. The nurse notes crackles on auscultation of the lungs, jugular vein distention, and cola-colored urine. The nurse learns that the patient had a beta-hemolytic streptococcal infection 2 weeks ago. The nurse anticipates which diagnosis? O Impetigo O Rheumatic fever O Infective endocarditis O Acute glomerulonephritis

O Acute glomerulonephritis Rationale Acute glomerulonephritis is characterized by general malaise, fluid overload, and decreased urine output. It is caused by inflammation of the glomeruli as a result of infection by the beta hemolytic streptococci. Impetigo, rheumatic fever, and infective endocarditis do not explain the patient's symptoms.

After applying direct pressure to a wound spurting bright red blood for 10 minutes, which action should the nurse take next if the dressing is saturated? O Apply a tourniquet above the level of the wound. O Remove the dressing, and replace it with a new one. O Apply indirect pressure to the carotid artery pressure point O Add an additional dressing on top of the current dressing and maintain pressure.

O Add an additional dressing on top of the current dressing and maintain pressure. Rationale Direct pressure is the most effective way to treat bleeding. If the dressing being used to apply direct pressure becomes saturated, the nurse should add an additional layer on top of the existing dressing. The dressing should not be removed by anyone but the health care provider. A tourniquet should only be used if all other methods to stop the bleeding have failed and the victim's life is in danger. Indirect pressure over a pressure point, such as the carotid artery, should only be done if direct pressure and elevation fail to stop the bleeding.

Which action to prevent hypoxia should the nurse perform before suctioning a patient? Select all that apply. O Administer 100% oxygen. O Have the patient take several deep breaths. O Suction the patient only twice. O Have an assistant apply a resuscitator bag. O Rinse the catheter with sterile normal saline.

O Administer 100% oxygen. O Have the patient take several deep breaths. O Have an assistant apply a resuscitator bag. Rationale Suctioning can cause oxygen levels to fall, resulting in hypoxia. Before suctioning, administering 100% oxygen, having the patient take several deep breaths, and/or having an assistant apply a resuscitator bag can help prevent hypoxia. The nurse can suction the patient up to three times. The catheter should be rinsed with sterile normal saline to maintain sterility. but this does not prevent hypoxia.

The caregiver of a patient with frostbite asks the nurse if giving alcohol to the patient will be beneficial. Which response would the nurse give? O Alcohol may cause the core temperature to drop further." O "Alcohol in a small amount may help raise the temperature." O "Warming the alcohol will increase the temperature more rapidly!! O "Wait until the patient's temperature increases, and then give the alcohol."

O Alcohol may cause the core temperature to drop further." Rationale If the victim of frostbite is conscious, warm fluids may be offered. Alcohol should never be given because of its vasodilatory effect on the blood vessels, it can cause the central core temperature to drop further. Alcohol should not be given in any quantity or at any temperature. If the alcohol is given after the patient's temperature has increased, it can cause the temperature to decrease, which can be detrimental to the patient.

Which statement about storing oxygen tanks is correct? O Tanks should be kept outside the home, such as in an outdoor shed. O All tanks kept at home should be stored upright and chained together. O Store tanks somewhere warm, such as in the home's basement near the furnace. O Extra oxygen tanks can be placed on their sides and stacked up in a pile

O All tanks kept at home should be stored upright and chained together. Rationale Oxygen tanks should be chained together and kept upright. Tanks should be kept away from extremes in temperature and therefore should not be stored outside or near a heat source. Placing tanks on their sides and stacking them in a pile are not advised because it can lead to combustion.

Which sign of hypoxia would the nurse assess for in a patient with chronic lung disease who requires intermittent oxygen? Select all that apply. O Anxiety O Cyanosis O Hypotension O Increased fatigue O Sinus cardiac rhythm

O Anxiety O Cyanosis O Increased fatigue Rationale Signs and symptoms of hypoxia include anxiety, cyanosis, and increased fatigue. The patient with hypoxia will be hypertensive, not hypotensive. Patients with hypoxia can present with cardiac dysrhythmias.

A patient arrives at the emergency room (ER) with a penetrating, sucking chest wound. Which action should the nurse take first to ensure patient safety? O Assess the vital signs. O Locate the emergency room health care provider. O Medicate the patient. O Apply an airtight dressing

O Apply an airtight dressing Rationale If there is a sucking chest wound, the nurse should apply an airtight dressing. Any available material is acceptable-gauze, plastic wrap, clothing, or a hand. The vital signs should be taken, the health care provider located, and the patient medicated, but the dressing should be applied first because a pneumothorax can become a tension thorax if air continues to enter the open wound. Sometimes the fourth side will have to be untapped to allow air to escape. This will be assessed further once the airtight dressing is in place.

Which information would be included when explaining safety precautions for home oxygen use to patients? Select all that apply. O Avoid open flames. O Refrain from smoking. O Increase oxygen as needed O Wear fire resistant clothing. O Use petroleum jelly at nares.

O Avoid open flames. O Refrain from smoking. O Wear fire resistant clothing. Rationale Oxygen is highly combustible and requires safety precautions, including avoiding open flames, refraining from smoking, and wearing fire resistant clothing. The patient should maintain the oxygen setting at the prescribed level and avoid petroleum jelly near the oxygen as it can cause combustion

Which intervention will help reduce the risk for infection in a patient with a urinary drainage system? O Decreasing fluid intake O Performing catheter care as needed O Tightly securing the catheter with tension O Avoiding placing the drainage bag above the level of catheter insertion

O Avoiding placing the drainage bag above the level of catheter insertion Rationale Avoiding the placement of the drainage bag above the level of the catheter insertion prevents urine from reentering the urinary tract and contaminating it. Fluid intake needs to be increased to flush the urinary tract. Catheter care needs to be performed at least twice a day and as needed. The catheter needs to be secured, but tension that can cause trauma must be prevented.

Which type of open wound exposes tendons and muscles? O Incision O Avulsion O Puncture O Laceration

O Avulsion Rationale An avulsion is a torn piece of tissue that results in a section being completely removed or left hanging by a flap. Underlying bones, tendons, or muscles may be exposed. A laceration is a wound that has jagged, irregular edges caused by motor vehicle accidents or injury involving blunt objects or heavy machinery. An incision is a smoothly divided wound made by sharp instruments. A puncture is a piercing wound of the skin caused by knives, nails, wood, glass, or other objects that penetrate the skin

After Ms. Burke ambulates with the physical therapist, the PN prepares to change the surgical dressing. When obtaining the supplies, the PN reviews the sterile procedure to be followed. At what step in the procedure should the PN don sterile gloves? O Prior to removing the dressing on the client's hip. O Before opening the new sterile dressing package. O Before cleansing the client's hip incision. O After cleansing the client's hip incision.

O Before cleansing the client's hip incision.

Which action should the nurse take first when a patient has a pulse but is not breathing? O Begin rescue breathing. O Start chest compressions. O Provide abdominal thrusts. O Sweep the mouth for obstruction.

O Begin rescue breathing. Rationale Respiratory arrest is possible without cardiac arrest. Rescue breathing is then carried out until the patient responds and/or the pulse is no longer palpable. Chest compressions are not warranted because the patient has a pulse, abdominal thrusts are used for dislodging food, and sweeping the mouth is done if choking is suspected.

What are signs of urinary tract infection in a patient with an indwelling urinary catheter? Select all that apply. O Incontinence O Bladder spasms O Foul odor O Increased output O Burning sensation

O Bladder spasms O Foul odor O Burning sensation Rationale Patients with an indwelling urinary catheter have an increased risk of urinary tract infections. Patients should be educated about the signs and symptoms of urinary tract infections that should be reported, including foul odor to urine, bladder spasms, and a burning sensation when urinating, Incontinence would not be a concern in a patient who has a catheter. Increased output helps flush bacteria from the urinary tract.

During the preoperative assessment, the nurse learns that the patient takes ginger for intestinal gas. Which preoperative test would the nurse anticipate because of this medication? O Electrocardiography O Blood clotting time O Blood levels of ginger O Orthostatic blood pressure measurement

O Blood clotting time Rationale The nurse should anticipate that blood clotting studies will be performed because ginger can increase clotting time and increase the risk for bleeding. Electrocardiography was likely performed before surgery to determine a baseline and would not be affected by the ginger. Blood levels of ginger would not be tested. Orthostatic blood pressure measurement is not indicated at this time.

Positioning a patient with their head slightly tilted back and then placing one hand on the forehead and sliding two fingers of the other hand into the groove between the trachea and sternomastoid muscle in the neck allows the nurse to assess for which physical finding? O Thyroid gland enlargement O Carotid artery pulse rate O Presence of tonsils O Tenderness of posterior cervical lymph nodes

O Carotid artery pulse rate Rationale The carotid artery is palpable in the anterior triangle, an anatomic space defined by the trachea, sternomastoid muscle and base of the jaw. The apex of the triangle is at the suprasternal notch. The carotid pulse rate is measured by placing one hand on the forehead and sliding two fingers of the other hand into the groove between the trachea and the sternomastoid muscle, within the anterior triangle. Palpation of the thyroid gland, including palpation for gland enlargement, involves taking a position behind the patient, who is sitting upright with their head bent slightly forward. With the nurses' hands loosely encircling the neck of the patient, the fingers are used to push the trachea slightly in both directions and palpating the gland while the patient swallows. Presence of tonsils is assessed via direct visualization of the posterior pharynx, not by external palpation. The posterior cervical lymph nodes are palpable bilaterally, between the sternomastoid and trapezius muscles in the neck (the posterior triangle), not between the trachea and sternomastoid muscle

Which food allergies indicate that a patient is susceptible to latex allergy? Select all that apply. O Orange O Chestnuts O Kiwi O Avocados O Pineapple

O Chestnuts O Kiwi O Avocados O Rationale An allergy to kiwi fruit, chestnuts, or avocadoes shows cross-sensitivity to latex. If the patient has an allergy to these foods, then the patient needs to be assessed for latex allergy as well. Allergies to oranges and pineapples do not show cross-sensitivity to latex

A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. Which assessment would be the priority when inspecting the skin that is distal to the bandage? O Bacteria O Inflammation O Impaired skin integrity O Circulatory impairment

O Circulatory impairment Rationale Assessing for signs of circulatory impairment provides a means for comparing changes in circulation after bandage application. Inflammation is a sign of infection and not the result of bandage application. Bacteria would be in the wound and cause signs of infection. Skin integrity should be checked before the bandage is applied.

A patient is scheduled for surgery. The patient has been fasting for the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. Which type of food would be most appropriate to give to the patient? O Solid food O Fried food O Fatty food O Clear liquids

O Clear liquids Rationale Patients usually have a fasting period before surgery. However, if the surgery gets postponed, the patient may be allowed clear liquids. Clear liquids can be metabolized within 2 hours and may not interfere with the gastrointestinal function or the anesthesia process. Solid food, fried food, and fatty food should not be given to the patient. Solid food requires 6 hours to metabolize. Fried food and fatty food requires hours to metabolize

In classifying wounds, which classification results from the presence of gastrointestinal (GI) products? O Dirty O Clean O Contaminated O Clean-contaminated

O Contaminated Rationale A contaminated wound results from the presence of Gl products; from acute, nonpurulent inflammation; or when aseptic technique is broken during surgery. A clean-contaminated wound is a surgical incision made into the respiratory, GI, or genitourinary tract after special presurgical preparation. A dirty wound is a wound that is infected before surgery. A clean wound is an uninfected surgical wound.

Which action should the nurse take for an 80-year-old patient with an arterial partial pressure oxygen (Pao 2) level of 82 mm Hg? O Call the rapid response team. O Notify the health care provider. O Increase oxygen administration. O Continue the current plan of care.

O Continue the current plan of care. Rationale Normal arterial oxygen levels decrease with age but continue on the low-end of normal. A normal PaO 2 is between 80 and 100 mm Hg. Many older patients display a Pao 2 level between 80 and 85 mm Hg without significant alterations in health. Therefore the nurse should continue the current plan of care with an 81-year-old patient whose PaO level is 82 mm Hg. The nurse does not need to call a rapid response, notify the health care provider, or Increase the amount of oxygen being administered as the patient's Pao reading represents a normal laboratory value

To prevent the thickening of secretions, the nurse would instruct the patient receiving oxygen to refrain from consuming which food or beverage? O Tea O Juices O Coffee O Dairy products

O Dairy products Rationale Dairy products, including milk and yogurt, can thicken secretions, making breathing more difficult. Tea, coffee, and other caffeinated beverages, as well as juices, should also be avoided because they can cause dehydration. However they do not affect secretion formation

The surgeon asks the nurse to apply an abdominal binder on a patient after surgery. Which function does an abdominal binder serve? Select all that apply. O Decreases tension around the wound O Holds the dressing in place O Helps the patient breathe slowly O Provides comfort to the patient O Helps the patient lose weight

O Decreases tension around the wound O Holds the dressing in place O Provides comfort to the patient Rationale Binders are elasticized fabric bands used to decrease the tension around a wound or a suture line. Abdominal binders are placed on abdominal incisions. They make it easier for the patient to breathe deeply or cough because they hold the dressing in place. Binders support the dressing and provide comfort to the patient. Binders do not help the patient breathe slowly as they do not affect the patient's breathing. The abdominal binder is not designed to help a patient lose weight

Which task should the nurse perform before inserting a catheter who requires nasotracheal suctioning? O Provide oral care. O Obtain Yankauer suction catheter. O Angle catheter in upward position. O Determine which nostril is most patent.

O Determine which nostril is most patent. Before inserting the nasotracheal suction catheter, the nurse should determine if either nostril is obstructed. Oral care is performed after the procedure. A Yankauer suction catheter is used for oropharyngeal suctioning. The catheter should be angled in the downward position

The PN is assisting Ms. Burke to the bedside commode on the second postoperative day. Ms. Burke states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the PN identifies which nursing diagnosis to add to Ms. Burke's plan of care? O Disturbed body image. O Disturbed personal identity. O Anticipatory grieving. O Disturbed personal identity.Situational low self-esteem.

O Disturbed personal identity.

The nurse in the ambulatory surgery center learns that the patient scheduled for surgery at 11 a.m. drank water at 7 a.m. Which action is best on the part of the nurse? O Alert the surgeon. O Cancel the surgery. O Document the finding O Warn the patient about the dangers of aspiration during surgery.

O Document the finding Rationale The patient can have clear liquids until 2 hours before the surgery unless the patient has a condition that causes delayed gastric emptying. Therefore, the appropriate action by the nurse would be to document the finding and continue the assessment. The nurse should report this information as part of the preoperative assessment to the health care provider, but the nurse should finish the assessment first. The surgery does not need to be cancelled at this time. The patient should be educated on the risks of aspiration, but this is not the most correct option.

Which action promotes thinning of respiratory secretions? O Drinking adequate amounts of water O Completing oral hygiene twice a day O Performing coughing and deep breathing O Ambulating and changing positions frequently

O Drinking adequate amounts of water Rationale Patients receiving oxygen should maintain adequate sugar-free and decaffeinated fluid intake to help liquefy secretions. Oral hygiene alleviates bad tastes from secretions but will not thin them. Coughing, deep breathing, ambulation, and changing positions frequently help mobilize secretions, but these actions will not alter their thickness.

The nurse is caring for a patient who just underwent right hip replacement. The nurse would be most concerned with preventing which postoperative complication? O Embolus O Pneumonia O Constipation O Muscle atrophy

O Embolus Rationale Although pneumonia, constipation, and muscle atrophy are complications of hip replacement surgery, the most serious and life-threatening complication is an embolus, which could lead to stroke, heart attack, and death

What will the nurse administer when prepping a patient for a gastrointestinal (GI) diagnostic procedure? O Enema O Sitz bath O Analgesic O Enteral feeding

O Enema Rationale A cleansing enema is frequently administered to clear the colon before GI diagnostic procedures. A sitz bath and analgesics are used to ease pain from hemorrhoids. Enteral feedings provide nutrition to patients who are unable to swallow or take in food orally.

What will the nurse administer when prepping a patient for a gastrointestinal (GI) diagnostic procedure? O Enema O Sitz bath O Analgesic O Enteral feeding

O Enema Rationale A cleansing enema is frequently administered to clear the colon before GI diagnostic procedures. A sitz bath and analgesics are used to ease pain from hemorrhoids. Enteral feedings provide nutrition to patients who are unable to swallow or take in food orally.

Which action by the licensed practical/vocational nurse (LPN/LVN) needs correction when applying a partial rebreather mask to a patient with low oxygen levels? O Using distilled water when applying humidified oxygen O Removing the mask every 2 to 4 hours to evaluate the skin for breakdown O Allowing a patient to place the partial rebreather mask on their own face O Filling the reservoir bag with oxygen after placing the mask on the patient

O Filling the reservoir bag with oxygen after placing the mask on the patient Rationale The LPN/LVN should cover the reservoir hole in the mask and allow the bag to completely fill before placing the partial rebreather mask on the patient. Distilled water should always be used to decrease the growth of microorganisms. Patients should be allowed to place the mask on their own face because this may alleviate feelings of suffocation and apprehension. The mask should be removed every 2 to 4 hours to assess for skin breakdown.

Which equipment would the nurse use to ensure the prescribed rate of oxygen is delivered? O Flow meter O Nasal cannula O Oxygen tubing O Venturi mask

O Flow meter Rationale An oxygen flow meter is used to set the prescribed rate of oxygen administration. The nasal cannula, oxygen tubing, and Venturi mask assist in the delivery of oxygen but do not determine the rate

A patient comes to the clinic with a cluster of vesicles at the corner of the mouth. The nurse anticipates the patient will be diagnosed with an infection caused by which organism? O Neisseria gonorrhoeae O Chlamydia trachomatis O Herpes simplex virus type 1 O Herpes simplex virus type 2

O Herpes simplex virus type 1 Rationale The patient demonstrates signs of a herpes simplex virus infection. Type 1 herpesvirus is more common than type 2, which generally affects the genitals. Neisseria gonorrhoeae and Chlamydia trachomatis do not cause vesicles at the corner of the mouth.

Which of the following elements will help to promote wound healing? O High protein O High carbohydrates O Vitamin C O Vitamin A O Vitamin D

O High protein O Vitamin C O Vitamin A

Which action when performing colostomy irrigation requires correction? O Placing irrigation cone inside the stoma O Priming tubing with solution to expel air O Filling irrigation bag with 1000 ml tepid water O Holding the irrigation bag 1 ft above patient

O Holding the irrigation bag 1 ft above patient Rationale The irrigation bag should be held at the patient's shoulder level when performing colostomy irrigation. Any higher level can cause abdominal cramping, increased pressure, and bowel damage. Placing the irrigation cone inside the stoma, priming the tubing to expel air, and filling the irrigation bag with 1000 mil tepid water are correct steps when performing colostomy irrigation

A nurse is teaching about preventing constipation in older adults. Which information would the nurse include? Select all that apply. O Limit lactose. O Increase fluids. O Increase activity O Decrease dietary fiber. O Keep daily meal journal.

O Increase fluids. O Increase activity O Keep daily meal journal. Rationale Increasing activity, increasing fluids, and keeping a daily meal journal are interventions that can prevent constipation in the older adult. Dietary fiber should be increased. Limiting lactose does not prevent constipation

Which action by unlicensed assistive personnel (UAP) when inserting of a rectal tube requires correction? O Places protective pad under the patient O Inserts rectal tube about 8 to 10 inches O Applies water-soluble lubricant to tube O Positions patient in the left side-lying position

O Inserts rectal tube about 8 to 10 inches Rationale The rectal tube should only be inserted 4 to 6 inches. Inserting the tube 8 to 10 inches could cause colorectal trauma and requires correction. Placing a protective pad under the patient protects the linens: Applying a water-soluble lubricant to the tube facilitates easy insertion. The patient should be placed in the left side-lying position.

Which interventions should the nurse implement to prevent thrombus formation in a patient after knee surgery? Select all that apply. O Instruct the patient not to cross the legs when in bed. O Use the knee gatch on the bed for safety and comfort. O Instruct the patient to reduce fluids and juices in diet. O Instruct the patient to perform leg exercises every 2 hours O Encourage the patient to get out of bed as often as possible

O Instruct the patient not to cross the legs when in bed. O Instruct the patient to perform leg exercises every 2 hours O Encourage the patient to get out of bed as often as possible Rationale The patient is at risk for thrombosis after a surgery because of inactivity and injury to the blood vessels resulting from anesthesia. The nurse instructs the patient not to cross the legs when in bed because this action impedes blood flow in the legs. The nurse instructs the patient to perform leg exercises every 2 hours and also encourages the patient to get out of bed as often as possible. The nurse avoids using a knee gatch as it hinders venous return in the patient. Reducing fluids and juices in diet is necessary to prevent edema in a patient with deep vein thrombosis.

A student nurse has been assigned to a patient who has a prescription for tracheal suctioning. Which action by the student indicates that the student needs additional teaching? O Suctions the patient during removal of the catheter O Disposes of the catheter after suctioning is completed O Checks the tracheostomy for edema, exudates, and obstruction O Instructs the patient to hold the breath before the catheter is introduced

O Instructs the patient to hold the breath before the catheter is introduced Rationale Preoxygenation is essential before suctioning to prevent oxygen depletion. Preoxygenation can be accomplished by having the patient take a deep breath, setting the ventilator to deliver 100% oxygen, or using a resuscitator. Having the patient hold the breath before suctioning would be an indicator for further teaching. The catheter should be discarded after suction is completed. Before suctioning, it is essential to assess the tracheostomy for edema, exudates, and obstruction. The student should perform suctioning only during removal of the catheter.

The nurse is performing the admission assessment of a patient at the nursing home. The nurse notes the patient has widespread nevi across the body. Which characteristic, if demonstrated by one of the nevi, would cause the nurse to be concerned about malignancy? O Flat surface O Regular color O A Circular shape O Irregular border

O Irregular border Rationale Moles with an irregular border should be further assessed for malignancy. Other indicators of malignancy include raised surface, variations in color in the mole, and an irregular shape.

A patient with urticaria is prescribed diphenhydramine therapy. Which medication effect best explains the purpose of prescribing this medication? O It prevents severe dryness of the skin. O It treats eczema and psoriasis. O It manages inflammation and pain. O It blocks histamine at the H1, receptor site.

O It blocks histamine at the H1, receptor site. Rationale Urticaria occurs as a result of the release of histamine in an antigen antibody reaction. Therefore, diphenhydramine, an antihistamine, is prescribed because it blocks histamine at the H receptor site. Urticaria does not cause dryness of skin, however, wheals or hives are caused by an allergic reaction. Estar Gel and PsoriGel are applied once a day at bedtime, along with a moisturizer, to treat eczema and psoriasis. Topical steroids are applied to manage inflammation and pain in the patient.

While inspecting a patient's wound, the nurse observes that the skin around the wound has softened and is broken. Which finding does this indicate about the wound? O It was covered with a dry dressing O It was covered with a gauze dressing O It was exposed to air for a long time. O It was covered with an occlusive dressing

O It was covered with an occlusive dressing Rationale The softening and breaking of the skin are indicative of maceration. This usually happens because of excessive moisture around the wound. An occlusive dressing prevents air from reaching the wound and keeps the wound moist, which may cause maceration. Dry or gauze dressings allow the passage of air through pores present on the dressing. These dressings do not make the wound moist and they can prevent maceration.

While providing first aid to a patient with a penetrating chest wound, the nurse observes the signs and symptoms of pneumothorax. Which intervention would be best to address this complication? O Dress the wound, taping securely on all four sides. O Leave one side of the dressing untaped for air to escape O Give the patient some water to drink to slow breathing O Slowly remove the object that caused the chest wound.

O Leave one side of the dressing untaped for air to escape Rationale If the signs and symptoms of pneumothorax are observed, then one side of the dressing should be left untaped. Tight taping of the dressing may cause respiratory distress. Intake of any liquids during this time may cause aspiration and should be avoided. Removal of an object may cause an escape of fluids into the plural space and increase the bleeding. The nurse should not remove the object.

While caring for a patient, the nurse finds that the patient's wound dressing has become yellow in color. Which parameter does the nurse assess further to investigate the abnormality? O zinc levels O Vitamin A levels O Platelet count O Leukocyte count

O Leukocyte count Rationale Yellow discharge on a bandage implies purulent discharge, which is caused by infection. During acute infections, the leukocyte count increases; therefore, to confirm the presence of infection, the nurse should check the patient's leukocyte count. Decreased zinc and vitamin A concentrations cause a reduced healing process, but these do not indicate the presence of infection. An increased platelet count is characterized by thrombosis. Therefore, it is not necessary to check zinc concentration, vitamin A concentration, or platelet count to identify the presence of infection.

Which different categories of anesthesia are used in surgical procedures? Select all that apply. O Local anesthesia O Conscious sedation O General anesthesia O Epidural anesthesia O Regional anesthesia

O Local anesthesia O Conscious sedation O General anesthesia O Regional anesthesia Rationale Local anesthesia involves loss of sensation at the desired site and is commonly used for minor surgical procedures, such as a biopsy of a tumor or removal of a growth. Conscious sedation involves giving drugs that depress the central nervous system or provide analgesia to relieve anxiety or provide amnesia during surgical diagnostic procedures. General anesthesia is used for major surgery requiring extensive tissue manipulation, and it produces amnesia, analgesia, muscle paralysis, and sedation. Regional anesthesia causes loss of sensation in an area of the body and is used for some surgical procedures and pain management. Epidural anesthesia is a type of general anesthesia.

A postsurgical mastectomy patient has a bandage on the left breast. To assess whether the patient is hemorrhaging, which measure should the nurse take? O Assess the corners of the gauze dressing for blood. O Remove the bandage to determine if blood exists. O Look under the patient for areas of blood O Use a scale to monitor the bandage for an increase in weight.

O Look under the patient for areas of blood Rationale To prevent undetected hemorrhaging, the nurse must inspect the dressing or incision and the area under the patient. Exudate follows the flow of gravity; therefore depending on the contour of the body, the dressing remains dry even though blood and exudates are flowing under the body. Looking under the patient will reveal blood that has flowed backward under the patient. Assessing the corners of the gauze will not reveal hidden blood. Weighing the bandage is not a correct way to assess hemorrhage.

Which action should be performed when a patient reports abdominal cramping while receiving an enema? O Lower the container O Administer an analgesic. O Remove the enema tube. O Notify the health care provider.

O Lower the container Rationale If a patient reports abdominal cramping during enema administration, the nurse should lower the container and instruct patient to perform deep breathing. The nurse does not need to administer pain medication. It is not necessary to notify the health care provider. The nurse should not remove the tubing tip from the rectum

Which inference would the nurse make about a patient who is demonstrating maladaptive behavior and has lost contact with reality? O Large ego O Mild anxiety O Mental illness O Poor self-concept

O Mental illness Rationale Maladaptive behavior is a characteristic of mental illness. Loss of contact with reality can result when an individual is suffering from mental illness. Distortion of reality is one of the symptoms that can be seen in patients with panic-level anxiety but not in patients with mild anxiety. Patients with large egos are in contact with external reality. Self-concept includes all perceptions and values held and all behaviors and interactions performed. Poor self-concept is a characteristic identified in mental illness.

Which statement regarding culture and ethnic considerations is considered to be a true statement? O Native Americans are often stoic when ill. O Written consent has more meaning than verbal consent among Arab Americans O Chinese Americans are usually very willing to ask for pain medications after surgery. O Direct eye contact is a sign of respect to many Southeast Asians and American Indians.

O Native Americans are often stoic when ill. Rationale Native Americans are often stoic when ill. Complaints of pain to the nurse may be in general terms, and undertreatment of pain is common. Verbal consent has more meaning than written consent among Arab Americans because it is based on trust. Chinese Americans may not ask for pain medications after surgery and may require education about pain relief. Direct eye contact may be avoided and considered disrespectful to many Southeast Asians and American Indians.

Which information does the nurse include when documenting a tracheostomy suctioning procedure? Select all that apply. O Peristomal skin condition O Use of sterile normal saline O Number of times suctioned O Color and amount sputum O Lung sounds before and after procedure

O Number of times suctioned O Color and amount sputum O Lung sounds before and after procedure

Which signs would the nurse expect to find to support a medical diagnosis of early stage of shock? Select all that apply. O Oliguria O Warm skin O Tachypnea O Hypotension O Altered level of consciousness O Bradycardia

O Oliguria- the production of abnormally small amounts of urine. O Tachypnea O Hypotension O Altered level of consciousness Rationale During shock the skin is cool and clammy, the patient loses consciousness, and the patient may experience an increase in heart rate (tachycardia) and pulse rate (tachypnea). Urinary output decreases (oliguria), and blood pressure goes down (hypotension). There is increase, not decrease, in heart rate, and the skin is not warm, but cool and clammy. Bradycardia may occur but usually in the late stages of shock.

A patient is being evaluated in the emergency room for a possible drug overdose. The nurse notes that the patient is stuporous, has pinpoint pupils, and has severe respiratory depression. The health care provider orders a urine toxicology screen, stat. Which substance does the nurse anticipate receiving a positive result for in the urine screen? O Opiates O Cocaine O Amphetamines O Cannabis

O Opiates Rationale Decreased level of consciousness, pinpoint pupils, and respiratory depression are indicators of opiate overdose. Cannabinol is the active ingredient in marijuana and does not cause central nervous system (CNS) depression. Both cocaine and amphetamines are CNS stimulants.

The nurse is caring for a diabetic patient who has injuries due to an accident. The nurse finds that the patient has delayed wound healing. What food does the nurse suggest to the patient to promote faster wound healing? O Apples O Peaches O Oranges O Watermelon

O Oranges Rationale Vitamins and nutrients play a major role in the process of wound healing, and vitamin C is particularly helpful. Vitamin C maintains tissue integrity and enhances the process of wound healing. Therefore, the nurse should suggest the patient eat fruits that contain vitamin C, such as oranges. Fruits such as apples, peaches, and watermelon do not contain large amounts of vitamin C, so they may be less helpful in promoting wound healing.

The nurse is performing an initial assessment of a patient who just returned from surgery. The nurse notes bright red on the surgical dressing. Which nursing action is best? O Change the dressing and use extra gauze. O Reinforce the dressing with more gauze and tape. O Outline the bloodstain in permanent marker, and reassess frequently O Call the health care provider and prepare the patient to return to surgery.

O Outline the bloodstain in permanent marker, and reassess frequently Rationale Occasionally, the patient will return from surgery with bloody drainage on the surgical dressing The nurse should outline the drainage in permanent marker and reassess frequently If the spot increases, the nurse should contact the health care provider. In general, the first dressing change is performed at a predetermined time by the surgeon; it is inappropriate for the nurse to change the dressing at this time, and it is not necessary to reinforce the dressing as yet. It is not necessary to call the health care provider and prepare the patient to return to surgery at this time.

Which factor would cause a keloid (firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to the color of the person's skin or red to dark brown in color )on the patient's skin at the site of injury? O Shortening of muscle tissue O Overgrowth of collagen O Impaired blood flow O Reduction in skin capillaries

O Overgrowth of collagen Rationale A keloid is a permanent raised, enlarged scar. It occurs due to an overgrowth of collagen Collagen is the fibrous structural protein found in connective tissue. A keloid develops in the final stage of healing, when the scar matures to produce the strongest scar tissue possible. Shortening of muscle tissue can occur when there is a wound around a joint. Impaired blood flow and reduction in skin capillaries are caused by peripheral vascular disease.

Which data would the nurse include when documenting a nasotracheal suctioning procedure? Select all that apply. O Capillary refill O Oxygen saturation O Bilateral breath sounds O Color and amount of sputum O Health care provider notification

O Oxygen saturation O Bilateral breath sounds O Color and amount of sputum Rationale The patient's oxygen saturation level, bilateral breath sounds, and the color, consistency, amount, and odor of sputum suctioned should be documented after the suctioning procedure. It is not necessary to assess capillary refill. The health care provider does not need to be notified.

Which signs are characteristic of hypoxia (Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) ? Select all that apply. O Pallor O Anxiety O Confusion O Restlessness O Decreased blood pressure

O Pallor O Anxiety O Confusion O Restlessness Rationale Signs of hypoxia include pallor, anxiety, confusion, and restlessness caused by lack of oxygen. The initial response to hypoxia is an increase, not a decrease, in blood pressure.

A nurse is caring for a patient who returned from surgery 8 hours ago and has yet to void. Which action should the nurse perform first? O Call the health care provider O Palpate for bladder distention O Perform a straight catheterization to determine urinary output. O Insert an indwelling catheter for accurate measurement of intake and output.

O Palpate for bladder distention Rationale Before calling the health care provider, the nurse should determine whether the patient has bladder distention. The provider may prescribe a straight catheterization to determine residual urine volume. It may be necessary to use an indwelling catheter to accurately measure the patient's output, but this is not the immediate action

Which delivery system would the nurse use for a patient with an oxygen saturation level of 69% on room air prescribed 100% oxygen to be delivered at 15 L/min? O Venturi mask O Nasal cannula O Nonrebreather mask O Partial non rebreather mask

O Partial non rebreather mask Rationale A nonrebreather mask is designed to administer 70% to 100% oxygen at 6 to 15 L/min. A Venturi mask delivers 4 to 10 L/min at 24% to 55% oxygen. Nasal cannula can only accommodate oxygen flow rates between 1 and 6 L/min at 24% to 44% oxygen. A partial rebreather mask provides 6 to 12 L/min at 60% to 90% oxygen.

While the nurse is starting a heparin lock on a patient with a diagnosis of a drug overdose, the patient begins to have a seizure. Which concern is the nurse's priority? O Patient safety O The medical history O Determining allergies O Securing the intravenous access

O Patient safety Rationale Victims must be protected from self-injury during a seizure or hallucinations by removing potential harmful objects from the patient's vicinity. The patient's safety is essential. Obtaining the medical history, determining allergies, and securing an intravenous access are essential but preventing injury is the priority.

Which information is essential to be documented in the chart after a dressing change? Select all that apply. O Patient's response O Patient's medication O Status of the wound O Level of consciousness O Location of the wound O Type of dressing applied

O Patient's response O Status of the wound O Location of the wound O Type of dressing applied Rationale After a dressing change, document the location of the wound, status of the wound, and description of the exudate or drainage. In addition, document the dressing applied, any teaching provided, and any response to therapy. The patient's level of consciousness and medication may be documented, but these are usually not addressed during wound care.

The nurse is caring for a patient who is experiencing incontinence. Which nursing intervention will the nurse include in the patient's plan of care? O Deep breathing exercises O Keeping the perineum clean O Pelvic muscle (Kegel) exercises O Awakening the patient at night to void

O Pelvic muscle (Kegel) exercises Rationale Kegel exercises are effective in correcting incontinence as they help tighten the pelvic muscles. Deep breathing exercises will calm the patient and improve voiding, but they may not prevent incontinence. The genitalia and the perineum are kept dean in all patients with urinary problems to prevent infection. Asking the patient to void before bedtime is more effective to prevent nighttime incontinence than awakening

Which action is essential for the nurse to implement before applying a bandage to an injured leg once the bleeding is controlled? O Elevate the leg. O Massage the calf. O Apply heat to the wounded area. O Place the leg in a functional position.

O Place the leg in a functional position. Rationale The nurse should control the bleeding before applying the bandage. The nurse should always bandage the part in the aligned position. The leg may be elevated after the bandage has been applied, massaging the calf may dislodge a clot, and heat is not indicated at this point.

Which finding in a patient with an indwelling urinary catheter needs correction? O Loose-fitting clothing worn O Leg bag used during the day O Powder noted in perineal area O Drainage bag below bladder level in

O Powder noted in perineal area Rationale Powders and lotions should not be used in the perineal area because they can lead to infection Patients with an indwelling utinary catheter should wear loose-fitting clothing to prevent catheter kinking The leg bag should be used during the day. The drainage bag should be below bladder level.

A patient returns from abdominal surgery at 1300 with a heart rate of 78, respiratory rate of 14, and blood pressure of 128/86. At 1400, the patient complains of light-headedness; the heart rate is 132, respiratory rate is 22, and blood pressure is 84/58. Which action should the nurse perform first? O Encourage deep breathing O Administer naloxone (Narcan) O Prepare the patient to return to surgery O Document the vitals.

O Prepare the patient to return to surgery Rationale The patient is demonstrating symptoms of hemorrhage and should be prepared to return to surgery. Although the vital signs should be documented, this is not the nurse's first action Encouraging deep breathing is not the best action at this time. Naloxone is used to reverse the respiratory depression effects of opioid medications and is not appropriate based on this patient's condition

A patient instructed to provide a composite urine sample. Which Instruction would the nurse include in teaching the patient the correct way to obtain the sample? O "Collect urine for 24 hours O Collect the first urine sample in the morning O "Collect thietiuritie specimers at hourly intrrvaly after dacardıng the hrsturite O Save allorne samplesina containm for a designated period after discarding the first unine specimen.

O Save all allorne samples in a container for a designated period after discarding the first unine specimen. Rationale It is the responsibility of the nurse to explain the correct way to collect a composite urine sample The patient should be Instructed to united discard the first unne specimen. The time should be noted at the start ef the test The patient should then save all urine samples from subsequent urinations in a containes for a designated period At the end of the designated period, the patient should be asked to urinate and add that urine to the container. The patient should be reminded to save all urine during the study perica A urine sample collected over 24 hours s used to test creatinine clearance. The first morning sample of urine is most suitable for urinalysis because it contains the highest concentration of the chemical and cells that need to be tested, Three urine samples collected at hourly intervals are used to test renal concentrating ability es.

The nurse is performing a preoperative assessment on a patient before elective knee replacement surgery. The patient reports an allergy to latex. Which action should the nurse perform first? O Document the finding O Contact the surgeon. O Cancel the surgery. O Seek more information.

O Seek more information. Rationale The nurse should obtain more information regarding the allergy, including date of onset, details surrounding the event, and the type and extent of the reaction. The nurse should document the finding and contact the surgeon, but the nurse must first seek more information. It is not appropriate to cancel the surgery at this time.

Which position would the nurse place a patient in for a cleansing enema? O Sims O Prone O Supine O Lateral

O Sims Rationale Sims position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving retention of the enema solution. The prone position, lateral position, or supine position does not allow the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum.

Which effect does a bacterial infection with exudate and drainage have on a wound? O Quickens the healing process O Slows the healing process O Causes intense pain in the patient O Leads to hypovolemic shock

O Slows the healing process Rationale A bacterial infection of the skin causes fluid to drain from the wound. This slows the healing process. It will not quicken the healing process or cause intense pain in the patient. It will also not lead to hypovolemic shock as there is no internal hemorrhage.

Which wetting agent solution would the nurse use while dressing a patient's wounds when a deodorizing effect is required? O Acetic acid O Povidone-iodine O Lactated Ringer's O Sodium hypochlorite

O Sodium hypochlorite Rationale Sodium hypochlorite solution has a deodorizing effect and is used for cleaning wounds that have necrotic debris because it enhances the process of wound débridement. Acetic acid is effective in preventing infection caused by Pseudomonas aeruginosa, but it does not have a deodorizing effect. Povidone-iodine solution is an antimicrobial solution used for cleaning intact skin but is not used to clean necrotic debris because it may cause irritation. Ringer's solution aids in mechanical debridement but does not have a deodorizing effect.

Which induction method does the anesthesiologist use while administering regional anesthesia to a patient scheduled for lower abdominal surgery? O Nerve block O Spinal anesthesia O Conscious sedation O Epidural anesthesia

O Spinal anesthesia Rationale Spinal anesthesia is used for lower abdominal surgery because the anesthetic effects extend from the tip of the xiphoid process down to the feet. Nerve block is used for orthopedic surgery involving extremities because the anesthesia needs to block the nerve supply to the operative site. Conscious sedation is another form of anesthesia that is given to relieve anxiety or provide amnesia during surgical diagnostic procedures. Epidural anesthesia blocks sensation in the vaginal and perineal areas and, thus, is often used for obstetric procedures.

Which nursing intervention is best when caring for a patient with a possible dislocated shoulder? O Reduce the joint. O Elevate the joint. O Splint the joint O Apply hot packs.

O Splint the joint Rationale Dislocation usually happens after a fall or a blow. In case of shoulder dislocation, the joint should be splinted to prevent any movements of the joint. Movements of the dislocated joint can be painful and may worsen the dislocation. The dislocated joint should not be reduced because it can cause soft tissue injury. The joint should not be elevated because it can tear the fragile soft tissues. Cold packs rather than hot packs should be applied to reduce the edema.

The nurse obtains a swab culture from a cellulitis infection of an adult patient. The nurse anticipates the culture will grow which causative species of bacteria? O Klebsiella pneumoniae O Staphylococcus aureus O Haemophilus influenzae O Streptococcus pneumoniae

O Staphylococcus aureus Rationale In adults, Staphylococcus aureus is the most common cause of cellulitis. In children, Haemophilus influenzae is the most common. Klebsiella pneumoniae and Streptococcus pneumoniae are not the most common causes of cellulitis.

Which positioning of a patient during suctioning can lead to aspiration of secretions? O Supine O Fowler's O Side-lying O Semi-Fowler's

O Supine Rationale A patient who is supine during suctioning is at risk for aspiration. The nurse should place the patient in a position that facilitates removal of secretions and promotes lung expansion, that is, Fowler's or semi-Fowler's position. The side-lying position should be used if the patient is unresponsive

The nurse identifies the patient as experiencing complicated grief. Which patient goal and expected outcome are the most reasonable? O The patient will establish new and meaningful relationships and interests. O The patient will engage in a new lifestyle different from the pre-crisis level. O The patient will relate realistically to the disappointments of the lost relationships. O The patient will cooperate with recommended treatment within 2 days.

O The patient will establish new and meaningful relationships and interests Rationale The most reasonable patient goal is that the patient will establish new and meaningful relationships and interests. The patient will engage in a constructive, meaningful lifestyle, similar to the precrisis level of functioning The patient will relate realistically to both the pleasures and the disappointments of the lost relationships. Patients will participate in the decision-making and cooperate with the recommended treatment within 2 weeks, not 2 days

The nurse observes a loss of appetite in a patient being treated for addiction. Which prescription would most likely be prescribed by the health care provider? O Phenytoin O Propranolol O Thiamine O Chlordiazepoxide

O Thiamine Rationale The administration of thiamine helps improve the patient's nutritional state. Phenytoin is an anticonvulsant medication used to treat seizures in an addicted patient. Propranolol is useful in treating cardiorespiratory distress. Chlordiazepoxide is used to treat tremors and nervousness in an addicted patient.

A patient comes to the clinic complaining of incontinence. The patient states, "I never have enough time between when I first feel need to void and when I'm incontinent." The nurse documents this as which type of incontinence? O Urge O Stress Overflow O Functional

O Urge Rationale Urge incontinence occurs when the urge to void happens without much warning immediately before an episode of incontinence Stress incontinence occurs with an increase in intraabdominal pressure. Overflow incontinence occurs when the patient is unable to fully empty the bladder, causing it to leak unexpectedly. Functional incontinence occurs because the patient does not realize he or she needs to urinate or is unable to get to the bathroom in time.

What would the nurse evaluate after completing nasopharyngeal suctioning to determine effectiveness of the procedure? Select all that apply. O Vital signs O Oral cavity O Level of fatigue O Patency of nares O Level of consciousness

O Vital signs O Level of fatigue O Level of consciousness The patient's vital signs, breathing pattern, levels of fatigue and consciousness, and color should be assessed after suctioning to determine the effectiveness of the procedure. The nurse should provide mouth care after suctioning but does not need to assess the oral cavity. The patency of the nares should be determined before the procedure.

The nurse is caring for a patient with asthma who has undergone surgery. Upon assessing the patient's medical history, the nurse finds that the patient is already using a steroid inhaler for maintenance therapy of asthma. The nurse also finds that the health care provider has prescribed vitamin A supplements. For which reason did the health care provider most likely prescribe vitamin A supplements? O Asthma causes vitamin A deficiency O Vitamin A counteracts steroid activity. O Asthma impairs the patient's visual acuity. O Vitamin A eases discomfort when breathing

O Vitamin A counteracts steroid activity. Rationale Patients with asthma use steroids, which hinder the process of wound healing by reducing the inflammatory response. Therefore, to counteract the activity of steroids, vitamin A supplements are prescribed to patients when they undergo surgery. Asthma is not associated with impaired absorption of vitamin A and does not cause vitamin A deficiency. Vitamin A does not affect the function of the upper respiratory tract, so it does not ease discomfort when breathing. Asthma does not cause visual acuity because it does not hinder ocular function.

When should cardiopulmonary resuscitation (CPR) be discontinued? Select all that apply. O When the patient vomits O When licensed medical personnel arrive O When the rescuer cannot continue O When the patient's ribs are broken O When an automated external defibrillator (AED) is available

O When licensed medical personnel arrive O When the rescuer cannot continue O When an automated external defibrillator (AED) is available Rationale Once started, CPR should not be stopped unless the patient becomes responsive licensed medical personnel arrive on the scene, an AED is available, or the rescuer is unable to continue. Broken bones and vomiting may occur doing CPR.

Which instruction would be given to patient beginning colostomy irrigation? Select all that apply. O instill 500 to 1000 ml slowly over 15 minutes!! O "Allow the fluid to sit in the bowel for 15 to 20 minutes." O "Insert the entire length of the lubricated cone into the stoma." O instruct the patient to sit on the toilet or in front of the toilet." O "Fill the irrigation container with 1000 ml of cold water.

O instill 500 to 1000 ml slowly over 15 minutes O instruct the patient to sit on the toilet or in front of the toilet." O "Allow the fluid to sit in the bowel for 15 to 20 minutes." Rationale Colostomy irrigation should include instilling 500 to 1000 mL slowly over 15 minutes. The fluid should be kept in the bowel for 15 to 20 minutes for maximum effect. Colostomy irrigation should be performed with the patient in the sitting position-either on the toilet or in front of the toilet. The cone should only be inserted part of the way into the stoma. The fluid used to irrigate should be tepid

A patient who is admitted involuntarily to a psychiatric facility is angry and wants to leave to see his wife. Which nursing intervention would be appropriate? O Encouraging the patient to talk to other patients O Has maladaptive behavior O Offering as much flexibility in visiting hours as possible O Offering the patient as-needed (PRN) lorazepam (Ativan) O Refusing to let him see family because his admission is involuntary)

Offering as much flexibility in visiting hours as possible Rationale The nurse should offer as much flexibility in visiting hours as possible to reduce the frustration of separation in the individual and the family. Encouraging the patient to talk to peers does not address the source of his frustration. Refusing to let him see family is incorrect; involuntarily admitted patients still have the right to visitors. Offering the patient PRN lorazepam (Ativan) at this time does not address the source of his anger.

A patient is being evaluated in the emergency room for a possible drug overdose. The nurse notes that the patient is stuporous, has pinpoint pupils, and has severe respiratory depression. The health care provider orders a urine toxicology screen, stat. Which substance does the nurse anticipate receiving a positive result for in the urine screen?

Opiates

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information?

Palms of the hands

Enzymes from the Pancreas

Pancreatic juice flowing into the small intestine contains one enzyme for triglycerides and another for cholesterol. First, pancreatic lipase breaks off one fatty acid at a time from the glycerol base of triglycerides. One free fatty acid plus a diglyceride and then another fatty acid plus a monoglyceride are produced in turn (Figure 3-9). Each succeeding step of this breakdown occurs with increasing difficulty. In fact, the separation of the final fatty acid from the remaining monoglyceride is such a slow process that less than one third of the total fat present reaches complete breakdown. The final products of fat digestion to be absorbed are fatty acids, monoglycerides, and glycerol. Some small amounts of remaining fat may pass into the large intestine for fecal elimination. The enzyme cholesterol esterase acts on cholesterol esters (not free cholesterol) to form a combination of free cholesterol and fatty acids in preparation for absorption into the lacteals (lymph vessels) and finally into the bloodstream (see Chapter 5).

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area? O Intact skin O The presence of tunneling O A deep, crater-like appearance O Partial-thickness skin loss of the epidermis

Partial-thickness skin loss of the epidermis

Extravasation

Passage or escape into the tissues; usually of blood, serum, or lymph

A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury?

Pat the skin dry after bathing.

Four Types of Grafts

Patient Teaching • Do not remove dressing unless ordered • Report changes in the graft to physician • Protect grafted skin from direct sunlight with a sunscreen lotion for at least 6 months • Keep surface of healed graft moistened daily 6-12 months • Wear a long elastic stocking for 4-6 months for grafts on lower extremities

Carlos Reyes' is 65 years old. What diagnostic examinations are recommended to be performed annually? Select all that apply. Eye examination Physical examination Prostate examination Stool for occult blood examination Hearing examination

Physical examination Prostate examination Stool for occult blood examination

A nurse is assisting a patient with dementia. In addition to reality orientation, which intervention would be important to implement in caring for patients with dementia?

Place bed in lowest position.

Plant Fats

Plant foods supply mostly monounsaturated and poly unsaturated fats, including the essential fatty acids. Food sources for unsaturated fats include vegetable oils (e.g., safflower, corn, cottonseed, soybean, peanut, olive; see Figure 3-4). However, as indicated previ ously, coconut and palm oils are exceptions; these plants provide saturated fats and are widely used in commercially processed food items.

The use of toys to assist a child to express feelings is known as which type of treatment?

Play therapy

Which characteristics are associated with a patient with mental illness? Select all that apply.

Poor self-concept Maladaptive behavior Avoidance of problems

A new clinic nurse is interviewing a male patient. The patient's chief complaint is constipation. What suggestion should the nurse give to the patient to prevent constipation?

Practice regular toilet habits

Which feature is common among depressive and bipolar disorders? O The extent of irritable mood O Timing of irritable mood O Presence of irritable mood O Assumed etiology irritable mood

Presence of irritable mood Rationale The presence ofan irritable mood is one of the features in both depressive and bipolar disorders. Duration, timing, and assumed etiology of the iritable mood differ between these disorders.

Which function does naloxone serve in Suboxone sublingual film? O Reduces respiratory depression O Minimizes withdrawal symptoms O Decreases tremors and agitation O Prevents abuse of buprenorphine

Prevents abuse of buprenorphine Rationale Suboxone is a combination of naloxone and buprenorphine that is used to treat opioid toxicity. The naloxone in the Suboxone product is used to prevent abuse of the buprenorphine as a narcotic antagonist. Buprenorphine has a ceiling effect on analgesia and respiratory depression in a patient with opioid abuse. Naloxone may not be helpful in minimizing withdrawal symptoms, Clonidine is used to decrease tremors and agitation in patients with oploid toxicity.

Protein Sparing Action of Carbohydrates

Protein Sparing •Maintain a lean body mass •Needed for repair and building tissue Ex: Severe form of malnutrition

After assessing an infant, the nurse finds that the infant is at a high risk of developing the bottle-mouth syndrome. What feeding activity would be advisable to ensure the infant's safety? O Adding a bit of sugar to the formula O Providing only water in the bottle during a bedtime feeding O Avoiding breast-feeding the infant late at night or early in the morning O Providing only natural juices when feeding the infant from a bottle

Providing only water in the bottle during a bedtime feeding

The nurse asks the family members of a terminally ill patient with a reduced appetite to bring home-cooked food. Which benefits result from this nursing intervention? Select all that apply. Faster patient recovery Enhancing the patient's comfort level Providing the patient's preferred food Extra nutrients in home-cooked foods Allowing the family to participate in the patient care

Providing the patient's preferred food Allowing the family to participate in the patient care Rationale Home-cooked food items can provide the patient's preferred food. Providing home-cooked food also helps family members participate in the patient's care, enhancing the patient's comfort level. Home-cooked foods do not necessarily have extra nutrients, nor do such foods help the patient recover faster.

A patient is diagnosed with obsessive-compulsive disorder. Which treatment possibilities does the nurse expect for the patient? Select all that apply. O Psychotherapy O Desensitization O Reality therapy O Electroconvulsive therapy O Drug therapy with clomipramine

Psychotherapy Drug therapy with clomipramine Rationale Obsessive-compulsive disorder is characterized by the inability to stop persistent, irrational, and uncontrollable acts compulsions) or thoughts (obsessions) contrary to the person's standards or judgment. The treatment possibilities for the obsessive-compulsive disorder include psychotherapy to uncover basic fears and to help the person distinguish between objective (actual) and imaginative dangers. The treatment also includes drug therapy with clomipramine, a tricyclic antidepressant. Desensitization is preferable in disorders such as phobias because this allows the patients to remain calm and relaxed. Reality therapy is not advisable in obsessive-compulsive disorder because patients with this disorder don't show disorientation from reality. Electroconvulsive therapy is effective in affective mood disorders.

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which?

Punch biopsy of the cutaneous lesions

Main intervention for hypovalemia

Push iv fluids

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The parents of a child are worried because the child tattles on others to justify his or her mistakes. Which defense mechanism should the nurse document in the child's medical record?

Rationalization

The parents of a child are worried because the child tattles on others to justify his or her mistakes. Which defense mechanism should the nurse document in the child's medical record? O Regression O Introjection O Identification O Rationalization

Rationalization Rationale Rationalization is a process of constructing plausible reasons to explain and justify one's behavior. People who use rationalization as a defense mechanism deny their actual thoughts and justify their actions by giving untrue, but seemingly more acceptable, reasons for their behavior. Regression is exhibition of behavior, thoughts, or feelings that characterize the earlier stages of a person's development. A quality or attribute of another person is internalized in people with introjection behavior. Identification is the defense mechanism where the person incorporates a characteristic thought or behavior of another person or group in his own

A patient with schizophrenia is admitted to the hospital. Which objectives does the nurse consider in planning the interventions to help the patient? Select all that apply. O Improving gait O Reducing anxiety O Improving social interactions O Improving orientation to reality O Avoiding interactions during delusions

Reducing anxiety Improving social interactions Improving orientation to reality Rationale Schizophrenia is characterized by inappropriate emotional responses, bizarre behaviors, impaired communications illusions, hallucinations, and inability to relate to other people. The objectives that a nurse would consider in planning the interventions would be to reduce anxiety by supporting the patient's feelings, improving the patient's social interactions, and improving the patient's orientation to reality by reinforcing the daily routine. Shuffling gait (abnormal limb movements) is not generally seen in schizophrenic individuals. The nurse should talk with the patient who has schizophrenia when the patient is delusional.

A patient with schizophrenia is admitted to the hospital. Which objectives does the nurse consider in planning the interventions to help the patient? Select all that apply.

Reducing anxiety Improving social interactions Improving orientation to reality

Which effective technique is used to help older adults cope with changing life circumstances? O Meditation O Reminiscing O Vigorous exercise O Listening to music

Reminiscing

A patient is taking lithium carbonate to stabilize his mood and behaviors. The nurse knows that the patient is at risk for toxicity, which is commonly encountered with lithium. Which action would increase the risk of toxicity? O Continually monitoring lithium levels O Restricting fluid intake and sodium in the diet O Reporting of nausea and vomiting by the patient O Educating regarding the taking of the medication

Restricting fluid intake and sodium in the diet Rationale Poor fluid intake and salt restrictions increase the risk of toxicity. Continually monitoring lithium levels decreases the risk of lithium toxicity. Reporting any nausea or vomiting by the patient decreases the risk of lithium toxicity. Educating the patient about taking the medication decreases the risk of lithium toxicity.

Which signs and symptoms are associated with morphine (MS Contin) withdrawal? Select all that apply. O Seizures O Rhinorrhea. O Piloerection O Hallucination O Pupillary dilation

Rhinorrhea. Piloerection Pupillary dilation Rationale The signs and symptoms associated with withdrawal of opioids such as morphine (MS Contin) and hydromor phone (Dilaudid) are rhinorrhea, piloerection, and pupillary dilation. Seizures and hallucinations are withdrawal symptoms of alcohol

Which signs and symptoms are associated with morphine (MS Contin) withdrawal? Select all that apply. O Seizures O Rhinorrhea. O Piloerection O Hallucination O Pupillary dilation

Rhinorrhea. Piloerection Pupillary dilation Rationale The signs and symptoms associated with withdrawal of opioids such as morphine (MS Contin) and hydromor phone (Dilaudid) are rhinorrhea, piloerection, and pupillary dilation. Seizures and hallucinations are withdrawal symptoms of alcohol

Ms. Burke is transferred to a stretcher and taken to the operating room (OR). The PN assists Ms. Burke off the stretcher and onto the OR table. After general anesthesia is induced, the PN helps position Ms. Burke for surgery. Which nursing diagnosis has the highest priority at this time? O Ineffective protection. O Ineffective tissue perfusion. O Risk for perioperative positioning injury. O Risk for imbalanced body temperature.

Risk for perioperative positioning injury.

A patient diagnosed with depression is prescribed fluoxetine. On assessment the nurse finds that the patient has a history of Parkinson's disease as well. Which risks are increased in the patient due to drug interactions?

Serotonin syndrome- occurs when you take medications that cause high levels of the chemical serotonin to accumulate in your body.

Anurse is attempting to prioritize nursing problems on the care plan of a terminllyill patient whose condition is consistently changing. Which nursing action would best meet the needs of this patient? Ask the family which problems are most important. Make all nursing problems a priority for the patient. Have the patient identify and prioritize problems. Shift the priorities according to the patient's condition.

Shift the priorities according to the patient's condition.

Which common behaviors are seen with illness? Select all that apply. O Shock O Anxiety O Acceptance O Forgiveness O Withdrawal O Questioning

Shock Rationale Denial, anxiety, shock, anger, and withdrawal are all common behaviors seen in those with illness. Questioning is often seen during an acceptance phase. Acceptance is usually seen after the patient has come to terms with the reality of the illness. Forgiveness may be seen during an acceptance phase.

Pain

Sign/Symptoms •Restlessness •Verbalization •Agitation •Moaning •Crying

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?

Silvery-white scaly lesions

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? O Oily skin O Silvery-white scaly lesions O Patchy hair loss and round, red macules with scales O The presence of wheal patches scattered about the trunk

Silvery-white scaly lesions

Which condition will be seen in a patient who abuses cocaine by snorting? O Sinusitis O Paranoia O Hemoptysis O Pneumonitis

Sinusitis Rationale The process of snorting cocaine erodes the nasal septum and causes sinusitis. Paranoia is seen in a patient addicted to methylphenidate (Ritalin) for a long time. The caustic chemicals used in cocaine can cause hemoptysis and pneumonitis in patients who smoke cocaine.

Which data collection related to monitoring is necessary before applying an external condom catheter on a patient? O Skin damage O Blood infection O Prostate trauma O Abdominal distension O Injury to pelvic veins

Skin damage Blood infection Rationale A condom catheter contains an adhesive that could damage the skin and increase the risk of blood infection (sepsis) in elderly patients. The nurse should monitor for both skin damage and blood infection. Prostate trauma is seen with use of internal catheters, not with external condom catheters. Abdominal distension is not a problem with the use of urinary catheters. Catheter condoms are helpful in preventing the effects of prostatic obstruction; they do not cause prostate trauma, Condom catheters do not affect the integrity of the pelvic veins.

The nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect which amount of discomfort during the procedure?

Slight because the local anesthetic may burn or sting

Which vital signs, when assessed in a dying patient, are indicative that the end of life is imminent? O Fast, bounding pulse; lowered blood pressure; abnormally slow respirations O Fast, bounding pulse; increased blood pressure; rapid, shallow, irregular respirations O Slow, weak, and thready pulse; lowered blood pressure; rapid, shallow, irregular respirations O Slow, weak, and thready pulse; increased blood pressure; rapid, shallow, irregular respirations

Slow, weak, and thready pulse; lowered blood pressure; rapid, shallow, irregular respirations Rationale In a dying patient, as the time of death becomes imminent, he or she will show signs of decreased oxygenation, manifested in a slow, weak, thready pulse; decreased blood pressure; and rapid, shallow, irregular respirations. A fast, bounding pulse, abnormally slow respirations, or increased blood pressure are not considered signs of imminent death.

An acutely ill client with a diagnosis of schizophrenia has just been admitted to the mental health unit which initial nursing intervention is the most therapeutic O Ego integrity Spend time with a client to build trust and demonstrate acceptance O Ego integrity Involve the client in occupational therapy and using diversional activity O Ego integrity Delay one on one client interactions until meditation has eased the psychotic symptoms O Ego integrity Involve the client in multiple small group discussions to distract attention from the fantasy world

Spend time with a client to build trust and demonstrate acceptance

Ulcer stage 4

Stage 4 ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone. There is a high risk of infection at this stage.

The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category?

Stage II

cleansing enema

Stimulates Peristalsis through the infusion of large volumes of fluid to distend the bowel. helps empty colon completely (used before gi diagnostic procedures)

SUGARS

Sugar per se is not necessarily a villain. After all, the form of carbohydrate that is found in fruit is a disac charide (a simple sugar). The difference between this type of sugar and the sugar in candy is that fruit also provides fiber, water, and vitamins. The problem with excess added sugar in the diet (e.g., sweets, desserts, candy, soda) is the large quantities of "empty calories" that many people consume, often to the exclusion of other important foods.

A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and nighttime What is the term applied to this type of delirium? O Disordered thinking O Schizophrenia O Dementia O Sundowning syndrome

Sundowning syndrome

Alginate (Medihoney)

Supports removal of necrotic tissue and aids in wound healing. For wounds with moderate to heavy amounts of exudate or when light packing is needed.

Which alteration could be occurring in a patient with dysthymia who reports frequent early morning awakening? O Terminal insomnia O Substance abuse O Manic depression O An emotional symptom of depression

Terminal insomnia Rationale Terminal insomnia is a type of sleep disturbance often seen in patients with depression in which a patient frequently wakes early in the morning. Substance abuse is a risk factor for depression; however, it does not cause terminal insomnia. Manic depression is seen in patients suffering from bipolar disorder; however, a patient with dysthymia does not exhibit manic depression. Frequent early morning awakening is a physical symptom of depression, not an emotional symptom.

A nurse is preparing a male patient with urinary incontinence for bed. Which type catheter is the best option to prevent skin breakdown in this patient? O Foley catheter O Texas catheter O Straight catheter O Mushroom catheter

Texas catheter Rationale The Texas, or candom, catheteris noninvasive option for the male patient with urinary incontinence for prevention of skin breakdown caused by moisture. Foley straight, and mushroom catheters are all invasive catheters and inappropriate for this use

amino acids

The building block for proteins containing carbon, hydrogen, oxygen, and nitrogen

The nurse is observing a toddler's psychosocial development based on Erikson's theory. What should be assessed in the child to find if the child has achieved age-appropriate development? O Feels inferior to his or her peers O feels guilty for not performing well O The child can say a four-word sentence. O Acts like an adult

The child can say a four-word sentence.

While reviewing the medical record of a patient, the nurse finds that the patient's height has decreased compared to the previous year's report. If this reading is accurate, which age group would the patient most likely belong to? O School-age children O The elderly O Adolescent children O The middle-aged

The elderly

The nurse is caring for a patient diagnosed with depression. The patient weighs less than normal because of poor nutrition. Which patient outcome would the nurse evaluate in the patient after providing effective nursing interventions to improve nutrition?

The patient eats 50% to 60% of each meal.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

Lactose.

The sugar in milk, which is formed in mammary glands, is lactose. Its two single-sugar units are glucose and galactose. Lactose is the only common sugar that is not found in plants. It is less soluble and less sweet than sucrose. Lactose remains in the intes tine longer than other sugars, and it encourages the growth of certain useful bacteria. Cow's milk contains 4.8% lactose, and human milk contains 7% lactose. Because lactose promotes the absorption of calcium and phosphorus, the presence of all three nutrients in milk is advantageous for absorption.

Which occurrence may precipitate feelings of anxiety?

Threats to self-esteem

A patient reports to the nurse that urination is painful. Which clinical findings does the nurse expect to see in the patient's report? O Kidney failure O Diabetes insipidus O Trauma to urethra O Decreased muscle tone

Trauma to urethra Rationale Painful urination is called dysuria and is caused by an infection or trauma to the urethra and the bladder. Kidney failure causes oliguria, in which the urine output decreases. Diabetes insipidus is a decrease in the production of antidiuretic hormone; it causes polyuria, or excessive urination. Decreased muscle tone causes incontinence

Acne Vulgaris

Tretinoin (Retin-A) •Derivative of Vitamin A •Blistering, peeling, crusting, burning & swelling •Apply sunscreens or protective clothing

squamous cell carcinoma

Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules.

A patient is admitted to the substance abuse treatment facility with a diagnosis of heroin addiction and is expected to go into withdrawal within 6 hours. For which signs and symptoms will the nurse monitor the patient? O Bradycardia, hypotension, and hypothermia O Vomiting, cramps, diarrhea, and hypertension O Pinpoint pupils, hypotension, fever, and vomiting O Tachycardia, hypoglycemia, and severe constipation

Vomiting, cramps, diarrhea, and hypertension Rationale Opiate withdrawal signs and symptoms in people addicted to heroin typically begin about 6 hours after the last dose and include vomiting, cramps, diarrhea, hypertension, flulike signs and symptoms, dilated pupils, watery eyes, runny nose, chills, fever, and diaphoresis. Pinpoint pupils are associated with acute opioid overdose. Hypotension, bradycardia, hypothermia, severe constipation, and hypoglycemia are not symptoms of acute opiate withdrawal.

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

Saturated Fatty Acid

When a substance is described as saturated, it contains all of the material that it is capable of holding (Figure 3-2, A). For example, a sponge is saturated with water when it holds all of the water that it can contain, Similarly, fatty acids are saturated or unsaturated according to whether each carbon is filled with hydrogen. Thus, a saturated fatty acid is heavy and dense (i.e., solid at room temperature). If most of the fatty acids in a triglyceride are saturated, that fat is said to be a saturated fat. Most saturated fats are of animal origin. Figure 3-3 shows a variety of foods with saturated fat, including meat, dairy, and eggs.

A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient, knowing that tremors from alcohol cessation are usually seen how long after cessation?

Within 6 hours

A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient, knowing that tremors from alcohol cessation are usually seen how long after cessation? O Within 6 days O Within 1 week O Within 6 hours O Within 2 to 3 weeks

Within 6 hours Rationale Tremors from alcohol cessation are seen 6 to 48 hours after the last drink and may last for 3 to 5 days.

Opioids Withdrawal Symptoms

Yawning Insomnia Irritability Rhinorrhea Diaphoresis Cramps N/V Muscles aches Fever "Cold Turkey" Diarrhea I

delirium tremens

a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol

addictive personality

a person who exhibits a pattern of compulsive and habitual use of a substance or practice to cope with psychic pain from conflict and anxiety.

health

a state of optimal physical, mental, and social well-being; relative freedom from disease or disability.

clinical criteria for brain death

absence of reflex activity, movements, and respiration. The pupils are dilated and fixed.

The traditional health care

approach only attempts change when symptoms of illness or disease already exist, at which point those who are ill seek a physician to diagnose, treat, and "cure" the condition (see the Drug-Nutrient Interaction box, "Introduction to Drug-Nutrient Interactions").

A 14-year-old survivor of a school shooting screams and dives under a table when firecrackers go off. What does this behavior represent? a. Phobia b. Post-traumatic stress disorder c. Obsessive-compulsive disorder d. Disordered thinking

b. PTSD

1. A developmental task of adolescence includes: a. concrete thinking. b. stabilizing identity. c. accepting competition. d. social interaction.

b. stabilizing identity.

Unstageable

covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) •None, Adherent film, gauze, enzymes,

pediculosis

infestation with lice

lysis

loosening, destruction

High-fructose corn syrups

manufactured by changing the glucose in cornstarch into fructose, are heavily used in processed food products, canned and frozen fruits, and soft drinks. These syrups are inex pensive sweeteners, and contribute to increased sugar intake in the United States. The per-capita consump tion of high-fructose corn syrup increased from zero in 1967 to a height of 19.7 teaspoons (tsp) per day in 1999 and was most recently estimated to be down to 14.4 tsp per day. While the change in high-fructose corn syrup intake has fluctuated significantly over the past 50 years, the overall intake of all caloric sweeteners has remained high. Figure 2-1 demonstrates the total added sugar in the American diet and that which comes from high-fructose corn syrup. Note that high fructose corn syrup is only one of the sweeteners regu larly used in the typical American diet.

The healthcare provider has discontinued clozapine for a client recovering from a psychotic episode which I'll come with the nurse expect to be included in the nursing plan of care? O obtain a stat blood pressure check O fasting plasma glucose levels annually O Monitor weight every three months O monitor white blood cells count weekly for at least four weeks

monitor white blood cells count weekly for at least four weeks

complete proteins

proteins that contain all nine of the essential amino acids found in animal origin and tofu

A profound disabling mental illness is characterized by bizarre non-reality thinking what is the illness O Manic disorder O schizophrenia O paranoia O bipolar

schizophrenia

Total Energy Expenditure

the sum of the energy used for basal metabolism, activity, processing food, deposition of new tissue, and production of milk •To maintain daily energy balance: •Food energy intake = body energy output •Intake > output = Weight gain (extreme: obesity) •Intake < output = Weight loss (extreme: anorexia)

homograft (allograft)

tissue for grafting that is taken from donor of the same species (generally from a cadaver in humans)

Burns

• 400,000 people each year seek medical attention for burns • 40,000 are hospitalized for burns each year • 3,400 die from burns each year • Thermal burns are the most common type of burn injury • Skin destruction depends on the burning agent, the temperature, condition of the skin & duration of contact. • Burns cause dramatic changes beginning in the first few minutes to the first 12 to 24 hours after • Depends on 2 factors: the extent of the body surface burned & the depth • Traditionally burns have been classified as first-, second-, and third-degree • Is measured in terms of the total body surface area (TBSA) • May also be classified as • Superficial-thickness injuries • Partial-thickness injuries • Full-thickness injuries All items

Minerals

• Are components of hormones, cells, tissues & bones • Acts as a catalyst for chemical reaction & enhancers of cell functions

Rehabilitation phase Patient Teaching

• Wound care • Signs/symptoms of complications • Dressings • Exercises • Clothing • ADLs • Social skills • Do not use lotion containing lanolin - will cause clusters • Avoid direct sunlight • Test water before getting into the shower • Bathe twice a day w/ mild soap • Discoloration and scarring are normal during healing

Psoriasis Medical Management

•Aimed at slowing the proliferation of epithelial layers of the skin •Topical steroids (hydrocortisone, bethamethasone) & keratolyticagents (decrease shedding)- monitor blood sugar •Photochemotherapy •Methotrexate and Vitamin D reduce proliferation

Symptoms that May indicate Illness or Infection

•Anorexia •Apathy •Change in functional status •Confusion •Dyspnea •Falling •Fatigue •Incontinence •Self-neglect •Shortness of breath •Tachypnea •Change in vital signs

inflammatory Eczema

•Chronic inflammatory disorder of the integument •Associated with allergies to food or clothing

Immune

•Tendency for lymphocyte counts to be low w/ altered immunoglobulin production •< resistance to infection & disease

Bleeding is almost always possible to control by the three-step measure

direct pressure, elevation, and indirect pressure

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

Compensation

(C) Excelling in one area to make up for deficits in another area

Stress urinary incontinence

(C) Involuntary loss of a small amount of urine with increased abdominal pressure

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning? 1 "Nicotine gum will help decrease nicotine dependence." 2 "CNS stimulants are helpful in treating nicotine addiction." 3 "The nicotine transdermal patch is the least beneficial option." 4"Only 10% of people who quit smoking will experience relapse."

1 "Nicotine gum will help decrease nicotine dependence."

A patient who smokes heavily decides to suddenly quit smoking and refrains for a couple of days. Which withdrawal symptoms are likely to be seen in the patient? Select all that apply. 1 Irritability 2 Pneumonitis 3 Disturbed sleep 4 Severe depression 5 Increased appetite

1 Irritability 3 Disturbed sleep 5 Increased appetite

The nurse is providing care for a patient who was recently admitted to the hospital for the treatment of marijuana addiction. Which conditions does the nurse expect to see in the patient? Select all that apply. 1 Stuffy nose 2 Panic reactions 3 General myalgia 4 Suicidal thoughts 5 Distorted perception

1 Stuffy nose 2 Panic reactions 4 Suicidal thoughts 5 Distorted perception

The nurse is assessing a child's speaking abilities and understands the telegraphic speech of the child. What could be the age of the child that the nurse is assessing? O 5 years old O 1-year-old O 3 years old O 7 years old

1-year-old

Figure-of-8

1. Anchor bandage at center of joint (see Steps 1 through 3, Circular). 2. Ascend obliquely around upper half of circular turn above joint followed by turn that descends obliquely below joint. 3. Continue in same manner, overlapping half of previous turn until desired immobilization is attained. 4. Be certain to cover the joint with bandage to prevent fluid shift to those tissues and subsequent impaired circulation. 5. Secure end of bandage. Used to cover joints and provide immobilization. Outer surface of fabric is against skin during ascending application of bandage. Each reverse turn places alternate side of bandage toward skin.

Reducing Sudden Infant Death Syndrome

1. Back to sleep, 2. Avoid exposure to cigarette smoke 3. Avoid the use of soft bedding or pillows 4. Keep the room well ventilated 5.Breast-feed if possible 6. Maintain regular medical checkups for infants

The six essential nutrients in human nutrition are the following:

1. Carbohydrates 2. Proteins 3. Fats 4. Vitamins 5. Minerals 6. Water

Wound Treatment

1. Closure - sutures, staples, surgical adhesive and steristrips 2. Drains and Drainage - at first drainage looks like blood (sanguineous), then it looks pink (serosanguineous) and finally, as the wound heals the drainage becomes clearer to slightly yellow fluid (serous) 3. Measurement of Wounds and Observation of Drainage - size, type, closure, size, condition of wound bed, condition of the skin surrounding the wound, pain, drainage. 4. Cleaning wounds 5. Dressings 6. Documenting wound care Give analgesics 30 minutes prior

8. The nurse is reviewing the arterial partial pressure of oxygen (PaO2) level on the patient's arterial blood gas report. Which level is most concerning to the nurse? 1. PaO2 75 mm Hg 2. PaO2 80 mm Hg 3. PaO2 85 mm Hg 4. PaO2 90 mm Hg

1. PaO2 75 mm Hg

1. The LPN/LVN is suctioning a patient through an endotracheal tube. What indicates proper technique? (Select all that apply.) 1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning 3. Using a clean catheter with each suctioning attempt 4. Withdrawing the catheter with the thumb continually covering the suction control vent 5. Suctioning the tube for at least 30 seconds with each suctioning attempt

1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning

The DRIS encompass the following four interconnected categories of nutrient recommendations:

1. RDA. This is the daily intake of a nutrient that meets the needs of almost all (i.e., 97.5%) healthy individu als of a specific age and gender. Individuals should use the RDA as a guide to achieve optimal nutrient intake. RDAs are established only when enough sci entific evidence exists about a specific nutrient. 2. Estimated Average Requirement. This is the intake level that meets the needs of half of the individuals in a specific group. This quantity is used as the basis for the development of the RDA. 3. Adequate Intake. The Adequate Intake is used as a guide when insufficient scientific evidence is avail able to establish the RDA. Both the RDA and the Adequate Intake may be used as goals for individ ual intake. 4. Tolerable Upper Intake Level. This indicator is not a recommended intake. Rather, it sets the maximal intake that is unlikely to pose adverse health risks in almost all healthy individuals. For most nutri ents, the Tolerable Upper Intake Level refers to the daily intake from food, fortified food, and nutrient supplements combined.

18. When providing care to a patient with a Hemovac drain, what actions are included in the plan of care? 1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations. 2. Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times. 3. Empty the bulb drainage receptacle when it is one-fourth full. 4. Pin the bulb above the insertion site to assist in proper drainage of exudate.

1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations.

Definition of Vitamins

1. be a vital, organic substance that is not a carbohydrate, fat, or protein and 2. be necessary to perform a specific metabolic function or to prevent a deficiency disease 3. It cannot be manufactured by the body in sufficient quantities to sustain life, so it must be supplied by diet.

Kubler-Ross Stages of Dying

1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance

Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. Chest and Stomach

19%

The clinical tests of a patient indicate elevated levels of liver enzymes, hypoglycemia, and abnormal blood protein levels. The patient does not have any chronic diseases. For which condition does the nurse assess? 1 Pneumonitis 2 Alcohol addiction 3 Delirium tremens 4 Altered perception

2 Alcohol addiction

Which drugs are classified as central nervous system (CNS) depressants? Select all that apply. 1 Caffeine 2 Barbiturates 3 Amphetamines 4 Benzodiazepines 5 Opioid analgesics

2 Barbiturates 4 Benzodiazepines 5 Opioid analgesics

A licensed practical/vocational nurse (LPN/LVN) is facilitating a group therapy session for patients with substance misuse and abuse problems. The nurse actively works to direct group communication, aware that the positive effect of group therapy is realized through which therapeutic effects? Select all that apply. 1 Helping the patient identify persons who may have caused addictive behaviors 2 Enabling and encouraging family members to participate in the patient's therapy 3 Helping the patient acknowledge the consequences of his or her addictive behaviors 4 Providing a formal mechanism for addicted patients to meet other addicted patients 5 Allowing the patient an opportunity to share interesting stories about intoxicated adventures 6 Confronting the patient's use of negative defense mechanisms such as denial or displacement

2 Enabling and encouraging family members to participate in the patient's therapy 3 Helping the patient acknowledge the consequences of his or her addictive behaviors 6 Confronting the patient's use of negative defense mechanisms such as denial or displacement

A student nurse confides in a classmate that she is concerned about her own risks for addiction because both her mother and father misused and abused certain substances, especially marijuana. She understands that she may be more likely to use drugs because her parents did. Which lifestyle changes will the classmate encourage her to continue to develop to make her more resistant to addiction? Select all that apply. 1 Eat a healthy diet and drink plenty of water. 2 Maintain a positive self-image and a positive attitude. 3 Earn enough money to always stay above the poverty level. 4 Learn effective and healthy stress management techniques. 5 Use a different substance than her parents, such as alcohol, to reduce risk. 6 If at all possible, choose to live in a rural area as opposed to an urban area.

2 Maintain a positive self-image and a positive attitude. 4 Learn effective and healthy stress management techniques.

A patient diagnosed with depression has been prescribed a tricyclic antidepressant. The nurse educates the patient to expect improvement in the depression within which period of time?

2 to 4 weeks

12. A patient comes to a sports medicine clinic after twisting his ankle while playing soccer. The health care provider determines he has a sprain. What discharge instructions will the nurse include in discharge summary for the patient? (Select all that apply.) 1. "Apply ice to the sprained area for 1 hour, then off for 1 hour." 2. "Wrap your ankle with an ACE bandage each morning." 3. "Elevate your leg as much as possible to prevent further swelling." 4. "Exercise your ankle as soon as you get home to prevent stiffness." 5. "You will use warm compresses to increase blood flow to the area after removing the ice."

2. "Wrap your ankle with an ACE bandage each morning." 3. "Elevate your leg as much as possible to prevent further swelling." 5. "You will use warm compresses to increase blood flow to the area after removing the ice."

1. A patient is developing shock. Which action should the nurse take? 1. Elevate the victim's head. 2. Elevate the victim's legs and feet. 3. Elevate the victim's upper body. 4. Leave the victim in a flat position.

2. Elevate the victim's legs and feet.

2. The nurse finds a client in a burning car. The client is breathing with fractured arm and lacerations that are bleeding profusely. What action should the nurse take first? 1. Splint the fractured arm. 2. Get the client out of the car. 3. Give mouth-to-mouth resuscitation. 4. Stop the bleeding.

2. Get the client out of the car.

8. The nurse is in the park and witnesses a child getting stung by a wasp. What action should the nurse implement first? 1. Cleanse the site with soap and water. 2. Remove the stinger with a scraping motion. 3. Apply ice to the stung area. 4. Determine whether the child has an allergy to wasps.

2. Remove the stinger with a scraping motion.

The nurse is caring for a patient injured in a car crash. The patient is manifesting signs of major alcohol withdrawal syndrome. Which symptoms will be seen in the patient? Select all that apply. 1 Sweating 2 Nausea 3 Visual hallucinations 4 Gross tremors 5 Seizures

3 Visual hallucinations 4 Gross tremors 5 Seizures

13. The patient suffered a fracture of the tibia after crashing his motorcycle. He tells the nurse that his health care provider told him he shattered his tibia in three places and will need surgery. The nurse is aware that the patient has which type of fracture? 1. Greenstick fracture 2. Spiral fracture 3. Comminuted fracture 4. Compound fracture

3. Comminuted fracture

16. The student nurse is correct when indicating which drain as providing suction-assisted drainage? 1. Jackson-Pratt 2. Hemovac 3. Penrose 4. Wound VAC system 5. T-tube system

3. Penrose

4. The nurse comes across a one-car automobile accident. The driver of the car is walking around with a dazed look on his face. He states that he was wearing his seatbelt but is unsure of what happened exactly. He has no visible injury. In checking his vital signs, the nurse finds his blood pressure is 84/56 mm Hg, his pulse is 110 beats per minute, and his respirations are 32 per minute. Another bystander says that an ambulance is on the way. What is the nurse's initial action? 1. Complete a neurologic assessment. 2. Instruct him to get back in the car and rest. 3. Position him on his back on the ground with legs and feet elevated. 4. Assess for any wounds that may be contributing to his memory loss.

3. Position him on his back on the ground with legs and feet elevated.

7. What is the first step when packing a wound? 1. Assess its size, shape, and depth. 2. Prepare a sterile field. 3. Select gauze packing material. 4. Irrigate the wound.

3. Select gauze packing material.

A patient has been admitted to the medical-surgical unit with a concussion and a fractured clavicle after a motor vehicle accident. When viewing the electronic medical record, the nurse notes that the patient had positive results for blood and urine alcohol, despite the patient reports of not having any problems with drugs or alcohol. Which explanation is the rationale for the patient's statements? 1 The patient is trying to avoid a ticket. 2 The patient is lying to avoid embarrassment. 3 A concussion can distort, alter, or eliminate parts of memory. 4 Denial is the predominant defense mechanism of substance abusers.

4 Denial is the predominant defense mechanism of substance abusers.

A nurse has been assigned a patient who abuses alcohol. The patient is at risk for delirium tremens (DTs). In monitoring the patient, which signs would alert the nurse to the development of DTs? 1 Stupor, severe agitation, muscle rigidity 2 Hypotension, ataxia, persistent vomiting 3 Hypotension, coarse hand tremors, agitation 4 Elevated temperature, hallucinations, and agitation

4 Elevated temperature, hallucinations, and agitation

7. The nurse comes upon a victim who is unconscious. Place in order the interventions that the nurse should take. 1. Administer 30 chest compressions. 2. Give 2 mouth-to-mouth breaths. 3. Check the carotid pulse. 4. Activate the EMS. 5. Open the airway.

4. Activate the EMS. 3. Check the carotid pulse. 1. Administer 30 chest compressions. 5. Open the airway. 2. Give 2 mouth-to-mouth breaths.

17. The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse? 1. Continue removing the sutures and apply the Steri-Strips. 2. Stop the suture removal and contact the health care provider immediately. 3. Continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing. 4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.

4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.

6. Which statement is correct in regard to the use of an abdominal binder? 1. It replaces the need for underlying dressings. 2. It should be kept loose for patient comfort. 3. The patient has to be sitting or standing when it is applied. 4. The patient must have adequate ventilatory capacity.

4. The patient must have adequate ventilatory capacity.

CLASSES OF CARBOHYDRATES

A carbohydrate composed of carbon (C), hydrogen (H), and oxygen (O). Its abbreviated name, CHO. monosaccharides have one unit; disaccharides have two units; and polysaccharides have many units. Monosaccharides and disaccharides are small, simple structures of respectively only one and two saccharide units; thus they are referred to as simple carbohydrates. However, polysaccharides are large, complex compounds of many saccharide units in long chains; thus they are called complex carbohydrates. For example, starch, which is the most significant polysaccharide in human nutrition, is composed of many coiled and branching chains in a treelike structure. Each of the multiple branching chains is composed of 24 to 30 units of glucose, which are gradually released during digestion to supply a steady source of energy over time. Table 2-1 summarizes these classes of carbohydrates and demonstrates their basic structure.

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? O A client incontinent of urine and feces O A client with chronic nutritional deficiencies O A client with a lowered mental awareness status O A client who is unable to move about and is confined to bed

A client with a lowered mental awareness status

hypovolemic shock

A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion. symptoms: urination less than 30 ml, tachycardia, low blood pressure, respiratory rate high

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data?

A superficial injury to tissue from the radiation

Type 2 (HSV-2)

A type of HSV that is associated with genital herpes. Various types of vesicles •Flulike symptoms occur 3-4 days after vesicles erupt •Pain, redness, pruritis •May experience difficulty voiding w/ severe outbreak.

A patient recently diagnosed with a terminal illness is crying. When the nurse enters the room, the patient states, "I hate everything and everyone including you." How should the nurse respond to the patient? A) "I see that you're upset; let's talk about how you're feeling." B) "I'll let you have some time alone, and I'll return when you feel better." C) "What family member should I call to help you deal with these feelings?" D) "Hate is temporary; your feelings will change as you begin to experience death."

A) "I see that you're upset; let's talk about how you're feeling."

A nurse is caring for a critically ill patient in a large hospital. Which set of data, if documented in the notes by a nurse, would indicate death may be imminent? A) Pupils are dilated and fixed. B) Skin is warm and dry to touch. C) Peripheral pulses are palpable. D) Vital signs are within normal limits

A) Pupils are dilated and fixed.

The ABC's of breathing

A- Airway: is the airway patent? • Untreated airway obstruction can rapidly lead to cardiac arrest. •B- Breathing: is the breathing sufficient? • Symmetry & effort • C- Circulation: is the circulation sufficient? Capillary refill time and peripheral pulses • Color changes, sweating, and a < LOC are signs of decreased perfusion. • Heart auscultation should be performed • Electrocardiography & BP S - Safety • Bed alarm, bed rails, call light • Nausea/vomiting

Foams (Allevy)

ALLEVYN* Adhesive Dressing is water/bacteria-proof. Indicated for moderate to high exudating wounds. Hydrocellular structure allows for a moist wound environment.

large intestine

Absorbs water & some other nutrients, & collects food residue for excretion

The nurse is caring for a patient recently diagnosed with shingles. The nurse anticipates administering which medication? O Penicillin O Acyclovir O Oseltamivir O Griseofulvin

Acyclovir Rationale Acyclovir is an antiviral used to treat shingles. Penicillin is an antibiotic, and griseofulvin is an antifungal, so both are inappropriate. Oseltamivir is a medication to treat influenza

Which processes does the nurse teach a patient with anxiety due to depression to encourage positive emotional growth? Select all that apply. O How to avoid stress in the person's daily life O Adaptive mechanisms to deal with stress O How to avoid thoughts that may lead to conflict O Using coping mechanisms to deal with anxiety O Techniques of reminiscence and life review to cope with life changes

Adaptive mechanisms to deal with stress Using coping mechanisms to deal with anxiety Rationale Learning adaptive or corrective ways to deal with stress and anxiety is a positive part of emotional growth. Coping mechanisms are a form of adaptive behaviors. Learning ways to avoid stress is not possible because stress in daily life is inevitable. Learning adaptive patterns helps an individual deal with and resolves stress. The techniques of reminiscence and life review are effective for helping older adults deal with changing life circumstances

Which concept do the four elements of excessive use or abuse-display of psychological disturbance, a decline of social and economic function, and uncontrollable consumption indicating dependence define? O Abuse O Addiction O Alcoholism O Addictive personality

Addiction These are the four elements of addiction that are often used as a synonym for drug dependence and substance abuse. Alcoholism refers to the addiction to alcohol Abuse is the misuse of alcohol, tobacco, caffeine, nicotine, or other drugs. A person with an addictive personality exhibits a pattern of compulsive and habitual use of a substance or practice to cope with psychic pain from conflict and anxiety.

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

Administer an opioid analgesic last taken 6 hours ago.

When a patient who has been hospitalized for heavy alcohol consumption displays symptoms of dehydration, which action would be taken first to prevent Wernicke's encephalopathy? O Initiation of glucose infusion O Initiation of intravenous therapy O Administration of oxazepam (Serax) O Administration of thiamine (vitamin B₁)

Administration of thiamine (vitamin B₁) Rationale Thiamine should be administered on priority to prevent Wernicke's encephalopathy. Glucose infusion should be initiated after administration of thiamine (vitamin B1). Intravenous therapy may be necessary, but thiamine (vitamin B1) administration should be on priority. Oxazepam (Serax) is administered to treat withdrawal symptoms.

adolescence

Adolescence is the bridge between childhood and adulthood. Adolescence is divided into three phases: early adolescence (10 to 13 years of age), middle adolescence (14 to 16 years of age), and late adolescence (17 to 20 years of age). The major tasks of adolescence include establishing a sense of identity, separation from family, establishing intimacy and peer relationships, and career planning. The physical, psychological, cognitive, and emotional aspects of development may mature at different rates. • Puberty refers to sexual maturity. The reproductive system is controlled by hormones regulated by the hypothalamus and secreted by the anterior pituitary glands and the ovaries or testes. Ovulation occurs 14 days before the menstrual period begins. • The changing body plays a role in the adolescent's development of self-image, self-esteem, and social interactions. Adolescents should engage in at least 60 minutes of physical activity every day and activity of vigorous-intensity at least 3 days per week. Adolescents engaging in competitive sports can benefit from strength training. Young adolescents are in the concrete phase of thinking.

34. A person sustains full-thickness burns to both forearms while lighting an outdoor grill. The nurse would intervene if a bystander attempts to perform which action? (417) 1. Removes smoldering clothing 2. Removes victim's wedding ring 3. Applies an antiseptic cream to the burns 4. Places forearms in cold water

Answer 3: No creams, ointments, sprays, or other topical applications should be put on the skin. The skin will have to be assessed and cleaned at the hospital and topical applications can create complications. The other actions are correct.

The nurse is caring for a patient who is taking spironolactone (Aldactone). Which food does the nurse instruct the patient to include in the diet plan? O Apricots O Apple juice O Raw bananas O Baked potatoes

Apple juice Rationale The nurse instructs the patient to include apple juice in the dict because apple juice has low potassium levels. Because the patient is on spironolactone (Aldactone), a potassium-sparing diuretic, the nurse should restrict the potassium content of the diet. Apricots are a rich source of potassium, whose intake is limited in the patients who are on spironolactone (Aldactone) therapy. Raw bananas are also rich in potassium. Baked potatoes have high levels of potassium, which leads to hyperkalemia in patients who are on spironolactone (Aldactone) therapy

A female patient is complaining of vaginal discomfort caused by dryness during intercourse. What advice should the nurse give to the patient? O Perform pelvic exercises to increase lubrication O Apply a liberal amount of lubricant O use a vaginal suppository before activity O Avoid sexual activity if pain continues

Apply a liberal amount of lubricant

Which second-generation antipsychotic agent can be administered as mg/mL solution? Aripiprazole lloperidone Olanzapine Ziprasidone

Aripiprazole Rationale Aripiprazole can be administered as an mg/mL solution iloperidone is administered as tablets. Olanzapine is administered in a tablet or injection form. Ziprasidone is administered as capsules or an injection.

angiomas

Tumors consisting principally of blood vessels or lymph vessels

Abnormal mole

Asymmetric borders are uneven multiple colors larger than 1/4 inch ' change shape size and color

A frustrated father asks the nurse what can be done for a child who is independent, wants to do things his own way, and is constantly using the word "no." According to Erikson's stages of psychosocial development, which stage should the nurse explain the child experiencing? O Basic trust versus mistrust O Autonomy versus shame and doubt O initiative versus guilt O Identity versus role confusion

Autonomy versus shame and doubt

A patient who did not respond to a tricyclic antidepressant or selective serotonin reuptake inhibitor is started on a monoamine oxidase inhibitor(MAOl). Which education should the nurse provide to the patient about MAOls? O Wear sunscreen when outside. O Avoid alcohol while taking an MAOl. O Take in the morning to avoid insomnia. O Serotonin syndrome is a potential side effect.

Avoid alcohol while taking an MAOl. Rationale MAOIs can cause a hypertensive crisis if the patient has tyramine in the diet, such as red wine or bee. Serotonin syndrome is not associated with MAOIs. Photosensitivity is not associated with MAOIs. Insomnia is not a side effect of MAOIs.

Which type of assessment is the nurse conducting when using the Beck Depression Inventory ll tool in a patient with a mood disorder? Basic mental status Psychomotor function Interpersonal relationships History of the mood disorder

Basic mental status Rationale The Beck Depression Inventor ll is a widely used tool used to assess a patient's basic mental status. Psychomotor function tests assess the patient's activity level While assessing the patient's interpersonal relationships, the nurse tries to identify any supportive people in the patient's life. The nurse obtains the history of the patient's mood disorder by determining the precipitating factors contributing to the mood changes.

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods between 10:00 am and 3:00 pm

Acne Vulgaris

Benzoyl peroxide Clyndamycin & Erythromycin •Produce drying & peeling •Severe local irritation •Assess for allergic reaction •Suppress growth of Propionibacterium acnes •Can be given clindamycin/benzyl combination

"Self" is a complex concept comprising four distinct parts that influence behavior. Which part includes feeling about the way one's body functions?

Body image

Types of Wound Drainage: Sanguineous

Bright red: indicates active bleeding

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE? O Spider rash O Butterfly rash O Lilac bush rash O Christmas trees rash

Butterfly rash

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion?

Venous circulation is being impaired.

Upon being told of her father's death, the daughter cries out, "No! Oh, God, no!" What stage of grief is the daughter in? a. Anger b. Bargaining c. Denial d. Prayer

C. Denial

Cellulose.

Cellulose is the chief component of cell walls in plants. It remains undigested in the gastroin testinal tract of humans, and it adds important bulk to the diet. This bulk helps to move the food mass along it stimulates normal muscle action in the intestine, and it forms soft feces for the elimination of waste prod ucts. The main sources of cellulose are the stems and leaves of vegetables and the coverings of seeds and grains. Within the same area of the plant, phosphorus is stored in the form of phytic acid; this compound is undigested in humans because of the lack of a neces sary enzyme (phytase). Phytic acid is a strong chelator of important minerals (see the Drug-Nutrient Inter action box, "Phytic Acid and Mineral Absorption").

When planning care fora patient receiving tricyclic antidepressants, which potential problem does the nurse consider? O Gastrointestina| (Gl) bleeding O Constipation O Renal calculi O Hypernatremia

Constipation Rationale Constipation is an anticholinergic effect common in patients taking tricyclic antidepressants. Patients must be monitored for this problem and preventive measures taken. Tricyclic antidepressants do not cause Gl bleeding, renal calculi formation, or hypernatremia.

a woman discovers that her spouse is having an affair and starts to experience sudden blindness with no medical cause. The nurse understands this to be an example of which defense mechanism? O Conversion O Sublimation O Displacement O Rationalization

Conversion Rationale Conversion is when a person turns emotional conflicts into a physical symptom, which provides the individual with some sort of benefit (secondary gain, such as more attention). Displacement is the expression of emotions toward someone other than at the actual source of the emotion. Sublimation is the discharge of sexual or aggressive energy and impulses in a socially acceptable way. Rationalization is a process of constructing plausible reasons to explain and justify one's behavior.

An inquest is ordered after the death of a patient in a motor vehicle accident. Who conducts the inquest? •Health care provider •Nurse •Judge •Coroner

Coroner Rationale An inquest is a legal inquiry into the cause or manner of death that has occurred as a result of an accident. The inquest is conducted under the jurisdiction of a coroner or medical examiner. the coroner is a public official, not necessarily a health care provider, who has been appointed or elected to inquire into the cause of death. The nurse or the judge is not allowed to undertake an inquest.

Which type of catheter would the nurse use for an adult patient with prostate enlargement? O Mushroom (de Pezzer) catheter O Coude catheter O whistle-tip catheter O Robinson catheter

Coude catheter Rationale The curved stylet of the Coudé catheter is used to assist the health care provider in the insertion of a urethral catheter in a male patient with prostate enlargement. Malecot and de Pezzer (mushroom) catheters are used to drain urine from the renal pelvis of the kidney, and the Robinson catheter has multiple openings in its tip to facilitate intermittent drainage. In patients with blood in their urine, a whistle-tip catheter may be used because it has a slanted, larger orifice at its tip.

Which positive behavioral patterns are associated with schizophrenia? Select all that apply. O Alogia O Delusion O Anhedonia O Hallucination O Concreteness

Delusion Hallucination Concreteness Rationale Schizophrenia is a psychotic disorder characterized by negative and positive behavioral patterns. Positive behavioral patterns include delusions, hallucinations, and disordered thinking. Concreteness is a form of disordered thinking. The individuals showing these patterns demonstrate only a few structural changes in the brain and respond well to drug therapy. Negative behavioral patterns include alogia (reduced content of speech) and anhedonia (the inability to experience joy).

Cholelithiasis is the term used to describe: A. biliary colic B. jaundice C. portal hypertension D. gallstones

D. gallstones

Folic Acid:

DNA & hemoglobin synthesis, cell division Also given to alcoholics, helps with hemoglobin synthesis Food Source: green, leafy vegetables, liver, beef, fish, legumes Deficiency: neural tube defects for pregnant women, (spinal Bifida & anencephaly)

Which domains are the id responsible for? Select all that apply. Demand for constant gratification O Reducing tension and increasing pleasure O Formation of ideals O Striving for perfection O Determining decisions about how to act

Demand for constant gratification Reducing tension and increasing pleasure

A patient with type 2 diabetes and a blood sugar level of 415 is eating candy bars and drinking soda. The nurse identifies this as an example of which defense mechanism?

Denial

Diagnostic

Determines the cause of a particular health problem

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. For which signs and symptoms of this syndrome would the nurse be monitoring? Select all that apply. O Diaphoresis O Hyperrigidity O Hyperthermia O Photosensitivity O Agranulocytosis

Diaphoresis Hyperrigidity Hyperthermia Rationale Neuroleptic malignant syndrome can cause hyperthermia, hyper rigidity, and diaphoresis as well as labile blood pressure, confusion, and cardiovascular collapse. Photosensitivity is associated with antipsychotics but is not part of the neuroleptic malignant syndrome. Agranulocytosis is associated with the antipsychotic clozapine but is not part of the neuroleptic malignant syndrome.

Essential Nutrients

Dietary fat supplies the body with the essential fatty acids (linoleic and alpha-linolenic acid). As long as adequate amounts of essential fatty acids are con sumed, the body is capable of endogenously produc ing other fats and cholesterol as needed. Also, foods high in fat are generally a good source of fat-soluble vitamins (see Chapter 7), and fat aids in the absorption of those vitamins.

Disaccharides

Disaccharides are simple double sugars that are com posed of two single-sugar units linked together. The three disaccharides that are important in human nutri tion are sucrose, lactose, and maltose.

The nurse documents that a patient who is restricted from physical activity is using denial as a defense mechanism. Which patient behavior led the nurse to this conclusion?

Doing sit-ups and push-ups

Which action should the nurse take while using a straight catheter to empty a distended bladder? O Collect a urine specimen O Drain the bladder too quickly! O Withdraw the catheter slowly. O Wash and dry the perineum.

Drain the bladder too quickly Rationale If a distended bladder is drained too rapidly, the bladder may collapse in spasm. Collecting a specimen, slowly withdrawing the catheter, and washing and drying the perineal area are appropriate.

The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? Select all that apply.

Dressing if present Nails for shape, contour, color, thickness and cleanliness Skin for color, integrity, scars, lesions, and signs of breakdown Facial and body hair for distribution, color, quantity and hygiene

Which antidepressant is also recommended to control diabetic peripheral neuropathic pain in an adult patient? Sertraline Fluoxetine Duloxetine Fluvoxamine

Duloxetine Rationale Duloxetine, a selective serotonin reuptake inhibitor type of antidepressant, is approved for the treatment of diabetic peripheral neuropathic pain. Sertraline is a selective serotonin reuptake inhibitor approved for use in patients with obsessive-compulsive disorder. Fluoxetine, another selective serotonin reuptake inhibitor type of antidepressant, has been approved for use in treating depression in children and adolescents. Fluvoxamine is also used to treat obsessive-compulsive disorder. Test-Taking Tip: This selective serotonin reuptake inhibitor is also used to treat generalized anxiety disorder and diabetic peripheral neuropathic pain.

Who provided a framework for understanding personality development in terms of task mastery? O Hippocrates O Philippe Pinel O Erik Erikson O Sigmund Freud

Erik Erikson

Which drug gained notoriety in the 1990s, is associated with club drug use, and is often called the "date-rape drug"?

Flunitrazepam (Rohypnol)

Which signs and symptoms are associated with cocaine withdrawal? Select all that apply. O Hypersomnia O Hallucinations O Unpleasant dreams O Respiratory depression O Increased appetite

Hypersomnia Unpleasant dreams Increased appetite Rationale Hypersomnia, increased appetite, and unpleasant dreams are complaints commonly described by patients going through cocaine withdrawal. Hallucinations are symptomatic of alcohol intoxication. Respiratory depression may be seen in patients with chronic use of cocaine.

Health Team

Health Team •Nurses •Physicians •Primary caregiver (Assumes responsibility for health maintenance of the patient) •Nurse Coordinator (Officially admit the patient to he hospice care) •Hospice social Coordinator (Must have at least a bachelor's degree) •Volunteer Coordinator (Assign a volunteer to give family respite care, Cannot give medications) •Hospice Pharmacist •Available for consultation on drugs •Evaluate drug interactions w/ food & other •Hospice Spiritual Coordinator •Assist with spiritual assessment of patient •Develop plan of care regarding spiritual methods •Must have a seminary degree

The health care provider prescribes blood tests for a patient brought to the emergency room after a motor vehicle accident (MVA), including blood alcohol levels. When reviewing the results, which laboratory results does the nurse note to indicate long-term alcohol abuse? Select all that apply.

Hypoglycemia Increased liver enzymes Abnormal blood protein levels

Which nursing intervention should the nurse promote for a child experiencing anxiety about undergoing venepuncture to relieve anxiety? O Practice abdominal or deep breathing. O Focus on a pleasant image and its details. O Use brisk walks, back rubs, and heating pads. O Imagine how a hero would tolerate the procedure.

Imagine how a hero would tolerate the procedure. Rationale A patient with anxiety already has fear due to anticipation of danger and may need support while undergoing painful procedures. The nurse should ask the patient to imagine how a hero would tolerate the procedure. By doing this the patient may gain confidence and relax. Deep breathing and focusing on pleasant images are regular relaxation techniques used to reduce anxiety in a patient but are not effective while undergoing painful procedures. Brisk walks, back rub, and heating pads would relax the patient but are not effective in a process like venipuncture.

A terminally ill patient experiencing the final stages of death is incontinent. Which nursing intervention should be implemented to address skin breakdown caused by urinary incontinence? •Using adult diapers •Encouraging voiding as needed •Changing the bed linens every 2 hours •Inserting a catheter or condom catheter

Inserting a catheter or condom catheter

Peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions?

It is caused by a tick carried by deer.

Large intestine

Large intestine

Which antidepressant therapy can cause a metallic taste? Lithium Vilazodone Trazodone Vortioxetine

Lithium Rationale Lithium is a monovalent cation that may cause a metallic taste as a rare adverse effect. Vilazodone adverse effects include diarrhea, nausea, and vomiting. Trazodone is atriazolopyridine antidepressant that may cause orthostatic hypotension. Vortioxetine antagonizes serotonin receptors and may cause abnormal dreams.

Benefits of Exercise in the Older adult

Maintains or improves cardiovascular fitness •Prevents or reduces the intensity of chronic diseases such as CAD, CHF, HTN, osteoarthritis, osteoporosis, diabetes, obesity & chronic lung disease •Prevents many falls & fractures •Improves muscle strength & flexibility, & balance •Enhances self-care abilities & promotes independent activities •Encourages social contact •Decreases anxiety, depression & insomnia

A nurse is preparing to care for a patient who sustained a high thoracic spinal cord injury. The nurse knows the patient will have which condition? O Flaccid bladder O Urethral stenosis O Neurogenic bladder O Recurrent urinary tract infections

Neurogenic bladder Rationale Patients with spinal cord injuries are likely to have neurogenic bladder. Flaccid bladder occurs with lower motor neuron lesion. Urethral stenosis is the narrowing of the urethra and is not likely caused by a spinal cord injury. It is possible that the patient will have recurrent urinary tract infections, but this is not the best answer.

A patient is scheduled to retire within the next year. Which action if taken by the patient will lead to positive outcomes related to the psychological adjustment during the retirement phase? O Making sure retirement is desired before strategic plans are finalized O Focusing on the family and planning retirement to accommodate these needs O Waiting until retirement occurs and then planning how to spend the retirement period O Planning and discussing hopes and expectations for the retirement period

Planning and discussing hopes and expectations for the retirement period

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? O The return of distal pulses O Decreasing edema formation O Brisk bleeding from the injury site O The formation of granulation tissue

The return of distal pulses

While counseling the parents of a 2-month-old infant, the nurse informs them, "Babies should always sleep on their backs." Why would the nurse say this?

To prevent sudden death of the infant

The nurse counsels the mother of an infant to avoid milk in the nighttime bottle. What is the reason for giving this advice to the infant's mother? O To promote proper sleep O To prevent crib death O To promote oral hygiene O To prevent chocking hazard

To promote oral hygiene

A male patient on a psychiatric unit admits to obtaining sexual gratification by wearing his wife's clothing. Which type of sexual disorder do these symptoms indicate?

Transvestic fetishism

A terminally ill patient in the intensive care unit (ICU) is on life-supporting measures. Which intervention does the nurse perform when caring for the patient to support the patient's right? Treat the body respectfully after death. Avoid using opioids to control the pain Don't let the patient change religious belief Avoid informing the patient of impending death

Treat the body respectfully after death.

An older client is complaining of chronic dry skin and occasional pruritus. The nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition?

Using astringents to clean the skin

What action by a student before taking atest should indicate to a nursing instructor that the studentis demonstrating signs of moderate anxiety? O Studies for 6 hours O Sleeps 6 hours because of fatigue O Vomits O Argues about the scheduling of the test

Vomits

The PN then reviews Ms. Burke's preoperative lab test results, which were obtained earlier in the week. Which serum lab value requires follow-up action by the PN? Sodium of 135 mEq/L WBC of 14,000/mm3 Creatinine of 0.8 mg/dL Hemoglobin of 14 g/dL.

WBC of 14,000/mm3 The normal white blood cell (WBC) count is 5,000 to 10,000/mm3. An increase may indicate the onset of an infection, which may be a contraindication to surgery. The PN should notify the charge RN of this abnormal lab value

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care?

Warm compresses

A patient is being discharged from the psychiatric unit with a prescription for an antipsychotic. Which information should the nurse educate the patient about before discharge?

Wear sunscreen and sunglasses when outside.

which atypical antipsychotic drug has the lowest hypotensive effects? Lurasidone Asenapine loperidone Ziprasidone

Ziprasidone Rationale Of the four drugs listed, ziprasidone has the lowest hypotensive effects. Test-Taking Tip: Keywords or phrases in the question stem such as first, primary, early, or best is important. Similarly, words such as only, always, never and ll in the alternatives are frequently evidenced of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

advantitious

accidental

Bile

an emulsifying agent produced by the liver and transported to the gallbladder for concentration and storage; it is released into the duodenum with the entry of fat to facilitate enzymatic fat digestion by acting as an emulsifier.

-otomy

cutting into

Which sign or symptom denotes the presence of dementia of the Alzheimer's type? select all that apply once some or all responses may be correct O Word salad O forgetfulness O flight of ideas O loose Association O Aphasia

forgetfulness Aphasia

Cephalocaudal

head to toe

wheals

itchy, elevated areas with an irregular shape; hives and insect bites are examples

Magnesium:

muscle action (heart) Food Source: whole grains, avocados, canned white tuna fish, cauliflower, oatmeal, green leafy vegetables, milk, peanut butter, potatoes Deficiency: twitching, hypertension, muscle weakness Toxicity: GI symptoms

Death rattle

noise made by a moribund person caused by air passing through a residue of mucous in the trachea and posterior oral cavity

essential nutrient

nutrients a person must obtain from food because the body cannot make them for itself in sufficient quantity to meet physiologic needs.

Intraoperative

period of time during surgery

triglycerides

the chemical name for fats in the body or in food; three fatty acids attached to a glycerol base.

Stage 2 care of burns

the intermediate or acute (or diuretic) phase, begins 48-72 hours after the burn injury, greatest concern is circulatory overload result from the fluid shift back from the interstitial spaces into the capillaries

acids

the nitrogen-bearing compounds that form the structural units of protein; after digestion, amino acids are available for the synthesis of required proteins.

ordinal position

whether the infant is an only child, an oldest child, a youngest child, or a middle child

recommended daily intake of fiber

women and men aged 19 to 50 years old is 25 and 38 g/ day, respectively. The DRIs are reduced to 21 and 30 g/day for women and men who are older than 50 years of age. This intake requires the consistent use of whole grains, legumes, vegetables, fruits, seeds, and nuts in the daily diet. Unfortunately, the average American does not consume the recommended servings of these food groups on a daily basis.

Zinc:

wound healing, immune system Food Source: meat, seafood legumes, whole grains Deficiency: poor wound healing, impaired taste & smell

Evisceration

• a life-threatening situation, exposure of abdominal contents can lead to necrosis of the intestines or overwhelming sepsis. Serosanguineous drainage is a sign of evisceration dehiscence. Interventions: • Low Fowler's w/ knees bent • Notify PHCP • Cover wound w/ sterile towel moistened w/ normal saline • Prepare for surgery • Take VS

Electroconvulsive Therapy

•Used when drug therapy is ineffective or is contraindicated •Suicidal or homicidal S/E: confusion, disorientation & short term memory loss, HA, hypotension, muscle soreness, nausea & tachycardia Interventions: •Consent •NPO 8 hours •Turn to the side to prevent aspiration •Check for gag reflex before feeding •Monitor for suicide ideation

Scabies

•Wavy, brown threadlike lines •Hands, arms, body folds & genitalia •Burrow eggs under skin S/E: itching

11. The nurse is educating a group of hikers about how to treat frostbite. Which statement by one of the hikers indicates the need for further teaching? 1. "I should place the frozen body part in hot water, around 110° to 114°F (43.3° to 45.6°C)." 2. "I can wrap a frozen body part in a warm moist towel." 3. "I should avoid vigorously rubbing the frozen body part." 4. "After the frozen part is warmed, I should wrap it in clean material and elevate it."

1. "I should place the frozen body part in hot water, around 110° to 114°F (43.3° to 45.6°C)." 2. "I can wrap a frozen body part in a warm moist towel." 3. "I should avoid vigorously rubbing the frozen body part." 4. "After the frozen part is warmed, I should wrap it in clean material and elevate it."

Dressing changes

1st are always changed by the doctor Reinforce dressing (if bleeding does not continue) Circle the area

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5%

Braden Scale for Predicting Pressure Sore Risk

6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

nurse is caring for a patient with acute renal failure (oliguric phase). Which finding would the nurse expect to assess in a patient with this diagnosis? O Low levels of serum creatinine O Decreased blood urea nitrogen O Urine output in excess of 2 L/day O Anorexia, nausea, vomiting, and decreased urine output

Anorexia, nausea, vomiting, and decreased urine output Rationale In a patient with acute renal failure (oliguric phase), typical clinical manifestations include anorexia, nausea, vomiting, and decreased urine output. The patient may also experience lethargy, headache, dry mucous membranes, diarrhea, poor skin turgor, and anasarca. A patient who is in the oliguric phase of acute renal failure will have an elevated serum creatinine. A patient who is in the oliguric phase of acute renal failure will have an elevation in the blood urea nitrogen value. A patient who is in the oliguric phase of acute renal failure will have a decreased urine output, usually less than 400 ml in a 24-hour period.

A terminally ill patient who is on lifesaving medications and other supportive measures wishes to die at home. How does the nurse manage this situation? A) Obtain family members' opinions. B) Insist the patient stay in the hospital. C) Modify the patient's room to look homelike. D) Respect the patient's desire and let the patient go home.

D) Respect the patient's desire and let the patient go home.

A patient who has just been sexually assaulted has come to the emergency department and is very calm and quiet. The nurse identifies this behavior as part of which defense mechanism? O Denial O Projection O Suppression O Rationalization

Denial Rationale Denial is a response by victims of sexual abuse. Reality is denied; it does not exist. Suppression is the intentional exclusion of painful thoughts, experiences, or impulses. Rationalization is a process of constructing plausible reasons to explain and justify one's behavior. Projection is blaming personal shortcomings on someone else.

Fat Substitutes

Several fat substitutes, which are compounds that are not absorbed and thus contribute little or no kilocalories, are available to provide improved flavor and physical texture to low-fat/fat-free foods and to help reduce total dietary fat intake. Fat substitutes that are currently on the market are considered safe by the U.S. Food and Drug Administration (FDA). However, the risks and benefits of long-term use of fat substitutes are not well established. There are many different types of fat substitutes. Two of the more common examples are Simplesse (CP Kelco, Atlanta, Ga), which is made by reshaping the protein of milk whey or egg whites, and Olean (Olestra, Procter & Gamble, Cincinnati, Ohio), which is an indigestible form of sucrose.

What should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy (ECT) remind the patient to do? a. Drink plenty of fluids before ECT to ensure adequate hydration. b. Bring a change of clothes in case of incontinence. c. Be prepared for visual disturbances after the treatment. d. Arrange for transportation to and from the appointment.

d. Arrange for transportation to and from the appointment. If the patient has not arranged for adequate transportation to and from the appointment, the treatment will be canceled because driving after ECT is dangerous. The patient is typically NPO before the procedure. Incontinence and visual disturbances are not common following the procedure.

Acid-Base Balance

• An acceptable pH (degree of acidity or alkalinity ) must be maintained in body fluids to support life. • Achieved by chemical and physiologic buffer systems • Acidity/alkalinity expressed in terms of pH

Toddler: 1 -3 years

•Anterior fontanel closes 12-18M •Walking climbing stairs (2 years), hoping (3 years) •Fine motor skills- picking up foods •Toilet training until 18-24M Erickson: Autonomy vs. Shame & Doubt •Piaget: Preoperational Stage

The nurse is teaching various health promotion strategies to a group of elderly people in a community. What information does the nurse include in the teaching plan? Select all that apply. O "Drink 1500 mL of fluids per day." O "Get an influenza vaccination once a year." O Remove excess furniture from your home O social contact is beneficial O you only need to get out of the house once per week

"Drink 1500 mL of fluids per day." "Get an influenza vaccination once a year." Remove excess furniture from your home social contact is beneficial

11. The nurse arrives outside of the public library and finds a person lying on the ground. What is the first action to take? (394) 1. Check if the victim is unconscious. 2. Check the carotid or brachial pulse. 3. Move the victim to a flat, hard surface. 4. Direct someone to call 911.

Answer 1: First, the nurse assesses level of consciousness. Based on the assessment, the nurse may decide to question the person, start CPR, call 911, or check for injuries.

24. The nurse is observing a new staff member perform a sterile dry dressing change. The nurse would intervene if the staff member performed which action? (622) 1. Loosens tape and gently pulls towards the incision 2. Uses sterile gloves to remove the old dressing 3. Cleanses wound by starting at incision moving outward 4. Allows antiseptic cleansing solution to air-dry

Answer 2: Clean gloves are adequate to remove old dressings. The other options are correct.

The nurse is reinforcing sun exposure precautions to a group of older clients. Which should the nurse include in the instructions? Select all that apply. O Sunscreen is not needed on cloudy days. O Wear loosely woven clothing for protection. O Apply sunscreen liberally 15 to 30 minutes before sun exposure. O Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. O It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

Apply sunscreen liberally 15 to 30 minutes before sun exposure. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

The nurse finds that a patient is overusing the mechanisms of introjection, denial, eating and reaction formation in daily life. Which suspicion would the nurse have about the patient's mental health? O May be undergoing a crisis O Has maladaptive behavior O Has a high level of anxiety O May have low self-esteem

O Has maladaptive behavior

Which selections indicate an understanding of foods that are rich in vitamin C? Select all that apply. O Orange juice O Lean meat O Kale salad O Summer squash O Bananas

O Orange juice O Kale salad O Summer squash

Following surgery, Ms. Burke is admitted to the Post Anesthesia Care Unit (PACU). The operative report indicates that Ms. Burke had a left hip replacement under general anesthesia. Initially, Ms. Burke is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70. What action should the PN implement first? O Position the client on her side. O Observe the surgical dressing. O Place the call bell within reach. O Remove the oral airway.

O Position the client on her side.

Invisible Fat

Some dietary fats are less visible, so individuals who want to control dietary fat must be aware of these food sources. Invisible fats include cheese, the cream portion of homogenized milk, nuts, seeds, olives, avocados, and lean meat. Basically, invisible fats are those that you cannot cut out of the food. Even when all of the visible fat has been removed from meat (e.g., the skin on poultry and the obvious fat on the lean portions), approximately 6% of the total fat surrounding the muscle fibers remains.

deep vein thrombosis (DVT)

Swelling in the affected leg. Rarely, there's swelling in both legs. Pain in your leg. The pain often starts in your calf and can feel like cramping or soreness. Red or discolored skin on the leg. A feeling of warmth in the affected leg. ways to prevent: ambulate, leg stockings, aspirin ways to identify: Ultrasound

Shallow Partial-Thickness Burns

The most common first-degree burns are simple sunburns or burns from contact with hot objects. Healing usually is spontaneous or occurs within 2 to 5 days and is uncomplicated. Signs and symptoms include erythema and pain.

basal metabolic rate (BMR)

The metabolic rate of a nongrowing, resting, fasting, nonstressed endotherm.

The nurse is caring for a patient diagnosed with depression who avoids interacting with others. Which activity by the patient would the nurse expect after providing effective nursing interventions? Select all that apply. O Watches a movie in a theater O Sleeps at a scheduled time each night O Interacts with other patients and staff O Maintains a regular and adequate eating pattern O Denies having thoughts of self-directed violence

Watches a movie in a theater Interacts with other patients and staff Rationale Depressed patients usually withdraw from society and avoid maintaining social interactions. The nursing interventions are aimed to encourage recreational activities and facilitate interaction with other patients. The patient watching a movie in a theater and interacting with other patients and staff indicates that the nursing interventions are effective. Sleeping at a scheduled time is an outcome not expected for a patient with a disturbed sleep pattern. The nursing interventions for a patient with imbalanced nutrition aim to maintain a regular eating pattern. The nursing intervention for a depressed patient with a risk of self-directed violence (suicidal thoughts) aims at reducing suicidal tendencies in the patient.

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?

Weeping of the skin

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which? A rash Dermatitis Reddened skin Weeping of the skin

Weeping of the skin

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. c. How is the syringe positioned for the irrigation? ________

c. Syringe is held 1 inch above the wound for irrigation.

To help prevent falls related to muscle weakness, what type of exercises should be selected for the aging patient? a. Daily b. Running c. Weight-bearing d. Aerobic

c. Weight-bearing

2. The toddler-age child is in Erikson's stage of: a. trust versus mistrust. b. initiative versus guilt. c. autonomy versus shame and doubt. d. identity versus role confusion.

c. autonomy versus shame and doubt.

Antidiuretic Hormone (ADH) Mechanism

• First-line defense against hypovolemia • ADH is also called vasopressin

A male patient who has heard numerous horror stories about prostate diseases comes to the primary health care provider's office for a routine examination. What would be the best advice the nurse can offer the patient to address concerns? O "A blood test and examination can be used to diagnose prostate problems." O all men will have a prostate disease after the age of 75 O don't worry; if yo have a prostate problem, you'll know it O wait until there's problem and then seek medical treatment

"A blood test and examination can be used to diagnose prostate problems."

Palliative care

"Active total care of patients whose disease is not response to curative therapy"' •Goals is the best possible quality of life for patients and their families and aggressive curative efforts are not pursued •Settings include home, nursing facilities, or long-term care facilities

Which statement by the nurse about the effects of alcohol indicates effective learning?

"Alcohol affects the frontal cortex, which governs self-control."

Which statement by the nurse about the effects of alcohol indicateseffective learning? O Alcohol does not affect hunger, thirst, and sexual desire. O Alcohol heightens judgment and feelings of pleasure. O "Alcohol affects the frontal cortex, which governs self-control." O Rapid and large-quantity consumption of alcohol causes death."

"Alcohol affects the frontal cortex, which governs self-control." Rationale Alcohol is a central nervous system depressant affecting the higher centers of the brain, such as the frontal cortex. As a result, the patient loses self-control. Alcohol affects the nucleus accumbens in the limbic system, which regulates hunger, thirst, and sexual desire. The patient's judgment is blocked and the memory of pleasure is retained after consuming alcohol. Rapid and large quantity consumption of alcohol can lead to unconsciousness and affect respiration. Death can occur only due to acute alcohol. poisoning.

A nurse is talking with the mother of an 8-year-old child who expresses concern that her child is more focused on friends than anything else. Which is the most appropriate response? O "You need to be concerned" O "Monitor your child's behavior very closely" O "At this age, the child is developing his own personality." O "YOu need to give more praise to your child to stop this behavior"

"At this age, the child is developing his own personality."

The nurse is teaching an infant's parents to take precautionary measures against accidents and injury to the infant. What instruction should the nurse give to the parents to ensure safety? Select all that apply. O Place the infant in the walker when you need to step away O "Do not give the infant popcorn and hard candies." O "Avoid placing pillows near the infant while he or she is sleeping." O encourage the infant to play only with plush toys and balloons O "Keep the sides of the crib up and set the mattress at its lowest position."

"Do not give the infant popcorn and hard candies." "Avoid placing pillows near the infant while he or she is sleeping." "Keep the sides of the crib up and set the mattress at its lowest position."

An experienced nurse is educating an elderly patient about common changes that occur with aging. What information if given by the nurse would best help the patient to adjust to changes associated with the heart? O consume adequate food and fluid intake O "Engage in daily exercise, rest, and a decreased-sodium diet." O turn, cough, and deep breathe as needed O Allow frequent rest periods during the day

"Engage in daily exercise, rest, and a decreased-sodium diet."

Eicosanoids are divided into four classes

(1) prostaglandins; (2) prostacyclins; (3) thromboxanes; and (4) leukotrienes. Eicosanoids are derived from the essential fatty acids.

Urge urinary incontinence

(A) Associated with central nervous system disorders; characterized by involuntary urine loss after a sudden urge to void

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36%

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition?

Blistering skin

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

A mother of a 5-year-old child complains to the school nurse, "My child is behaving very stubbornly these days and does not follow my instructions." The nurse explains to the mother Piaget's stages of development in children. Which statement by the mother indicates a better understanding? O My child requires more attention from us O My child needs to be restricted from playing O "My child has age-appropriate behavior." O My child needs counseling by a therapist

"My child has age-appropriate behavior."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

The nurse is teaching a group of mothers in a community regarding toddler diet requirements. What does the nurse inform the mothers? O "wheat bread during breakfast should be avoided O Two eggs per day will prevent allergies O "Serve at least one serving of meat a day." O serve a bowl of grapes and carrots daily

"Serve at least one serving of meat a day."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client?

"Take a shower immediately, and lather and rinse several times."

When reviewing the lab values ofa patient being treated with lithium for bipolar disorder, which lithium level would the nurse interpret as a normal therapeutic value? 0.2 mEq/L 2.0 mEq/L 0.8mEq/L 1.6mEq/L

0.8mEq/L Rationale Anormal lithium level is between 0.4mEq/Land 1.2mEq/L. A level of0.2 mEq/Lis too low and would not be considered within the therapeutic range. A level of2.0 mEq/L orl.6mEq/Lis to high and can indicate toxicity.

A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?

54%

Which statement by the nurse about the treatment for nicotine addiction indicates effective learning?

"Nicotine gum will help decrease nicotine dependence."

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? O "I need to have clear fluids only on the morning of the test." O "I need to take my prednisone on the morning of the test." O "I need to shower on the morning of the test using povidone-iodine." O "I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area."

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? O "I will apply the ointment once a day and leave it open to the air." O "I will apply the ointment twice a day and leave it open to the air." O "I will apply the ointment once a day and cover it with a sterile dressing." O "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."

"I will apply the ointment once a day and cover it with a sterile dressing."

A parent of a preschooler is concerned about the child's behavior. Which statements if made by the parent would indicate to the nurse that instructions on setting limits on behavior were effective? O "I will explain acceptable behavior." O "I should reinforce positive behavior." O " I must stay calm when arguing with the child." O Rules should change based on the behavior O I am keeping a record of all the bad behavior

"I will explain acceptable behavior." "I should reinforce positive behavior." " I must stay calm when arguing with the child."

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching?

"I will remove the dressing when I get home and wash the site with tap water."

A pediatric nurse is educating a young mother about feeding a toddler. Which statement, if made by the mother, indicates teaching has been ineffective? O I will introduce cereal first O I will not mix different foods together O "I will try several new foods at the first feeding." O I will avoid fast foods such as chicken nuggets

"I will try several new foods at the first feeding."

nurse is providing education to a patient on self-catheterization. Which statement indicates the patient's understanding of the home self catheterization technique? O Sterile technique is required to prevent urinary tract infections." O "I will use clean technique when catheterizing myself at home." O "I can boil and reuse the disposable straight catheters." O "I should never drain my urine directly into the toilet while performing a self catheterization."

"I will use clean technique when catheterizing myself at home."

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat."

Which statements by the nursing student indicate effective learning about acamprosate (Campral)? Select all that apply. O "It reduces the rewarding effects of alcohol." O "It helps patients maintain abstinence from alcohol." O "It is contraindicated in patients with severe renal failure." O "It causes nausea and vomiting when alcohol is consumed." O "It helps in relapse prevention associated with opioid abuse."

"It is contraindicated in patients with severe renal failure." "It causes nausea and vomiting when alcohol is consumed." Rationale Acamprosate (Campral) is used to help individuals maintain abstinence from alcohol. Acamprosate (Campral) is contraindicated in patients with severe renal failure, which is indicated by a renal clearance of less than 30 mL/min. Acamprosate (Campral) does not reduce the rewarding effects of alcohol, may not induce nausea and vomiting when alcohol is consumed, and is not used to prevent relapse in patients with opioid abuse.

Which statements by a nursing student indicate the need for further learning about acamprosate (Campral)? Select all that apply. O "It reduces the rewarding effects of alcohol." O "It helps in maintaining abstinence from alcohol." O "It is contraindicated in patients with severe renal failure." O "It does cause nausea and vomiting when alcohol is consumed." O "It enhances abstinence and reduces drinking rates in alcohol-dependent patients.

"It reduces the rewarding effects of alcohol." "It does cause nausea and vomiting when alcohol is consumed." Rationale Acamprosate (Campral) helps individuals maintain abstinence from alcohol, enhances abstinence, and controls drinking rates in alcohol-dependent patients. Acamprosate (Campral) is contraindicated in patients with severe renal failure with a renal clearance of less than 30 mL/min because it may result in renal toxicity. It does not reduce the rewarding effects of alcohol, and it does not cause nausea and vomiting when alcohol is consumed.

The parents ask the nurse why their alcohol-addicted adolescent is prescribed disulfiram (Antabuse) during the rehabilitation phase. Which is the best response by the nurse?

"It will encourage abstinence from alcohol consumption."

Which statement by the nurse about the use of ketamine indicates effective learning?

"Most of it is sold as an anesthetic drug for veterinary use."

Which statement by the nurse about the use of ketamine indicates effective learning? O It is consumed by dissolving in alcohol." O "It is unlikely to cause any serious injuries. O "Most of it is sold as an anesthetic drug for veterinary use." O It has been a popular club drug since the 1980s."

"Most of it is sold as an anesthetic drug for veterinary use." Rationale Ketamine is an anesthetic drug approved by the U.S. Food and Drug Administration for human and veterinary use, and most of it that is sold legally in the United States is intended for veterinary use. The drug cannot be dissolved in alcohol but is snorted or injected. Ketamine use causes hallucinations and may cause fatal respiratory problems at higher doses. There has been an increased use in the drug since 2008, but 3,4-methylenedioxymethamphetamine (MDMA), also known as Ecstasy, has been a popular club drug since the 1980s.

On interacting with a newborn's parent, the nurse understands that the newborn is sufficiently breastfed. Which statement by the newborn's parent has enabled the nurse to reach this conclusion? Select all that apply. O My baby passes watery stools four times a day O My baby passes rust-colored urine immediately after feeding O "My baby passes seedy stools about three times a day." O "My baby passes urine frequently and wets six diapers a day." O My baby breasts-feeds continuously for 5 minutes

"My baby passes seedy stools about three times a day." "My baby passes urine frequently and wets six diapers a day."

A patient is worried that the use of opioids for pain management after surgery might develop into an addiction. Which response by the nurse would be appropriate? O "You have to take medications that are prescribed for you." O You will be referred for rehabilitation in case of addiction. O "It is more important to control pain than worry about addiction." O "Nonopioids, which do not cause addiction, will be used after a few days."

"Nonopioids, which do not cause addiction, will be used after a few days." Rationale Opioid need and the severity of pain in postoperative patients reduce gradually; therefore the patient is administered nonopioids by the third postoperative day. As a result, there is no risk for addiction. The nurse should share this information with the patient to relieve the patient's anxiety. Telling the patient that the medications are necessary will increase the patient's anxiety. Telling the patient about rehabilitation indicates that there is a possibility of addiction, which may make the patient anxious. Telling the patient that it is more important to control pain than to worry about addiction will not help to reduce the patient's fears.

A patient arrives at the clinic complaining of stress incontinence after delivery of her second child. Which suggestion would the nurse make first? O "Limit fluid intake." O "Wear protective underwear." O "Perform Kegel exercises four times per day! O "Request a prescription for oxybutynin (Ditropan XL)."

"Perform Kegel exercises four times per day! Rationale The nurse should suggest strengthening the pelvic floor muscles to prevent stress incontinence. The patient should not limit fluid intake. Although protective underwear may be beneficial to the patient, this does not fix the stress incontinence. Medication is not the appropriate first choice of treatment.

While providing care to patients that include a large population of Native Americans, the student notices that several of the patients seen during the rotation are exhibiting the consequences of long-term alcohol abuse. The student nurse has heard stories that Native Americans drink more and asks the nurse practitioner to validate her perception. Which response from the nurse practitioner would be appropriate? O They don't drink any more than anyone else; they just get sicker from it. O " They drink a lot because all of their liquor is discounted or free at the casinos." O "They drink because that is all they have left to do. Everything else has been taken from them." O "Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater

"Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater Rationale Deficiencies in some hepatic enzymes necessary to metabolize alcohol contribute to the development of alcoholism in some people, including many Native Americans, Asians, and Inuit. Alcoholism rates are higher in these ethnic groups. The effect of alcohol consumption varies by many factors. Long-term abuse has serious, significant effects regardless of one's ethnicity. The ideas that Native Americans drink more because of a discounted cost or in response to historical treatment support a stereotypical perspective and are not based on evidence.

While providing care to patients that include a large population of Native Americans, the student notices that several of the patients seen during the rotation exhibit the consequences of long-term alcohol abuse. The student nurse has heard stories that Native Americans drink more and asks the nurse practitioner to validate her perception. Which response from the nurse practitioner would be appropriate? O They do not drink any more than anyone else; they get sicker from it. O " They drink a lot because all of their liquor is discounted or free at the casinos." O "They drink because that is all they have left to do. Everything else has been taken from them." O "Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater

"Physiologic differences, such as reduced liver enzymes, make their incidence of alcoholism greater Rationale Deficiencies in some hepatic enzymes necessary to metabolize alcohol contribute to the development of alcoholism in some people, including many Native Americans, Asians, and Inuit. Alcoholism rates are higher in these ethnic groups. The effect of alcohol consumption varies by many factors. Long-term abuse has serious, significant effects regardless of one's ethnicity. The ideas that Native Americans drink more because of a discounted cost or in response to historical treatment support a stereotypical perspective and are not based on evidence.

A patient with a visual impairment is accompanied to the clinic by a family member. The family member asks the nurse what can be done at home to help the patient function. What would be the most appropriate response for the nurse to give? O Avoid the use of night-lights O "Place essential items in the direct visual path." O Make sure that the lighitng in the room is dim O Dark colors such as gray, black, and blue are best

"Place essential items in the direct visual path."

The parents inform the nurse, "Our child has bad dreams and wakes up in the night crying." What suggestion would the nurse give to the parents to improve the sleep patterns in the child? Select all that apply. O Sleep along with the child at night O "Read stories to the child at night." O "Play soothing music in the child's room." O "Bathe the child with warm water before sleep." O Encourage the child to watch TV before sleep

"Read stories to the child at night." "Play soothing music in the child's room." "Bathe the child with warm water before sleep."

Parents of a toddler have brought their child to the health care center for a routine checkup. The nurse learns that the toddler's parents are planning to send the child to a day-care center. What should the nurse suggest to the parents regarding the selection of a day-care center? Select all that apply. O Select one where the caretaker supervises the child's calorie intake O "Select one that separates children by age group." O "Select one that has ample space for the children to play." O "Select one that has proper educational structures for the children." O Select one where a nurse effectively takes care of all the children

"Select one that separates children by age group." "Select one that has ample space for the children to play." "Select one that has proper educational structures for the children."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? O "Come to the emergency department." O "Apply calamine lotion immediately to the exposed skin areas." O "Take a shower immediately, and lather and rinse several times." O "It is not necessary to do anything if you cannot see anything on your skin."

"Take a shower immediately, and lather and rinse several times."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client?

"The local anesthetic may cause a burning or stinging sensation."

Which statement by a nursing student about suicide related to depression indicates the need for further teaching? "The risk of suicide decreases with age." "A prior suicide attempt is a risk factor for depression." "Suicide is the third leading cause of death in adolescents." "Depressive disorders and suicides tend to cluster in families."

"The risk of suicide decreases with age." Rationale The risk of suicide increases with age instead of decreases. Older adults commit suicide more frequently than depressed people of other age groups A prior suicide attempt is indeed a significant risk factor for the development of depression. Suicide statistics indicate that it is the third leading cause of death in adolescents. Relatives of patients with depression are two to three times more likely to develop depression; hence, depression and suicide cluster in families.

A young mother comes to the clinic with her 2-month-old daughter. While taking vital signs, the nurse finds that the baby's heart rate is 120 bpm. The mother expresses concern about the fast heart rate. What is the best response by the nurse? O Her pulse is okay O Has your daughter been having trouble breathing O "This is a normal heart rate for a 2-month-old baby." O Don't worry; I'll let the health care provider

"This is a normal heart rate for a 2-month-old baby."

A nurse is assessing a toddler on evening rounds. The mother is upset and explains to the nurse that the toddler consistently has temper tantrums. What should the nurse teach the parent about the behavior? O "use a thin belt and tap the thighs of the toddler to break the bad habit" O "Place the child in a time-out for an hour after each temper tantrum takes place" O "Unless the child or others may be harmed, ignore the negative behavior." O "It is best to give toddlers whatever they want to prevent the tantrums from occuring

"Unless the child or others may be harmed, ignore the negative behavior."

The nurse is assessing an elderly patient who reports pain in the joints. On assessment, the nurse finds that the patient also has stiffness in the joints. What suggestion should the nurse provide? Select all that apply. O "Walk on a regular basis." O "Avoid walking on sloped surfaces." O "Use a walking stick while walking." O You require full bed rest O Use weights to strengthen your muscles

"Walk on a regular basis." "Avoid walking on sloped surfaces." "Use a walking stick while walking."

Which question by the nurse is best to help identify a patient's addictive behavior pattern during an assessment?

"What do you do to relieve stress?"

Which question by the nurse is best to help identify a patient's addictive behavior pattern during an assessment? O "What do you do to relieve stress?" O Do you often feel overwhelmed?" O "When was the last time you used drugs? O How often do you have the urge to drink?"

"What do you do to relieve stress?" Rationale Patients who suffer from depression or chronic medical conditions often have problems with substance abuse. The nurse should ask the patient what the patient does to relieve stress or pain. It will help the nurse to understand whether the patient is addicted to alcohol or other substances. The patient may feel overwhelmed due to anxiety or other psychological issues, so it may not be an indication of addiction. Asking when the patient last used drugs will not help obtain an honest answer. The patient may not be honest and may try to hide a substance abuse problem if the nurse asks directly about the patient's urge to drink.

A nurse is caring for a patient who is suspected of drug dependence. Which questions are the most appropriate for the nurse to ask?

"What type, how much, and what effects do the drugs have on you?"

What questions should the nurse ask to assess the psychomotor function of a patient with a mood disorder? Select all that apply. "Do you take regular naps?" "When did you last go to work?" "Do you visit your parents or friends regularly?" "Have you lost weight in recent months?" "Did you brush your teeth this morning?"

"When did you last go to work?" "Do you visit your parents or friends regularly?" "Did you brush your teeth this morning?" Rationale The nurse assesses the psychomotor function to determine the patient's activity level. To assess if the patient is able to work, the nurse asks, "When did you last go to work?" The answer to the question, "Do you visit your parents o friends regularly?" helps the nurse determine the patient's ability to fulfill social responsibilities. To assess if the patient is able to perform activities of daily living the nurse asks, "Did you brush your teeth this morning?" The answer to the question, "Do you take regular naps?" helps the nurse asks the patient's sleep pattern; this question is unrelated to psychomotor functions. Weight loss or gain provides information on the patient's dietary history, not psychomotor function.

A patient is scheduled for electroconvulsive therapy (ECT) tomorrow morning. She has been pacing the halls and biting her nails for the past 10 minutes. The patient tells the nurse, "I don't know if I can go through with this. I don't remember any side effects to expect!" Which response by the nurse would be best at this time?

"You might experience short-term amnesia and headache after the procedure."

A patient is scheduled for electroconvulsive therapy (ECT) tomorrow morning She has been pacing the halls and biting her nails for the past l0 minutes. The patient tells the nurse, "I don't know if can go through with this. I don't remember any side effects to expect!" Which response by the nurse would be best at this time? O "Many people get ECT and do fine." O "Eat a small meal beforehand to prevent possible nausea." O "You might experience short-term amnesia and headache after the procedure." O "You will be awake during the procedure; the controlled seizure lasts only 5 seconds."

"You might experience short-term amnesia and headache after the procedure." Rationale Possible side effects include headache, confusion on awakening, and short-term amnesia. Telling the patient that many people get ECT and do fine would not alleviate the patient's anxiety. Patients are under general anesthesia during the procedure and have a controlled seizure that lasts 30 to 60 seconds. Patients should have nothing by mouth (NPO) forat least 8 hours before treatment.

A nutrient is essential if either of the following is true

(1) its absence will create a specific deficiency disease; or (2) the body cannot manufacture it in sufficient amounts and must obtain it from the diet.

Match each phase of wound healing with its correct description. Inflammatory (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination.

Match each term with its definition. Extravasation (A) Passage of escape into the tissues, usually of blood, serum, or lymph (B) Infection of the skin characterized by heat, pain, erythema, and edema (C) Collection of extravasated blood trapped in the tissues or in an organ, resulting from incomplete hemostasis after surgery (D) Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection (E) Protrusion of an internal organ through a wound or surgical incision (F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen (G) Separation of a surgical incision or rupture of a wound closure

(A) Passage of escape into the tissues, usually of blood, serum, or lymph

Posttraumatic stress disorder

(B) A response to an intense traumatic experience that is beyond the usual range of human experiences

Match each phase of wound healing with its correct description. Maturation (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(B) Fibroblasts exit the wound and the wound continues to gain strength.

Functional urinary incontinence

(B) Occurs as a result of an inability or unwillingness to toilet because of physical limitations or emotional issues

Behavior therapy

(B) Used to relieve anxiety by conditioning and retraining responses by repetition

Psychoanalysis

(C) A long-term process used to bring unconscious feelings to the surface

Akathisia

(C) An inability to sit still with continuous movements

Match each phase of wound healing with its correct description. Reconstruction (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(C) Collagen is formed and the wound begins to develop a scar.

Cognitive therapy

(D) Breaking negative thought patterns and developing positive feelings about memories or thoughts

Projection

(D) Placing the blame for personal shortcomings on another person or group

Obsessive-compulsive disorder

(D) Recurrent, intrusive thoughts that produce anxiety and repetitive, ritualistic behaviors

Rationalization

(F) A process of making plausible reasons to justify or explain one's behavior

Match each term with its definition. Adhesion (A) Passage of escape into the tissues, usually of blood, serum, or lymph (B) Infection of the skin characterized by heat, pain, erythema, and edema (C) Collection of extravasated blood trapped in the tissues or in an organ, resulting from incomplete hemostasis after surgery (D) Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection (E) Protrusion of an internal organ through a wound or surgical incision (F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen (G) Separation of a surgical incision or rupture of a wound closure

(F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen

Free association

(F) Speaking thoughts without censorship

Displacement

(H) The expression of emotions toward someone or something other than the source of the emotion

Nasopharyngeal suctioning Approximate length of insertion

(a) Adults: 16 cm (b) Older children: 8 to 12 cm (c) Infants and young children: 4 to 8 cm

Preoperative Teaching

-Provides a smoother, shorter recovery period -Decreases anxiety, increases compliance -TCDB exercises -Diaphragmatic breathing exercises -Incentive spirometry: helps to prevent atelectasis and pneumonia -Leg/feet exercises -SCDs, TED hose (Compression socks): will prevent DVT can also use blood thinners -Pain management -Nause relief measure

Piaget: Sensorimotor Stage

0-2 years- first stage, children learn entirely through the movements they make and the sensations that result. They learn they cause things to happen, they are separate from objects and people around them, things continue to exist even if they can't see them.

When assessing an adolescent in the early stages of drug addiction, which information does the nurse provide to the parents about the adolescent's recovery? 1 "Recovery is possible even without treatment." 2 "There will be severe impairment in all areas of function." 3 "There is no chance of improvement with any treatment." 4 "There is low chance of recovery without any treatment."

1 "Recovery is possible even without treatment."

In preparing for a position at a treatment addiction center, a new nurse reviews research materials related to addiction and identifies which main elements of addiction? Select all that apply. 1 Display of psychological disturbance 2 Excessive use or abuse of a substance 3 Decline of social and economic function 4 Preoccupation with substance, including talking about it constantly 5 Uncontrollable consumption of the substance, including dependence 6 Incarceration or hospitalization for actions or behaviors related to use or misuse of the substance

1 Display of psychological disturbance 2 Excessive use or abuse of a substance 3 Decline of social and economic function 5 Uncontrollable consumption of the substance, including dependence

A young patient says that he gets annoyed when friends tell him that he drinks too much. He also reports that sometimes he thinks he should try and cut down a little on his drinking. The nurse in the clinic would draw which conclusion about the likelihood that the patient has alcoholism based on the CAGE questions? 1 It is probable that the patient has alcoholism. 2 The patient probably does not have alcoholism. 3 There is an increased risk to develop alcoholism. 4 The information provided is inadequate for making any determination.

1 It is probable that the patient has alcoholism.

Which are naturally occurring hallucinogens? Select all that apply. 1 Psilocybin 2 Mescaline 3 Ketamine 4 Phencyclidine (PCP) 5 Lysergic acid diethylamide (LSD)

1 Psilocybin 2 Mescaline

Which factor does the success of a patient going through a substance abuse treatment program depend on? 1 The motivation of the user 2 The effectiveness of group therapy 3 The type of assistance received while in the program 4 The treatment plan established by the health care provider

1 The motivation of the user

Which interventions does the nurse implement while providing care for an intoxicated patient? Select all that apply. 1 Using padded side rails and floor pads 2 Keeping the bed in a flat position at all times 3 Placing the patient in a side-lying position 4 Ensuring that the patient has a patent airway 5 Monitoring the patient's intravenous sites often

1 Using padded side rails and floor pads 3 Placing the patient in a side-lying position 4 Ensuring that the patient has a patent airway 5 Monitoring the patient's intravenous sites often

closed wound signs and symptons

1) edema usually appears within 24 to 48 hours; (2) discoloration is likely to result from the formation of a hematoma (swelling containing blood): initially the discoloration is blackish blue and then turns to green or yellow within a few days; (3) deformity of the limbs is caused by fractures and dislocations; (4) shock often follows from the force of the trauma; (5) pain and tenderness at the site are possible; and (6) signs of internal bleeding are sometimes present.

General Anesthes

1. Loss of consciousness • Amnesia regarding the procedure 3. Pain relief 4. Skeletal muscle relaxation 5. Blocking reflexes such as coughing & gagging, as well as endocrine and autonomic responses • Disadvantages include risk for aspiration due to vomiting. respiratory or cardiac arrest, brain damage, stroke & death. Will have a respirator breathing for the patient

Recovery room

1. Maintain airway and gas exchange: R. Spon, and breath sounds, assess skin color; provide suction PRN • ABCs 2. Monitor cardiac function: BP AP, peripheral pulses, skin temp 3. VS every 5-15 minutes as determined by the condition 4. Monitor level of responsiveness 5. Monitor surgical site and drains 6. Administer IV fluids 7. Equipment: telemetry, O2, Foley catheter, NG, PCA, etc. 8. Assess and medicate pain, nausea, and other discomforts (Zofran or Phenergan for nausea) 9. Safety interventions (Bed alarm, side rails, call light, lights, low bed position) 10. Documentation

14. Several high school teachers completed a CPR class. Which comment by one of the teachers demonstrates knowledge of proper CPR? (Select all that apply.) 1. "The chest compression rate should be at least 100 per minute." 2. "A jaw-thrust maneuver should be used on all patients when I open the airway." 3. "The proper sequence for CPR is circulation, airway, and breathing." 4. "I should look, listen, and feel for breathing for no more than 10 seconds." 5. "The adult chest should be compressed at least 2 inches during compressions."

1. "The chest compression rate should be at least 100 per minute." 3. "The proper sequence for CPR is circulation, airway, and breathing." 5. "The adult chest should be compressed at least 2 inches during compressions."

5. A patient is being discharged to home with an order for oxygen. The order reads, "Continuous O2 at 2 L per N/C." What is the best explanation of this order for the nurse to give the patient? 1. "You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters." 2. "You will need to wear your oxygen during the hours you are awake since your body uses more oxygen during the day. Your order is for 2 liters by nasal cannula." 3. "Your doctor has ordered oxygen for you to use at home to keep your blood oxygen levels at a good level." 4. "You will need to wear oxygen at home whenever you are feeling short of breath. Be sure to set your flowmeter at 2 liters and use your nasal cannula."

1. "You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters."

12. The nurse is preparing to perform tracheostomy care and suctioning. What is the best order of actions when performing these two procedures? Place the steps in the correct order. 1. The nurse performs tracheostomy suctioning. 2. The nurse changes the tracheostomy ties/strap. 3. The nurse changes the dressing around the tracheostomy. 4. The nurse cleans around the tracheostomy with prescribed solution.

1. The nurse performs tracheostomy suctioning. 4. The nurse cleans around the tracheostomy with a prescribed solution. 3. The nurse changes the dressing around the tracheostomy. 2. The nurse changes the tracheostomy ties/strap.

3. What is the maximum time suction should be applied during nasotracheal suctioning? 1. 15 seconds 2. 20 seconds 3. 30 seconds 4. 45 seconds

1. 15 seconds

spiral reverse bandage

1. Anchor bandage at distal border of area to be covered (use one to three circular turns). 2. Advance bandage on ascending angle of approximately 30 degrees. 3. Halfway through each turn fold bandage toward you and continue around part in downward stroke. 4. Continue advancing bandage as in Steps 2 and 3 until desired proximal point is reached. Secure bandage. Used to cover inverted cone-shaped body parts such as calf or thigh.

Spiral

1. Anchor bandage at distal end of body part with two circular turns (note Steps 1 through 3, Circular). 2. Advance bandage on ascending angle, overlapping each preceding turn by half to two-thirds the width of bandage roll until proximal border of area is covered. 3. Secure end of bandage. Used to cover cylindric body parts, where contour of part does not vary significantly in size (e.g., slender wrist and forearm).

Recurrent

1. Anchor bandage with two circular turns (see Steps 1 through 3, Circular) at proximal ends of body part to be covered. 2. Make reverse turn at center front, and advance fabric over distal end of the body part to center back, forming covering perpendicular to first circular turns. 3. Make reverse turn at back and bring bandage forward, overlapping one-half of perpendicular bandage on one side. Make reverse turn at front and overlap opposite side of center, continuing on to back. Repeat these steps, overlapping each previous strip of bandage until entire area is covered. 4. Anchor bandage with two circular turns. 5. Secure end of bandage. Provides caplike coverage for scalp or amputation stump.

3. The health care provider has ordered the patient's wound be irrigated. What is the primary rationale for this procedure? 1. To remove debris from the wound 2. To decrease scar formation 3. To improve circulation from the wound 4. To decrease irritation from wound drainage

1. To remove debris from the wound

Wound Treatment

1. Closure: 2. Drains and Drainage • 80-120ml 1st 24hrs normal • 300ml is the maximum normal 3. Measurement of Wounds & Drainage • Size, condition of wound bed, condition of skin surrounding wound, pain • Drainage (serous, serosanguinous, sanguineous & purulent) 4. Cleaning wounds 5. Dressings • Circle the drainage 6. Documenting wound care • S/S infection: purulent drainage, foul odor, pain, redness, warmth & fever. • Protein to enhance healing and prevent edema. • Vitamin C (Ascorbic Acid) for the formation of collagen For diabetic patients need to control blood sugar, smoking cause vasoconstriction which can hinder healing

6. The home health nurse is visiting a patient who is on home oxygen therapy. What action by the patient and family members alerts the nurse that further teaching about home oxygen therapy is necessary? (Select all that apply.) 1. The nurse notes a fire extinguisher in the kitchen. 2. The patient's brother-in-law is in a separate room smoking a cigarette. 3. The patient states that when shaving an electrical razor is used. 4. The patient is using a water-soluble gel to help with lubricating dry mucous membranes. 5. The oxygen tubing is coiled and secured with a rubber band to prevent the patient from tripping over the tubing.

1. The nurse notes a fire extinguisher in the kitchen. 2. The patient's brother-in-law is in a separate room smoking a cigarette. 3. The patient states that when shaving an electrical razor is used.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy?

Covering the application with a warm, moist dressing and an occlusive outer wrap

11. What are the traditional purposes of a wet-to-dry dressing? (Select all that apply.) 1. Débridement 2. Cooling 3. Comfort 4. Prevent infection 5. Maintenance of moisture at the wound bed

1. Débridement (the removal of damaged tissue or foreign objects from a wound) 5. Maintenance of moisture at the wound bed

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? 1 " I didn't hear anyone talking; come with me to your room." 2 "What you heard was in your head; it was your imagination." 3 "Come to the dayroom and watch television; you'll feel better." 4 "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."

1. I didn't hear anyone talking; come with me to your room. The nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.

Circular

1. Unroll 3 to 4 inches (7.62 to 10.16 cm) of bandage from back of roll. 2. Place flat bandage surface on anterior surface of portion of body to be covered and hold end in place with thumb of nondominant hand. 3. Continue rolling bandage around same area until two overlapping layers of bandage cover part. Remove excess bandage roll. 4. Secure end of bandage with safety pin or clip if it is attached to end of bandage. If end of bandage has raw edge, fold to 1 inch (1.27 to 2.54 cm) under before securing bandage. Gauze bandage is possible to secure with strip of adhesive tape.

4. If a patient's condition requires a very precise delivery of oxygen concentration, the nurse anticipates that the health care provider will order oxygen to be delivered via which device? 1. Venturi mask 2. Simple face mask 3. Nasal cannula 4. Transtracheal cannula

1. Venturi mask

Maintaining Fluid & Electrolyte Balance

• Fluid & electrolyte must be kept in balance • When solutions on both sides of a permeable membrane are equal in concentration then they are isotonic

While assessing a female patient, the nurse finds that the patient has been prescribed an estrogen supplement. Which symptoms does the nurse expect to find in the patient? Select all that apply. O Swollen neck O Edema O Sweating during the night O Excess hair growth O clubbing of the fingernails

Edema Sweating during the night

How much sterile water is instilled in the balloon when preparing to insert an indwelling urinary catheter? O 3 mL O 5 mL O 10 mL O 15 mL

10 mL Rationale The balloon used to hold a routine indwelling urinary catheter in place should be filled with 10 mL of sterile water. Using 3 mL and 5 mL would not anchor the catheter in place: 15 ml may cause the balloon to burst

Sodium:

135-145 normal range water balance, muscle action Food Source: cured meat, canned or processed food Deficiency: poor skin turgor, rapid, thready pulse Toxicity: dry mucous membrane, thirst, flushed, >temp,

The nurse is caring for a patient who has been abusing a central nervous system (CNS) depressant and anticipates finding which signs and/or symptoms during the assessment process? Select all that apply. 1 Agitation 2 Memory loss 3 Dilated pupils 4 Slurred speech 5 Decreased respirations 6 Increased hunger and thirst

2 Memory loss 4 Slurred speech 5 Decreased respirations

The nurse is caring for a patient who has been abusing a central nervous system (CNS) depressant and anticipates finding which signs and/or symptoms during the assessment process? Select all that apply.1 Agitation2 Memory loss3 Dilated pupils4 Slurred speech5 Decreased respirations6 Increased hunger and thirst 1. agitation 2 Memory loss 3. dilated pupils 4 Slurred speech 5 Decreased respirations 6 increased hunger and thirst

2 Memory loss 4 Slurred speech 5 Decreased respirations

The nurse caring for a patient admitted to the health care facility for drug overdose observes track marks on the patient. Which potential health problems does the nurse expect the provider to evaluate for in the patient? Select all that apply. 1 Septal necrosis 2 Phlebitis 3 HIV/AIDS 4 Hepatitis B and C 5 Chronic sinusitis

2 Phlebitis 3 HIV/AIDS 4 Hepatitis B and C

The mother of a 2-year-old is concerned that her child is not eating enough at each meal. What education should the nurse provide when the mother asks how much this child should consume at each meal? O 4 teaspoons of each solid food O 2 teaspoons of each solid food O 1 tablespoon of each solid O 2 tablespoons of each solid food

2 tablespoons of each solid food

A patient diagnosed with depression has been prescribed a tricyclic antidepressant. The nurse educates the patient to expect improvement in the depression within which period of time? O 4 to 6 days O 1 to 2 weeks O 2 to 4 weeks O 2 to 3 months

2 to 4 weeks Rationale lt takes approximately 2 to 4 weeks for a tricyclic antidepressant to reach therapeutic blood levels. Four to days and l to 2 weeks is too short for therapeutic levels to be achieved. The patient should notice changes in depression sooner than 2 to 3 months.

When can a patient who has been started on a selective serotonin reuptake inhibitor(SSRI) expect to no longer feel depressed? 1 week 10 days 2 to 4 weeks 4 to 6 months

2 to 4 weeks Rationale lt takes it takes 2 to 4 weeks of therapy with an SSRl to obtain the full therapeutic beneft when treating depression. period of l week or lo days is not enough time to establish a blood level of the medication, and a decrease in depression is not expected to be seen. Patients will see improvement before 4 to 6 months of SSRI therapy.

Piaget Preoperational Stage

2-7 years- Once children acquire langage they can use symbols to represent objects. Still egocentric thinking and they assume everyone sees things from the same viewpoint. Understand concepts like counting, classifying according to similarity, and past-present-future but focused on present and concrete rather than abstract.

13. The nurse has just performed oropharyngeal suctioning. Which documentation is the most complete after this procedure? 1. "Suctioned patient using a Yankaur suction catheter. Large amount of mucus suctioned. Patient tolerated procedure well and is breathing better." 2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored." 3. "Oropharyngeal suctioning performed due to patient being unable to expectorate secretions. Used Yankaur suction catheter to perform procedure. Patient breathing better following suctioning." 4. "Patient requiring suctioning. Oropharyngeal suctioning performed. Patient unable to cough up thick mucus. Breathing improved after suctioning. Used a Yankaur suction catheter for procedure."

2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored."

14. The health care provider has ordered a patient diagnosed with pneumonia to have oxygen via a simple face mask. The nurse is aware that the patient will be receiving a FiO2 of what percentage depending on the flowmeter setting? 1. 24%-44% 2. 35%-55% 3. 24%-55% 4. 60%-90%

2. 35%-55%

9. The nurse is assessing an adult patient who has been brought to the hospital with third-degree burns covering his head, right arm, and right leg. The nurse demonstrates accurate assessment skills by determining what to be the extent of the patient's burns? 1. 27% 2. 36% 3. 45% 4. 54%

2. 36%

13. The student nurse is changing a patient's dressing. What action indicates the need for further education? (Select all that apply.) 1. Enclose the soiled dressing within a latex glove. 2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves.

2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves.

Sterols

Sterols are a subgroup of steroids, and they are amphipathic in nature. Sterols made by plants are called phytosterols, and sterols produced by animals are called zoosterols. Sterols play a variety of important roles, including membrane fluidity and cellular signal ing. Cholesterol is the most significant zoosterol.

19. During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding? 1. The dressing is saturated with bright red sanguineous drainage, and the patient has an increased urinary output. 2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased. 3. The dressing is saturated with serosanguineous drainage, and the patient is diaphoretic with a decrease in pulse and respirations. 4. The dressing is dry and intact, and the patient reports shortness of breath and has an elevated temperature.

2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased.

15. Which patient is more at risk for wound dehiscence? 1. The patient who smokes 2. The patient who is obese 3. The patient with a history of peripheral vascular disease 4. The patient who is immunocompromised

2. The patient who is obese

10. The nurse observes the student nurse suction the patient with a tracheostomy. Which action by the student nurse requires the nurse to intervene? (Select all that apply.) 1. The student preoxygenates the patient before beginning suctioning. 2. The student suctions the patient for 30 seconds during each suctioning attempt. 3. The student uses tap water to clear the catheter tubing between suction attempts. 4. The student applies intermittent suction when withdrawing the suction catheter from the airway. 5. The student places the thumb over the suction control vent when advancing the catheter into the patient's airway.

2. The student suctions the patient for 30 seconds during each suctioning attempt.

Urine Diagnostic testing

24-Hour Urine Collection •First urine is discarded •Keep specimen on ice or refrigerated Specific Gravity •Measure the ability of the kidneys to concentrate urine •Normal value 1.003 -1.030•>: dehydration, <renal perfusion or >ADH •<: >FI, Diabetes insipidus, renal disease, diuretic use

A 59-year-old homeless man is admitted with diagnoses of hypothermia and pneumonia. The nurse notes that the patient is malnourished and has multiple ecchymotic areas on his arms and legs. The nurse also notes the odor of alcohol coming from the patient. In addition to being alert to the consequences of hypothermia and pneumonia, to which other signs and symptoms should the nurse be alert during her shift? 1 Rebound hyperthermia and burn injuries to the skin 2 Decreasing level of consciousness and bradypnea 3 Tremors, diaphoresis, disorientation, and restlessness 4 Dyspnea, hypotension, bounding pulse, and urinary retention

3 Tremors, diaphoresis, disorientation, and restlessness

How soon after treatment with antipsychotic medications is neuroleptic malignant syndrome (NMS) likely to develop? 24 to 72 hours 3 to 9 days 2to 3 weeks 3 to 4 years

3 to 9 days Rationale NMS typically occurs after 3 to 9 days of treatment with antipsychotic medications. Once NMS begins, symptoms rapidly progress over 24 to 72 hours. Pseudoparkinsonian symptoms associated with the extrapyramidal symptoms of using antipsychotic medication begin after 2 to 3 weeks of antipsychotic drug therapy. Tardive dyskinesia develops in about 20%to 25% of patients receiving typical antipsychotic medications on a long-term basis (months to years).

9. Which phrase best describes serous drainage? 1. Fresh bleeding 2. Thick and yellow 3. Clear, watery plasma 4. Beige to brown and foul smelling

3. Clear, watery plasma

3. A neighbor tells the nurse that her 12-year-old child has been burned with scalding water. The arm is red and starting to blister. In addition to advising her to see a health care provider, what will the nurse tell the neighbor to apply to the burn? 1. Hydrogen peroxide 2. Petroleum jelly 3. Cool compresses 4. Salt water compresses

3. Cool compresses

6. A neighbor tells the nurse that her 5-year-old son has ingested one of her liquid cleaning supplies. The child is in no distress at this time. The mother shows the nurse the bottle; the nurse is unfamiliar with the ingredients. Which action by the nurse is appropriate? 1. Give syrup of ipecac to induce vomiting. 2. Give milk to neutralize any acids. 3. Give water to dilute the poison. 4. Call the poison control center.

3. Give water to dilute the poison.

4. What is the best indicator that a wound has become infected? 1. Palpation of the wound reveals excess fluid under its edges. 2. Wound cultures are positive. 3. Purulent drainage is coming from the wound area. 4. The wound has a distinct odor.

3. Purulent drainage is coming from the wound area.

10. The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention? 1. Collection of wound drainage 2. Reduction of abdominal swelling 3. Reduction of stress on the abdominal incision 4. Stimulation of peristalsis from direct pressure

3. Reduction of stress on the abdominal incision

11. The health care provider has ordered oxygen at 100% via a nonrebreathing mask. The nurse evaluates that the mask is working properly when making which observation? 1. The reservoir bag collapses 50% when the patient inhales. 2. The reservoir bag collapses completely when the patient inhales. 3. The reservoir bag remains nearly full when the patient inhales. 4. The reservoir bag inflates when the patient inhales.

3. The reservoir bag remains nearly full when the patient inhales.

10. A man suffers heat exhaustion while mowing the grass. The man's wife demonstrates knowledge of proper care of her husband with which action? (Select all that apply.) 1. The wife calls 911 immediately. 2. The wife encourages her husband to sit in a tub of cold water. 3. The wife gives her husband cold water and a sports drink. 4. The wife carefully monitors her husband while he finishes mowing. 5. The wife loosens her husband's clothing.

3. The wife gives her husband cold water and a sports drink. 5. The wife loosens her husband's clothing.

5. The nurse is told in report that one of the patients has been very depressed lately. On checking the unit, the nurse finds the patient in the bathroom with one wrist bleeding profusely. The patient states that he broke a glass and used it to cut his wrist in a suicide attempt. What should the nurse do after sending someone to call for help? 1. Attempt to find out what has been causing her depression. 2. Apply a tourniquet above the injury. 3. Use 4- × 4-inch gauze pads to apply direct pressure. 4. Thoroughly wash the wound.

3. Use 4- × 4-inch gauze pads to apply direct pressure.

Physical Activity Guidelines & Recommendations

Children • 60 minutes or more daily Adults •150 minutes/week •Moderate intensity •Brisk walking •75 minutes vigorous intensity •Running or jogging •Include muscle strengthening 2x/week •Weight bearing exercise

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36 %

How much normal saline is used to irrigate a nasogastric tube? O 15 ml O 30 ml O 45 ml O 60 ml

30 ml Nasogastric tubes should be irrigated with 30 ml of normal saline; 15 ml is not enough

A patient has been admitted to the medical-surgical unit with a concussion and a fractured clavicle after a motor vehicle accident. When viewing the electronic medical record, the nurse notes that the patient had positive results for blood and urine alcohol, despite the patient reports of not having any problems with drugs or alcohol. Which explanation is the rationale for the patient's statements? 1 The patient is trying to avoid a ticket. 2 The patient is lying to avoid embarrassment. 3 A concussion can distort, alter, or eliminate parts of memory. 4. Denial is the predominant defense mechanism of substance abusers.

4 Denial is the predominant defense mechanism of substance abusers.

A school nurse asks a group of high school-age students to write down the last time they used alcohol or other illicit substance and to describe the circumstances associated with that occurrence. The nurse then examines them for evidence of a problem with dependence. The nurse identifies which student in the group as exhibiting the strongest indicator of dependence? 1 The student who had two glasses of wine with family members at dinner. 2 The student who drank three cans of beer and vomited at an after-prom party. 3 The student who had a "puff" of marijuana with an older brother who was home from college. 4 The student who removed several ounces of vodka from the parents' supply and replaced it with water.

4 The student who removed several ounces of vodka from the parents' supply and replaced it with water.

To which depth is tubing inserted into the rectum when administering a soap suds enema? O 1 inch O 4 inches O 7 inches O 12 inches

4 inches Rationale For a standard enema, the tube should be inserted 3 to 4 inches into the rectum. A shorter distance could cause the solution to leak. Inserting the tubing more than 4 inches could result in trauma to the rectum or colon.

How many inches should an indwelling catheter be lubricated before inserting in a male patient? O 1.5 O 4.5 O 3 O 6

6 Rationale Because the urinary tract of a male is longer than that of a female, approximately 6 to 7 inches of the catheter will need to be lubricated. In a female patient, 1.5 to 2.0 inches of the urinary catheter should be lubricated. Lengths of 3 and 4.5 inches are too short for a male patient. Inadequate lubrication leads to friction and trauma to the tissue.

2. A patient's physician told the patient that she was suffering from hypoxia. The patient asks the nurse what that means. Which statement by the nurse is most accurate? 1. "Hypoxia means that there is a deficient amount of oxygen in your blood." 2. "It would be best if you asked your physician to explain hypoxia." 3. "There is too much carbon dioxide in your blood." 4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

The nurse is physically examining a 5-month-old healthy infant. On reviewing the birth report, the nurse finds that the infant's weight was 3 kg at the time of birth. What would be the present approximate weight of the infant? O 4 kg O 9.5 kg O 6 kg O 11.5 kg

6 kg

How often does a 76-year-old need screening for preventative health? O Every two years O every six months O every three years O every year

every year

12. What action should the nurse implement to reduce surgical wound infection? (Select all that apply.) 1. Adhering to the principles of hand hygiene 2. Cleansing the incision from the least contaminated to the most contaminated area 3. Leaving the incision open to the air 4. Changing the dressing using sterile technique 5. Ensuring the patient is consuming an adequate diet

4. Changing the dressing using sterile technique

Which condition is associated with delirium tremens (DTs)? O Fetal alcohol syndrome O Overdose of opioid analgesics O excessive alcohol consumption O a motivational cannabis syndrome

excessive alcohol consumption

When the nurse discussed as prevention of cardiac disease balls and depression with a group of older adults the benefits of where our important to stress? O nutrition O medication O exercise O sleep

exercise

Reproductive

< testosterone production & size of testes •<rate & force of ejaculation •> size in prostate •Reproductive capacity ceases in women •Vaginal changes, including < muscle tone & lubrication •Impotence or sexual dysfunction for both genders; sexual function varies & depends on general physical condition, mental health status & medications

5. Which nursing entry is the most complete in its description of a wound? 1. Wound appears to be healing well, dressing dry and intact 2. Wound well approximated with minimal drainage 3. Drainage size of quarter; wound pink; 4 × 4 applied 4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied

4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied

15. When the nurse is caring for a person who has developed a nosebleed, which nursing action is appropriate? 1. Apply steady pressure to the bridge of the nose for 5 minutes. 2. Remind the victim to try to breathe through the nose. 3. Avoid using ice over the nose. 4. Keep the victim's head tilted slightly forward.

4. Keep the victim's head tilted slightly forward.

8. What is the correct procedure for the wet-to-dry dressing method? 1. Place dry gauze into the wound and remove it when it is wet. 2. Medicate the patient for pain after you change the dressing. 3. Complete this type of dressing change just once a day. 4. Place moist gauze into the wound and remove it when it is dry.

4. Place moist gauze into the wound and remove it when it is dry.

2. The nurse finds that the patient's incision has eviscerated. What action should the nurse take? (Select all that apply.) 1. Place the patient in high Fowler's position. 2. Give the patient fluids to prevent shock. 3. Do not allow the patient to get out of bed. 4. Replace dressings with sterile fluffy pads. 5. Apply warm, moist sterile dressings.

5. Apply warm, moist sterile dressings.

The nurse learns that a patient is apathetic, hostile, and in denial after losing a friend in an accident. What does the nurse expect the patient to be experiencing? O A crisis O Anxiety O Conflict O Frustration

A crisis Rationale A crisis is an unstable period in a person's life characterized by an inability to adapt to a sudden change from a precipitating event. A crisis often tends to resolve itself over a 4- to 6-week period. If the crisis is not resolved, it may result in physical illness or an emotional breakdown. Apathy, hostility, and denial are features of an unresolved crisis. Anxiety is a vague feeling of apprehension that results from a perceived threat to one's self, although the source is often unknown. Conflict results from the presence of opposing or incompatible thoughts. Frustration is an emotional response to anything that interferes with goal-directed activity.

A patient tells a nurse that he must walk around the table four times before he eats any meal; otherwise he will get sick. Which clinical symptom would the nurse document in the patient record?

Compulsion

Hydrogel

A hydrogel is a network of crosslinked polymer chains that are hydrophilic, sometimes found as a colloidal gel in which water is the dispersion medium. A three-dimensional solid results from the hydrophilic polymer chains being held together by cross-links.

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which condition in a patient is a sign of Wernicke's encephalopathy?

Involuntary eye movement the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).

Which patient undergoing vilazodone therapy is at potential risk for gastrointestinal bleeding? A patient who drinks grapefruit juice regularly A patient who underwent general anesthesia A patient undergoing monoamine oxidase inhibitor therapy A patient undergoing nonsteroidal antiinflammatory drug therapy

A patient undergoing nonsteroidal antiinflammatory drug therapy Rationale Selective serotonin reuptake inhibitors ( such as vilazodone) may enhance the anticoagulant effects of nonsteroidal anti-inflammatory drugs and increase the potential for gastrointestinal bleeding. Grapefruit juice inhibits the metabolism of vilazodone, which increases its serum levels and the potential for toxicity. Anesthetics enhance the sedative effects associated with vilazodone therapy. Severe reactions such as excitement, diaphoresis, rigidity, convulsions, hyperpyrexia, and death may result from the concurrent use of monoamine oxidase inhibitors and vilazodone.

Women are often the subjects of study in obesity research.

A significant difference in ethnicity exists with regard to the incidence of women 20 years old or older who are overweight in the United States: 82.1% of black or African-American women 76.9% of Mexican women 62.9% of white women Evidence is accumulating to suggest that biologic differ ences in lipid metabolism among ethnic groups may contribute to these differences. Researchers have found that obese African-American women uptake fatty acids from circulation into adipose tissue at a higher rate than their white counter parts. In addition, African-American women have an increased capacity to synthesize fat in adipose tissue as compared with white women. Subsequently, African-American women are more efficient at converting excess kilocalories into stored fat. These types of differences continue to unfold with ongoing genetic studies. Differences such as these will also guide indi viduals in their dietary choices with regard to how their bodies will respond to specific nutrients. The path from fat in our food to fat on our bodies continues to provide many questions for inspection and evaluation. The science of lipid digestion, metabolism, and use will remain a hot topic for debate and research for years to come.

The nurse is teaching a patient about transurethral needle ablation (TUNA) to treat benign prostate hypertrophy (BPH). Which statement from the patient regarding TUNA indicates that the patient needs further education? O A specially designed urinary catheter is inserted into the bladder O The time is heated to 446 F12 approximately minutes per lesion" O A comprehensive history and physical animation determines its use"

A specially designed urinary catheter is inserted into the bladder Rationale In TUNA, an interstitial radiofrequency needle is inserted through the urethra and into the lateral lobes of the prostate A specially designed urinary catheter is used in transurethral microwave thermotherapy. In TUNA, the tissue is heated to 446"F (230:c) for approximately 3 minutes per leslon, which results in coagulation necrosis Heat-induced coagulation necrosis reduces the volume of the prostate. A comprehensive history and physical examination of the patient helps determine the benefits of TUNA. This ensures the safe and effective use of the procedure.

Which statement regarding diagnosable mood disorders in the United States for all age groups is correct? About 0.4% to 1.6% of people will have a diagnosable mood disorder during their lifetimes. About 15%to 20% of people will have a diagnosable mood disorder during their lifetimes. About 20%to 30% of people will have a diagnosable mood disorder during their lifetimes. About 45% to 60% of people will have a diagnosable mood disorder during their lifetimes.

About 0.4 % to 1.6% of peopl will have a diagnosable mood disorder during their lifetimes. Rationale About 15%to 20% of people in the United States will experience a diagnosable mood disorder during their lifetimes. About 45% to 60% of patients with depression suffer from endocrine abnormalities, such as excessive secretion of cortisol and abnormal thyroid-stimulating hormone. About 20%to 30% of patients with major depression recover fully and do not experience another bout of depression. The prevalence rate of bipolar disorder is 0.4%to l.6% of the adult population of the United States.

Which statement about patients with depression is correct? O Depressive symptoms are seen more in men. O Manic depression is also called a unipolar disorder. O Beta-adrenergic blocking agents are used to control depression. O About 45%to 60% of patients with depression have endocrine abnormalities.

About 45%to 60% of patients with depression have endocrine abnormalities. Rationale Excessive secretion of cortisol and the abnormal thyroid-stimulating hormone is the results of endocrine abnormalities. These abnormalities are found in 45% to 60% of patients with depression. The frequency of depressive symptoms is about 26% for women and 12% for men. Bipolar disorders were once known as manic depression, not a unipolar disorder. Beta- adrenergic blocking agents are used to control hypertension; in fact, these drugs are known to cause depression.

According to American Psychiatric Association, what are the long-term goals associated with the treatment of substance abuse? Select all that apply. O Prevention of drug misuse and abuse O Abstinence in the use and effects of substances O Reduction in the frequency and severity of relapse O Improvement in psychological and social functioning O Development of professional attitudes and behaviors

Abstinence in the use and effects of substances Reduction in the frequency and severity of relapse Improvement in psychological and social functioning Rationale According to the American Psychiatric Association, the long-term goals of treating substance abuse are abstinence in the use and effects of substances, reduction in the frequency and severity of relapse, and improvement in psychological and social functioning Prevention of drug misuse and abuse is an important priority in the practice of every healthcare profession. The curricula of healthcare profession educational programs should ensure that students have multiple opportunities for the development of professional attitudes and behaviors.

When the laboratory report of a chronic alcoholic patient shows a creatinine clearance of 25 mL/min, which medication would be contraindicated in this patient? O Phenytoin (Dilantin) O Warfarin (Coumadin) O Disulfiram (Antabuse) O Acamprosate (Campral)

Acamprosate (Campral) Rationale Acamprosate (Campral) is prescribed to help chronic alcoholic patients abstain from alcohol. It is contraindicated in patients with a creatinine clearance of less than 30 mL/min because it may aggravate the renal toxicity. Phenytoin (Dilantin) is contraindicated with disulfiram (Antabuse) because it may result in phenytoin toxicity. Disulfiram (Antabuse) may enhance the anticoagulant effects of warfarin (Coumadin) and should be used with caution. Patients who use phenytoin (Dilantin) and disulfiram (Antabuse) concurrently should be monitored for signs of phenytoin toxicity.

A patient who has prescribed a medication for rehabilitation for chronic alcohol abuse complains of diarrhea after discontinuing the medication. Which medication is responsible for this side effect? O Naltrexone (ReVia) O Disulfiram (Antabuse) O Clorazepate (Tranxene) O Acamprosate (Campral)

Acamprosate (Campral) Rationale Acamprosate (Campral) is used in alcohol rehabilitation programs to help chronic alcoholic patients maintain sobriety. This drug causes diarrhea as a side effect upon sudden discontinuation. Naltrexone (ReVia) is an opioid antagonist that is prescribed to block the pharmacologic effects associated with opioids and alcohol. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting and may cause drowsiness and fatigue as side effects. Clorazepate (Tranxene) is a benzodiazepine that is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion.

When does the healthcare provider want to prescribe a medication that reduces the drinking rates of alcohol, which medication combination would the nurse anticipate to be ordered? O Naltrexone and disulfiram O Disulfiram and acamprosate O Clorazepate and disulfiram O Acamprosate and Naltrexone

Acamprosate and Naltrexone Rationale Acamprosate helps patients maintain abstinence from alcohol. Naltrexone blocks the high from drinking. Higher success rates are documented when these drugs are used together rather than individually. Disulfiram reduces the desire for alcohol by inducing nausea and vomiting. Clorazepate is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion.

Which stages would a nursing student identify as part of Kubler-Ross's stages of dying? Select all that apply. Acceptance Anger Bargaining Denial Depression Reorganization

Acceptance Anger Bargaining Denial Depression Rationale Kubler-Ross's theory of grief and mourning is a behavior-oriented theory. It includes five stages. In the acceptance stage, the individual accepts the loss and looks forward to the future. In the anger stage, the individual resists the loss and may lash out at everyone and everything. The individual postpones the awareness of the reality of the loss and may try to deal in a subtle or overt manner as though the loss can be prevented. This is the bargaining stage. In the denial stage, the individual acts as though nothing has happened and may refuse to believe or understand that the loss has occurred. The individual feels overwhelmingly lonely and withdraws from interpersonal interaction in the depression stage. Reorganization is a stage of Bowlby's phases of mourning.

Which concept do the four elements of excessive use or abuse—display of psychological disturbance, decline of social and economic function, and uncontrollable consumption indicating dependence—define?

Addiction

When discussing aging to whom does the term late adulthood apply? O Ae 55 and above O Age 65 and above O Ape 7O and above O Age 75 and above

Age 65 and above

A patient is prescribed haloperidol. The nurse advises the patient to rise slowly from sitting to standing position. Which potential side effect of the medication would support this intervention? O Akathisia O Dry mouth O Blurred vision O Morning hangover

Akathisia- a state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs. Rationale Haloperidol is an antipsychotic agent. Akathisia is an extrapyramidal side effect of antipsychotic agents characterized by an inability to stand still and the presence offoot tapping. The nurse advises the patient to rise slowly from sitting to a standing position to avoid alling. Dry mouth is an anticholinergic side effect, and sugaless candy is suggested for dry mouth. Blurred vision is a side effect of monoamine oxidase inhibitors (MAOls). Patients with morning hangover are advised to rise slowly, but this side effectis not associated with antianxiety agents.

21. After a total abdominal hysterectomy, a post-operative patient develops a wound evisceration. What should the nurse do first? (629) 1. Check the patency of the intravenous (IV) site for delivery of fluids. 2. Place the patient in low Fowler's position to reduce strain on the wound. 3. Prepare the patient for surgery and contact the surgeon. 4. Cover the wound with a sterile dressing moistened with saline.

Answer 2: The patient should be placed in a low Fowler's position with the knees slightly flexed The wound should be covered with sterile dressings moistened with saline.. The surgeon should be notified. A patent IV is needed because the patient is likely to need a surgical repair.

A nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. Which symptoms would the nurse assess for with regard to tardive dyskinesia?

Involuntary movements of the mouth and tongue

8. With appropriate instruction and supervision, which tasks related to wound care can be delegated to unlicensed assistive personnel? Select all that apply. (642) 1. Emptying a closed drainage container 2. Removing sutures or staples 3. Applying an abdominal binder 4. Assessing breathing with a breast binder in place 5. Measuring intake and output

Answer 1, 3, 5: Removing sutures or staples requires concurrent assessment of the wound, so this cannot be delegated. Likewise, assessment of breathing and patient comfort cannot be delegated.

Stage 3 care of burns

long-term rehabilitation phage, burn wound treatment, returning to baseline as possible

5. Which patient has the best chance to fully recover because of the nurse's actions? (395) 1. 4-year-old drowns; nurse starts cardiopulmonary resuscitation (CPR) within 4 minutes of clinical death 2. 32-year-old with brain death has a cardiac arrest; nurse starts CPR within 2 minutes 3. 17-year-old with biologic death has a respiratory arrest; nurse immediately delivers rescue breaths 4. 55-year-old is electrocuted; nurse starts CPR within 10 minutes of clinical death

Answer 1: Clinical death means that the heart beat and breathing have stopped. If cardiopulmonary resuscitation (CPR) is started within 4 minutes, tissue is spared and condition can be reversed. In brain death or bioloic death the damage is permanent. A delay of 10 minutes in initiating CPR is likely to result in brain death.

Which patient is the most likely candidate for an endotracheal tube? (346) 1. The patient is discovered in the bathroom, unresponsive and pulseless. 2. The patient is choking on a foreign body that cannot be dislodged. 3. The patient needs long-term mechanical ventilation for oxygenation. 4. The patient needs a precise, controlled concentration of oxygen.

Answer 1: Endotracheal tubes (ET) are used in emergency situations to establish an airway for patients who are not breathing. Also ET tubes are used for surgical patients who need general anesthesia. An emergency tracheostomy is needed if foreign body cannot be dislodged. Patients who need long-term mechanical ventilation may get tracheostomy. Those needing precise controlled concentrations would be fitted with a venturi mask.

Which individual is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record?

An irregularly shaped lesion

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

16. A patient had surgery 4 days ago and now reports an increase in pain and has a temperature of 101.6° (38.7° C). The incision site looks red compared to yesterday and a small amount of purulent drainage is seeping around the suture line. Which laboratory result will the nurse check before contacting the surgeon? (619) 1. Hemoglobin and hematocrit 2. White blood cell count 3. Platelet count 4. Blood glucose level

Answer 2: The nurse suspects that an infectious process is occurring and knows that an elevated white blood cell count is likely to validate this suspicion.

30. A young man who is injured is brought to the clinic by his friends. They are all very excited, but they are able to point out that he has a stick poking out of the anterior chest wall. Which symptoms indicate that the patient has a pneumothorax? Select all that apply. (407) 1. Pain worsens with inspiration and expiration efforts. 2. Breathing is labored and difficult. 3. A hissing sound is audible as air flows in and out of his chest. 4. The patient is unconscious and unresponsive to normal stimuli. 5. Pulse is weak, rapid, and thready. 6. His chest does not expand on the side of injury during inspiration.

Answer 1, 2, 3, 5, 6: Respiratory distress, pain, and decreased perfusion are signs/symptoms of a pneumothorax or hemothorax. A patient could be unconscious and responsive if excessive blood is lost or decreased oxygenation of tissues has occurred; however, patients with a hemothorax or pneumothorax are frequently conscious and experiencing pain, anxiety, and severe respiratory distress.

13. In caring for a patient with a tracheostomy, what interventions will the nurse use to reduce the risk for infection? Select all that apply. (346) 1. Evaluate the patient for excess secretions and suction as often as necessary. 2. Provide constant airway humidification. 3. Provide frequent mouth care. 4. Wear a mask when performing routine tracheostomy care. 5. Remove water that condenses in equipment tubing. 6. Change or clean all respiratory therapy equipment every 8 hours.

Answer 1, 2, 3, 5, 6: The nurse would not routinely wear a mask to do tracheostomy care, unless the patient is under airborne or droplet precautions. The other options are correct.

15. A patient has just returned from surgery. What are the initial assessments that the nurse would make related to the surgical site? Select all that apply. (620) 1. Inspect the protective dressing that was placed by the surgical team. 2. Look at the area around the dressing and record observations. 3. Check under the patient to make sure that the exudate is not pooling. 4. Carefully remove the dressing and inspect the suture line for intactness. 5. Expect and note the amount of serous drainage that is coming from the wound

Answer 1, 2, 3: Initially, the nurse inspects the dressing for intactness and for any signs of hemorrhage. The skin surface around the dressing is also noted for baseline comparison. Exudate will drain downwards, so the nurse must look underneath the patient to ensure that there is no drainage present. The initial dressing is generally removed by the surgeon. Sanguineous drainage is expected at first; serous drainage occurs later as wound healing progresses.

16. Which interventions are appropriate for a victim who is in hypovolemic shock at the scene of an accident? Select all that apply. (403) 1. Establish an airway. 2. Control bleeding. 3. Keep the head elevated. 4. Cover with a blanket or coat. 5. Provide oral fluids, such as water. 6. Administer over-the-counter analgesics.

Answer 1, 2, 4: Immediate measures are to establish an airway and control bleeding. Body temperature should be maintained, so covering the person helps minimize heat loss. The head should not be elevated, because this will decrease perfusion to the cerebrum. Also, spinal precautions would be applied if head or neck injuries are suspected. Oral fluids are typically withheld. Intravenous fluids would be started if available. No medication should be given at the scene of the accident.

22. A postoperative patient who was happy and cheerful earlier now demonstrates restlessness and anxiety. He reports feeling "a little lightheaded." He is mildly diaphoretic and his pulse feels thready. What assessments does the nurse perform to identify a suspected complication? (628, 629) 1. Checks the pulse rate, blood pressure, and assesses for pain 2. Assesses for localized warmth or redness with tenderness 3. Observes the incision site for wound edge approximation 4. Takes the temperature and checks for purulent drainage

Answer 1: For a postoperative patient, the nurse is likely to first suspect hemorrhage, so taking the pulse and blood pressure and checking for pain would be the best actions. The nurse would check for wound approximation. The patient is more likely to report a pop or release sensation if the incision comes apart. Infection is also a possibility. The symptoms in the scenario could accompany septic shock, but the goal is to identify infection signs prior to the onset of septic shock. (Note to the student: The patient's symptoms could also be related to other disorders such as pulmonary emboli or hypoglycemia.)

9. The nurse sees that the patient takes steroids for a respiratory condition. What would be the expected affect of steroids on wound healing? (618) 1. Decreased inflammatory response 2. Prolonged bleeding times 3. Decreased keloid formation 4. Impaired formation of granulation tissue

Answer 1: Patients who take steroids can have a decreased inflammatory response. Steroids are used to decrease inflammation in disorders, such as arthritis.

31. The home health nurse sees the patient lying on the floor. On entering the house, the nurse can smell a strong odor of gas and the house is extremely hot. What should the nurse do first? (410) 1. Step out of the house and call 911. 2. Call Poison Control and describe the situation. 3. Establish responsiveness and start cooling measures. 4. Open the windows and move the patient out of the house.

Answer 1: The nurse cannot immediately determine if the patient has been overcome by gas or heat, or by something else; however, for the nurse's safety, he/she steps out of the house and calls 911. If the nurse is overcome by gas and help has not been summoned first, the nurse and the patient could die. If the nurse can remove the patient from the house, this would be the best thing for the patient; however, if the nurse cannot safely move the patient, the nurse should use critical thinking. (Windows could be broken from the outside. Two strong neighbors could assist the nurse to drag the patient from the house.) Cooling measures and contacting Poison Control can be done once the victim is out of the hot and toxic environment.

28. An older patient comes to the clinic for epistaxis (acute hemorrhage from the nostril, nasal cavity, or nasopharynx). It is readily controlled with steady pressure applied to the bridge of the nose. What additional assessment is most important for this patient? (405) 1. Measuring the blood pressure 2. Understanding of self-care measures 3. First-aid attempts performed by the patient 4. Checking an oral temperature

Answer 1: The nurse should assess all of the options; however, for elderly patients hypertension is a primary risk factor. If hypertension is the underlying cause, the blood pressure is likely to be very high. Because the bleeding was easily controlled, the nurse suspects that the patient did not know how or could not perform the self-care measures to stop the bleeding, so knowledge and skill must be assessed. Infections can also contribute to nosebleeds, so checking the temperature would also be appropriate.

18. The nurse is preparing to remove the patient's staples, but after assessment, the nurse decides that the staples should not be removed. The decision was based on which finding? (630) 1. The wound edges were partially separated. 2. Dried serous drainage was noted around the staples. 3. The patient was anxious about staple re-moval. 4. Early keloid formation was observed.

Answer 1: The nurse would not remove staples or sutures if the wound edges appeared to be separating. Serous drainage is a sign of healing and should be cleaned away. The patient's anxiety can be addressed before the procedure. Staple removal should feel like a tug or a pinch, but should not cause great pain. The site can be reinforced with SteriStrips, so this should decrease worries about the incision coming apart. Keloid formation and scarring could be aggravated by leaving the staples in too long.

27. The patient needs a breast binder. What is the most important consideration for the nurse when implementing this application? (642) 1. Respiratory function must not be restricted. 2. Vomiting and nausea are a contraindication. 3. Binders cannot be used for patients who are obese. 4. Older patients have difficulty tolerating the binder

Answer 1: The primary concern is that respiratory function could be restricted if the binder is too tight. Vomiting and nausea are not contraindications, but the patient may need assistance in positioning the emesis basin. Binders can be used for obese patients, but the appropriate size is needed. Older patients do have more fragile skin, so the skin must be assessed frequently, or the nurse may decide that the binder should not be used because of the fragile skin.

11. The nurse is caring for a patient with a tracheostomy. What signs/symptoms indicate the need for suctioning? Select all that apply. (353) 1. Fine crackles in posterior lobes 2. Gurgling sounds heard during respiration 3. Restlessness or anxiety 4. Emesis in the oral cavity 5. Drooling excessive secretions 6. Patient indicates need for suctioning

Answer 2, 3, 4, 5, 6: Gurgling sounds, restlessness, emesis in mouth, and drooling are objective signs that indicate the need for suctioning. Conscious patients are frequently able to indicate the need for suctioning. Fine crackles may indicate a respiratory disorder, such as pneumonia, but the pathology is at the alveoli level, and suctioning removes secretions in the upper airway.

The nurse is caring for a patient who is on 3 L oxygen per nasal cannula. What tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. (340) 1. Ensuring that the oxygen flow is set at 3 L/ min throughout the shift 2. Helping the patient to clean area around nares and ears 3. Counting the respiratory rate and taking the pulse oximeter reading 4. Listening to breath sounds before and after the patient coughs 5. Assisting the patient to a semi-Fowler's position 6. Observe the nares, external nasal area, and ears for breaks in skin integrity

Answer 2, 3, 5: UAP can assist the patient with hygiene, position changes and take vital signs. The nurse is responsible for ensuring the correct flow rate and assessment.

19. Two nurses are shopping together in a mall and they witness a person collapse and become unresponsive. Based on the assessment, they initiate two-rescuer CPR. Under which circumstances can the two nurses discontinue the CPR? Select all that apply. (394) 1. A relative of the unresponsive person tells them to stop. 2. Mall personnel arrive with the automated external defibrillator. 3. The curious crowd pushes in and bystanders are loud and unruly. 4. Trained medical personnel arrive and take over CPR. 5. The person remains unconscious but spontaneous pulse and breathing occur. 6. A layperson offers to take over the role of doing compressions.

Answer 2, 4, 5: CPR can be stopped to apply the automated external defibrillator (AED), and for trained personnel to take over. If the person is spontaneously breathing and has a pulse, CPR should be discontinued even if the person remains unconscious. Pulse and breathing should be continuously monitored. The nurses should not trade off with a layperson unless they are exhausted and unable to continue with CPR. Trading causes delay. In addition, the nurses are more likely to have experience, recent training, and better compression technique than a lay rescuer. The nurses should not be distracted by the relative or the crowd. CPR requires intense effort and timing. The nurses could stop if the relative or crowd were threatening their personal safety.

21. Which assessment finding confirms cardiac arrest? (396) 1. Absence of radial pulse 2. Absence of carotid pulse 3. Absence of spontaneous respirations 4. Unresponsiveness to normal stimuli

Answer 2: Absence of a carotid pulse is indicative of cardiac arrest. The peripheral pulses are not as strong and blood flow to extremities will decrease to preserve the brain and heart. It is possible for respirations to cease while the heart continues to beat (e.g., choking or drowning); however; cardiac arrest will quickly follow respiratory arrest. There are many reasons for decreased responsiveness (e.g., diabetic coma, stroke, drug overdose, electrolyte imbalance) where the heart will continue to beat.

29. Which patient has the greatest risk for internal bleeding? (406) 1. A 20-month-old child who stumbled and struck his forehead on a coffee table 2. A 70-year-old woman sustained a hip fracture and takes an anticoagulant 3. A 25-year-old man who was punched and kicked in the stomach 4. A 30-year-old woman who was admitted for postpartum hemorrhage

Answer 2: All of these patients are at risk for internal bleeding; however, for patients who are on anticoagulants, fractures of hip or femur can result in 500-1500 mL of blood loss. Small children with bumps to the forehead usually do well and are generally discharged to parents with a careful explanation of what to watch for. Blunt trauma to the abdomen can cause rapid or slow internal bleeding. Serial abdominal assessments are performed on these patients and increasing or unrelieved pain is immediately reported to the RN or provider. Women with postpartum hemorrhage can die if the bleeding is excessive or if there are complications, (e.g., disseminated intravascular coagulation), but generally a dilation and curettage and IV fluid replacement are sufficient treatment.

2. To address the signs and symptoms of the inflammatory phase, which action would the nurse perform? (616) 1. Cover the wound with clean gauze and apply direct pressure. 2. Elevate the injured part and apply an ice pack as ordered. 3. Observe for purulent exudate and cleanse the wound. 4. Observe for granulation tissue and keep the wound moist.

Answer 2: During the inflammatory phase, erythema, heat, swelling, pain and tissue dysfunction occur. Elevation and ice packs can reduce pain and swelling if applied during this phase.

10. The nurse notes heavy spurting of bright-red blood from the patient's groin area after he returns from an arteriogram procedure. The nurse dons clean gloves and applies gauze and direct pressure. The gauze is quickly saturated. What should the nurse do first? (404) 1. Increase the patient's IV fluid, take vital signs, monitor bleeding, and notify the provider. 2. Place an additional layer of gauze on top of the saturated dressing and continue to hold pressure. 3. Elevate the hips and apply more pressure over the groin area; ask someone to check a distal pulse. 4. Apply a pressure bandage and monitor distal pulses, sensation, and temperature of the skin.

Answer 2: For active arterial bleeding, place additional gauze on top of the saturated dressing and continue to hold pressure. The nurse could ask another nurse to check pulses or call the provider. Taking vital signs can be delegated to UAP. Elevating the hips is impractical and applying a pressure dressing over the groin area would be difficult. Once the bleeding has stopped, monitoring for rebleeding and for distal perfusion is appropriate action.

35. Which patient is most likely to need a tetanus toxoid injection? (406) 1. Patient fell off a bike and has abrasions on the knee, last known tetanus shot was several years ago. 2. Patient sustained a puncture wound from stepping on a nail that went through his workboots. 3. Patient was elbowed during a basketball game and has swelling and ecchymoses on the right lateral chest. 4. Patient sustained a deep cut on the hand while washing a drinking glass; there was extensive bleeding.

Answer 2: Patients who sustain puncture wounds should have a tetanus toxoid injection unless they had one within the past 10 years. Patients with closed wounds do not need tetanus shots. The patient who was cut by a drinking glass is also likely to get a tetanus shot, but the wound bleed freely and the drinking glass is a less likely source of tetanus compared to a dirty object such as a nail.

11. After abdominal surgery, a patient is at risk for wound stress related to coughing and moving. What equipment does the nurse need to teach the patient the self-care measure of splinting? (617) 1. An abdominal binder 2. A pillow or rolled blanket 3. A large triangular bandage 4. Several wide elastic bandages.

Answer 2: Splinting is accomplished by holding a pillow, a rolled blanket or palms of hands over the incision area when coughing. This reduces the tension on the suture line.

14. The nurse is caring for a patient who has a large abdominal incision. The patient tells the nurse that she is afraid to sit up or even move because of the pain and the strain on the incision site. What instructions should the nurse give to the patient? (617) 1. "Rest in bed until the incision site is less tender and healing has progressed." 2. "Roll to one side, use your elbow as a lever, and push to a sitting position." 3. "Hold a pillow next to your abdomen and roll forward into a sitting position." 4. "Call for assistance whenever needed and someone will help you sit up.

Answer 2: The nurse helps the patient learn to move independently and safely. This is accomplished in steps: rolling, leverage, and pushing. The patient should not be encouraged to just lay in bed. Holding a pillow to the abdomen is appropriate during coughing and deep-breathing. Calling for assistance is okay, but this limits independence.

18. The nurse finds a person lying at the bottom of a long staircase. The person is conscious but appears dazed and confused. There are no obvious injuries or signs of bleeding. What should the nurse do first? (394) 1. Assist the person to sit up and suggest that he rest on a step. 2. Instruct the person to remain still and ask for permission to assist. 3. Initiate spinal cord precautions and hold head and neck in alignment. 4. Ask the person what happened and if he is having pain or distress.

Answer 2: The person should not be moved, but since he is conscious it would be appropriate for the nurse to identify self and ask for permission to help. Resist the impulse to assist the person into a sitting or standing position. (Person may also be attempting to get up.) Initiating spinal precautions is correct; however, failure to ask permission or explain actions could be interpreted as an attack, especially if the person is confused and the nurse is a stranger to him/her. Asking the person about pain, symptoms, and events is appropriate after he is calm, immobile, and help has been summoned.

17. During a camping trip, a person who is allergic to bee stings is stung by a bee. The nurse immediately scrapes the skin to remove the stinger. Which question should the nurse ask first? (411) 1. "What happens when you get stung by a bee?" 2. "Do you want to go to the hospital?" 3. "Where is your epinephrine pen?" 4. "Do you have any diphenhydramine?"

Answer 3: A person with a known allergy to bee stings is supposed to carry an epinephrine pen and the pen should be immediately available in case the person has an anaphylactic reaction or becomes unconscious or unable to speak. If a pen is not available, taking diphenhydramine and immediately seeking medical assistance would be the next best thing. Discussions about past episodes of allergic reaction should not delay treatment or seeking medical assistance. Allergic reactions can be progressively worse with repeated exposures to allergens.

10. The nurse must be vigilant for signs of hypoxia in an older patient who has dementia and also has risk for decreased oxygenation because of chronic respiratory disease and immobility. What is an early sign that warrants additional assessment of respiratory status? (341) 1. Lips are cyanotic, fingers are cool, and capillary refill is sluggish. 2. Respirations are slow and shallow. 3. Patient seems restless and anxiously picks at linens. 4. Pulse is slower than normal and is thready and weak.

Answer 3: For patients who are unable to verbalize complaints or symptoms, the nurse must be vigilant and investigate subtle changes in behavior, such as anxiety or a change in mental status. Cyanosis and slowing of pulse and respiratory rate are late signs.

7. The nurse is teaching basic CPR to a new group of unlicensed assistive personnel (UAP). When would the nurse intervene? (397) 1. The UAP leans forward over the mannikin and creates pressure to depress the sternum at least 2 inches (5 cm). 2. The UAP compresses at a rate of 100 to 120 compressions per minute without pausing between compressions. 3. The UAP places the heel of one hand over the lower end of the sternum and places heel of the other hand on top. 4. The UAP interlaces fingers to keep them off the chest and keeps hands in contact with the chest.

Answer 3: Heel of the hand should be placed over the center of the sternum between the nipples. This position decreases the likelihood of fracturing the xiphoid process or ribs or lacerating an organ and maximizes the compression action over the heart.

14. The person gives the universal sign for choking. How does the nurse prepare to perform abdominal thrusts? (401) 1. By instructing the person to lean over the back of a chair 2. By placing the fist over the sternum 3. By placing the fist slightly above the navel 4. By putting the heel of the hand over the xiphoid process

Answer 3: Placing the fist just above the navel is the position to create enough force to expel the foreign body, and to avoid fracturing underlying bone structures. Bending over the back of a chair is a method that should be tried if a person is alone and unable to summon assistance.

12. Which lunch tray is best for providing protein, vitamins A and C, and zinc, the nutrients required for wound healing? (617) 1. A peanut butter sandwich with a glass of milk 2. A bowl of bean soup with crackers and iced tea 3. Broiled seafood with spinach salad and tomato juice 4. Stir-fried mixed vegetables with rice and hot tea

Answer 3: Seafood supplies protein and zinc. The salad provides vitamin A and the tomato juice provide vitamin C. The other meals also provide good nutrition, but do not offer all of the required nutrients.

In performing nursing skills and procedures for patients, which nursing action demonstrates the nurse's understanding and use of Standard Precautions? (339) 1. Always checks the patient's armband and asks the patient to state his or her name 2. Assesses the patient's understanding and teaches accordingly 3. Performs hand hygiene before and after every patient encounter 4. Evaluates the patient's response to and tolerance of the procedure

Answer 3: Standard Precautions are based on the assumption that every patient is a source of infectious organisms, so hand hygiene before and after every patient encounter contributes to safety and infection control. The other options are important aspects of performing any procedure.

37. The nurse is on a hiking trip and one of the children finds an injured bat and picks it up. The bat bites the child before any of the adults can intervene. What should the nurse do first? (411) 1. Monitor for shock and seek medical attention immediately. 2. Capture the bat and observe for injury or signs and symptoms of the disease. 3. Immediately wash the bite area with soap and water for 5 minutes. 4. Assess for and control bleeding and apply a thick gauze bandage.

Answer 3: Studies show that through wound cleansing markedly reduces the incidence of rabies. It would be appropriate to capture the bat if it can be done safely and quickly; then take the child and the bat (for rabies testing) and seek medical assistance.

22. The latest recommendation for CPR is to go "hard and fast" when performing chest compressions. What is the best rationale for maintaining the recommended 100 compressions/ minute? (397) 1. The rescuer will become fatigued if compressions exceed 100/minute. 2. Lacerations of the liver or spleen are more likely to occur if speed is excessive. 3. Releasing external chest compression allows time for blood to flow back into the heart. 4. A smooth motion is required to prevent rocking and rolling that decrease the force.

Answer 3: The goal of CPR is to mimic the pumping action of the heart and if compressions are too rapid and the heart is not allowed to fill with blood, there is nothing to pump out. The rescuer will become fatigued even if the proper rate is maintained; altering the speed of compressions is not the solution. Lacerations or fractures are more associated with proper hand position than speed of compressions. A smooth motion is more related to proper position of arms and hands in relation to the victim's body. Rescuer fatigue could also contribute to smoothness of movements.

20. The patient returned to the unit 3 hours ago after having surgery on the abdomen, and the dressing is now saturated with red, watery drainage. What should the nurse do first? (633) 1. Notify the charge nurse and the surgeon. 2. Take the patient's vital signs and assess for pain. 3. Securely reinforce the dressing with layers of gauze. 4. Remove the dressing and observe the wound site.

Answer 3: The nurse should first reinforce the dressing, because this may help stop or slow the bleeding. Next, the nurse would assess for signs of shock. The charge nurse and the surgeon should be notified about the saturated/reinforced dressing and the vital signs and pain symptoms. The dressing should not be removed at the 3-hour point by anyone except the surgeon.

6. The nurse observes that the dressing over the wound has exudate that has a strong, pungent odor. Which action is the most important? (633) 1. Weigh the soiled dressing. 2. Cleanse the wound with an antiseptic. 3. Perform a wound culture. 4. Circle and date the drainage on dressing.

Answer 3: The nurse would obtain a wound culture and notify the surgeon about possible infection. Weighing the dressing and circling the drainage and dating the dressing are used to track the amount drainage. Cleansing the wound with antiseptic might be ordered by the surgeon, but a wound culture should be obtained first.

26. The nurse hears a scream; a patient has slipped in the bathroom. There is bright-red blood spurting from her forearm. What should the nurse do first? (404) 1. Don sterile gloves and apply firm pressure using a sterile gauze pad. 2. Use layers of sterile dressing material and wrap them snugly with an elastic bandage. 3. Don clean gloves and use a clean towel to apply direct pressure; elevate the arm. 4. Locate the brachial artery and use the

Answer 3: The patient has an arterial bleed, so the nurse would not waste time seeking out sterile supplies. Clean gloves and a clean towel are adequate. Elevation above the level of the heart will also help control the bleeding. Wrapping the area with layers of sterile gauze would be done after initial bleeding is controlled. Pressure to the brachial artery would only be done if direct pressure and elevation were not controlling bleeding.

The nurse walks into the room and notices that the patient is anxious, demonstrates labored breathing, and seems to be struggling to get out of bed. What should the nurse do first? (342) 1. Gently advise the patient to calm down, then and ask him what is wrong. 2. Count the respiratory rate, note rhythm, and auscultate breath sounds. 3. Assist him to sit upright and calmly in-struct him to take slow, deep breaths. 4. Stay with the patient, apply oxygen, and have another nurse call the provider.

Answer 3: The patient is in obvious distress and there are many things that could be causing his behavior, but oxygenation is the priority. The quickest action is to help the patient sit upright; this allows for maximum chest expansion and is the most comfortable position for patients with respiratory distress. Helping him to take slow deep breaths, maximizes use of room air oxygen. If oxygen is immediately available in the room the nurse could apply it. (Note to student: Oxygen does require a provider's order, but in an emergency situation, the nurse must use critical thinking; apply oxygen as needed and get an order as soon as possible.) Taking vital signs should be done as soon as oxygen needs are met. Nurse uses clinical judgment to decide when to ask the patient to answer questions (talking interferes with breathing).

25. A nurse is supervising a nursing student who is doing a wet-to-dry dressing change. What does the nurse do when the student applies a dry dressing over the wet gauze? (624) 1. Directs the student to moisten all of the layers. 2. Hands the student an occlusive dressing. 3. Tells the patient that the student is doing a great job. 4. Suggests removal of all layers and starting over.

Answer 3: The student has performed the correct action. Telling the patient that the student is doing a great job gives the student positive reinforcement, while reassuring the patient that the student's technique is correct. The other options are incorrect.

20. The provider informs a patient's wife that her husband has suffered brain death and is in an irreversible coma, even though his heart is still beating. Which comment indicates that the wife has understood what the provider said? (395, 396) 1. "His heart is still beating, so there is still a chance he'll recover." 2. "He is in a coma, but do you think that he can hear what I say?" 3. "I must notify the family so that everyone can come and say goodbye." 4. "How long do you think he will have to stay in the intensive care unit?"

Answer 3: The wife is acknowledging that it is time to say goodbye. It is not uncommon for families to need additional time at the bedside when someone dies. The other statements indicate a belief or hope that he can still recover.

3. During the reconstruction phase of healing, what is the most serious complication? (616) 1. Keloid formation 2. Granulation tissue 3. Wound dehiscence 4. Phagocytosis

Answer 3: Wound dehiscence occurs most frequently during the reconstruction phase. Nurse would have the patient remain in bed and receive nothing by mouth (NPO). Tell the patient not to cough; place a warm, moist sterile dressing over the area until the surgeon evaluates the site. Keloid formation is a collagen overgrowth. It is not dangerous, but appearance of the scar tissue may upset the patient. Granulation tissue develops during healing by secondary intention. Phagocytosis a process by which certain cells engulf and dispose of microorganisms and cell debris.

13. Which sign or symptom of a foreign body airway obstruction is of greatest concern? (400) 1. Says, "I think I swallowed something." 2. Is coughing so hard that he can't speak. 3. Makes a wheezing sound between coughs. 4. Demonstrates a high-pitched inspiratory noise.

Answer 4: A high-pitched inspiratory noise suggests that there is an object in the airway that is allowing a small amount of air to go around the object. This is an emergency, because the object could become lodged and allow no air movement. If the person can speak, this means that air is passing over the vocal cords and into the airway. Forceful coughing is a good sign because it is the most effective means for the person to independently rid the airway of a foreign body. If the person is coughing, rescuer would not interfere, even if some wheezing is heard.

15. For an unconscious adult victim with a foreign body airway obstruction, what should the nurse do? (401) 1. Apply a series of three quick chest thrusts. 2. Repeat 10 abdominal thrusts and attempt to ventilate. 3. Perform finger sweeps between abdominal thrusts. 4. Visually look for object each time before providing a breath.

Answer 4: The nurse would visually inspect the mouth for an object, open the airway, and attempt to ventilate. If ventilation is not possible, deliver five abdominal thrusts; then look in the mouth for foreign object and repeat sequence until object is dislodged and breathing resumes, or if no spontaneous breathing, initiate CPR.

24. An infant is observed picking up something from the floor and putting it into his mouth before the mother can stop him. He demonstrates coughing, gagging, stridor, and respiratory distress. What should the nurse do first? (401) 1. Instruct the mother to hold the child and look into the mouth with a flashlight. 2. Place the infant in a supine position and deliver five chest thrusts. 3. Place two fingers just above the navel and deliver five abdominal thrusts. 4. Hold the infant with the head lower than trunk and deliver five back blows.

Answer 4: For infants, use five back blows, turn him over and deliver five chest thrusts. For back blows and chest thrusts, head should be lower than the trunk. See Figure 16-9. If the object is expelled during blows or thrusts and the head is downward, gravity will help. Using a flashlight and looking in the mouth will delay the intervention of clearing the airway. The child is likely to struggle out of fear and respiratory distress and visualizing the back of the mouth will be very difficult.

What does the nurse observe during the first phase of healing if fibrin is functioning correctly? (616) 1. Erythema, heat, edema, and pain occur. 2. There is an overgrowth of whitish collagen. 3. Wound looks irregular, raised, and purplish. 4. Clot begins to form and bleeding subside

Answer 4: Hemostasis is the first phase of wound healing and fibrin in the clot begins to hold the wound together and bleeding subsides. The second phase is inflammatory and erythema, pain, swelling and heat are expected. In the third phase, reconstruction, the wound is purplish, raised and irregular. In the maturation phase a white, red or pink overgrowth of collagen (keloid) may form in some people.

27. Under what circumstances would the nurse use a tourniquet? (404) 1. The nurse is acting in good faith and con-forms to Good Samaritan principles. 2. The provider gives a telephone order to apply a tourniquet. 3. The victim tells the nurse to apply a tourniquet. 4. Pressure and elevation have failed to control life-threatening bleeding.

Answer 4: If direct pressure, elevation, and indirect pressure have failed to control bleeding and the patient's life is in danger, the nurse would use a tourniquet. Use of a tourniquet should not be considered part of general first aid or the Good Samaritan principles. A provider could order the application of a tourniquet over the phone or the victim could request it; however, as with other procedures that are not within the scope of practice, the nurse should decline unless he/she deems that the patient's life is in jeopardy.

19. The nurse is preparing to change the patient's dry sterile dressing. Upon attempting the removal of the old dressing, it adheres to the site. What should the nurse do? (621) 1. Notify the surgeon. 2. Leave the dressing alone. 3. Pull the dressing off quickly. 4. Moisten the dressing with saline.

Answer 4: If the dressing is moistened with saline, this will help loosen the crusty exudate.

32. The nurse comes home and finds that her teenage son and his friends have been challenging each other to chug large shots of whiskey. Which adolescent needs to be taken to the hospital for serious alcohol intoxication? (411) 1. Face appears flushed and seems sleepy. 2. Demonstrates slurred speech and continuously giggles. 3. Is loudly singing and starting to remove clothes. 4. Is incontinent of bowel and bladder and is hallucinating.

Answer 4: Loss of bowel and bladder function, rapid and weak pulse, labored breathing, seizures, nausea, vomiting, diarrhea, loss of memory, lack of coordination, and depressed muscle reflexes are signs of serious intoxication. The other adolescents are demonstrating signs and symptoms of mild intoxication.

8. The nurse initiates CPR on a frail older woman who has a cardiac arrest. During the compressions, the nurse hears and feels the cracking of the ribs. What should the nurse do? (397) 1. Change hand position and then continue compressions. 2. Stop compressions and assess for crepitus or flail chest. 3. Stop compressions, but continue to deliver the rescue breaths. 4. Verify correct hand position and continue compressions.

Answer 4: Nurse verifies hand position; incorrect hand position increases the chance for factures, but even with correct positioning, fracturing the ribs is a possibility, especially in the frail elderly. Resuscitation efforts should continue.

The patient requires suctioning of pulmonary secretions. What is the most accurate problem statement for this patient's condition? (341) 1. Potential for fluid volume excess 2. Inability to maintain breathing pattern 3. Potential for inadequate tissue perfusion 4. Inability to clear airway

Answer 4: Secretions are obstructing the air passages; suctioning will clear the airway.

What is included in the preparation for tracheostomy care in the acute care environment? (342) 1. Using clean technique and supplies for cleaning 2. Preparing cotton balls to clean inside the ostomy 3. Removing and cleaning the outer cannula 4. Placing the patient in a semi-Fowler's position

Answer 4: Semi-Fowler's position allows the patient to breathe easier and allows easy access for nurse. Sterile technique is required. The outer cannula is not removed. Cotton balls should not be inserted into the tracheostomy.

7. What is an important nursing responsibility associated with a Penrose drain? (633) 1. Drainage in bulb should be observed and measured, suction should be reestablished. 2. Ensure that the irrigation pressure does not exceed 4 to 15 psi. 3. Drain should be observed for patency and flushed as needed. 4. Drainage on dressing should be observed, the position of the safety pin is noted

Answer 4: The Penrose drain is an open system made of rubber tubing that goes from inside the wound through a surgical stab wound and the drainage is collected on a dressing. A sterile safety pin is inserted through the drain to prevent it from sliding back into the wound. With a Jackson-Pratt the drainage in the bulb should be observed, measured and discarded and then the bulb is depressed to reestablish suction. Drains are never irrigated or flushed unless surgeon specifys irrigation or flushing.

The nurse is reviewing laboratory results and sees that the PaO2 level for a 75-year-old patient is 80 mm Hg. What should the nurse do first? (344) 1. Notify the provider about the unusually low level. 2. Contact the clinical laboratory to verify the low result. 3. Check the previous laboratory values for comparison. 4. Assess the patient for signs/symptoms of respiratory distress.

Answer 4: The nurse would immediately assess the patient for respiratory distress and intervene as necessary. If the patient is not in immediate distress, the nurse would consider factors that could affect PaO2: such as age or chronic health conditions. Comparing past laboratory data is also useful to note trends. Based on assessment of the patient and contributing factors, the nurse may or may not decide to immediately call the provider.

36. The patient has a sutured laceration on the palmar surface of the hand. When will the super-vising nurse intervene? (409) 1. The student nurse positions the hand in the anatomical position before applying the bandage. 2. The student nurse covers the entire wound with the dressing and roller gauze is applied uniformly. 3. The student nurse applies roller gauze with a number of evenly spaced overlapping turns. 4. The student nurse covers the tips of the fingers with the gauze bandage and secures roller gauze with tape.

Answer 4: Tissue distal to the wound, in this case the fingers, should not be covered. This allows the nurse to assess capillary refill, skin temperature and finger joint movement. The other actions are correct.

33. It's the Fourth of July and the nurse is working at a walk-in clinic. Several people who were viewing a parade come in and report abdominal cramps, headache, weakness, nausea, and diaphoresis. All are alert and oriented. Which intervention would the nurse use first? (413) 1. Establish peripheral intravenous sites for everyone. 2. Give everyone several cool compresses. 3. Assist everyone to remove constrictive clothing. 4. Move everyone into a cool environment.

Answer 4: Victims are first moved into a cool environment. Next, the nurse would assist to remove constrictive clothing, offer cool drinks, and give cool compresses. A circulating fan will also help.

Which type of adverse reaction is occurring in a patient taking amitriptyline and experiencing blurred vision and constipation? Cholinergic effects Akathisia symptoms Anticholinergic effects Tardive dyskinesia symptoms

Anticholinergic effects Rationale Anticholinergic effects include blurred vision; constipation; dryness of the mouth, nose, and throat; and urinary retention. Amitriptyline has the most anticholinergic activity and desipramine the least. Dryness of the mouth may be relieved by sucking hard candy or ice chips or by chewing gum. Stool softeners should be used for constipation. Cholinergic effects include increased heart rate, constipation, urinary retention, and decreased sweating. Akathisia symptoms include pacing and inability is still Tardive dyskinesia symptoms are random movements in the tongue, lips, or jaw, and facial grimacing; movements of arms, legs, fingers, and toes; or even swaying movements of the trunk or hips. The movements disappear during sleep, and they can be mild, moderate, or severe.

Which statement is a major advantage of using selective serotonin reuptake inhibitors (SSRls) over tricyclic antidepressants in the treatment of depression? Anticholinergic or cardiovascular effects do not occur with SSRls. SSRIs do not have a sedative or other central nervous system effects. 0 There are minimal interactive effects with other drugs and SSRls. There is no lag period before the full therapeutic effect of SSRIs.

Anticholinergic or cardiovascular effects do not occur with SSRls. Rationale A particular advantage of the SSRls is that they do not have the anticholinergic or cardiovascular side effects that often limit the use of the tricyclic antidepressants. SSRls have a sedative effect and may induce restlessness agitation, anxiety, and insomnia early in therapy. SSRsinteract with phenytoin and a variety of other neuroleptic drugs. It takes 2to 4 weeks to experience the full therapeutic effects of SSRIs.

A patient is preparing to receive electroconvulsive therapy (ECT) The nurse caring for this patient identifies which nursing concern is the highest priority? O Concern with cognition related to confusion O Anxiety-related to the uncertainty of the events of the test O Concerns with cognition related to temporary memory loss O Lack of knowledge related to lack of information regarding the procedure

Anxiety-related to the uncertainty of the events of the test Rationale Patients undergoing ECT will have a high level of anxiety related to procedures and what to expect. The nurse can alleviate some of the anxiety with continual reassurance, support, and attentiveness before and after each treatment. Anxiety occurs as a result of deficient knowledge; therefore explaining what to expect will alleviate some of the patient's anxieties. concern with cognition would be a result of the ECT following the procedure.

What is the patient at risk for with Stage IV pressure injury?

Anyone with existing bedsore may be at risk of developing a stage 4 bedsore. In assisted living facilities, this may happen when residents are left to lie in bed, in a chair, or in a wheelchair without being properly tended to. Anemia Decreased mental awareness Diseases that affect blood flow, such as diabetes Fever Fragile skin Hypoxemia (low oxygen levels in the blood) Immobility or limited mobility Infection Ischemia (restriction of blood flow to a part of the body) Neurological disease Neuropathy (nerve damage that causes pain, weakness, and/or numbness) Obesity Poor nutrition or dehydration Spinal cord injury Urinary or fecal incontinence

The nurse is caring for a patient with schizophrenia who has undergone electroconvulsive therapy (ECT) Which intervention should the nurse perform before administering oral medication post-electroconvulsive therapy? O Establish an intravenous line. O Assess the patient's vital signs. O Assess the patient's gag reflex. O Arrange for someone to accompany the patient.

Assess the patient's gag reflex. Rationale The patient is usually sedated during ECT. Therefore the nurse should assess the patient's gag reflex before giving anything orally to avoid the risk of aspiration. The establishment of an intravenous line and assessment of the vital signs are general measures and not specific to care after electroconvulsive therapy. Arranging for someone from the family of the patient to accompany him or her during the procedure is necessary before ECT.

DIGESTION OF FATS MOUTH

As with other macronutrients (i.e., carbohydrates and proteins), fats are broken down into their basic building blocks, fatty acids, through the process of digestion (summarized in Figure 3-8). When foods are eaten, some initial fat breakdown may begin in the mouth by the action of lingual lipase, an enzyme that is secreted by the Ebner's glands at the back of the tongue. Lingual lipase is only important for digestion during infancy. For adults, the primary digestive action that occurs in the mouth is mechanical. Foods are broken into smaller particles through chewing and moistened for passage into the stomach.

Which atypical antipsychotic drug causes moderate levels of extrapyramidal symptoms (EPSs)? Asenapine Aripiprazole loperidone Olanzapine

Asenapine Rationale Asenapine causes moderate levels of EPS. Aripiprazole, iloperidone, and olanzapine cause lower levels of EPSs.

A nurse is caring for a patient immediately after a transurethral resection of the prostate (TURP). The nurse is assessing the patient's output from the continuous bladder irrigation system and notes blood-tinged drainage in the fluid. Which action should the nurse perform first O Document the findings. O Call the health care provider O Assess the patient's vital Signs: O Prepare the patient to return to surgery.

Assess the patient's vital Signs Rationale The nurse should assess the patient's vital signs every 2 hours when assessing the irrigation fluid for blood. if the vital signs are within normal limits, the nurse should document the findings. The nurse would contact the health care provider only if the patient's vital signs cause concern. The patient does not need to be prepared for a return to surgery at this time

Which nursing intervention would be appropriate in managing a patient who has been admitted to the emergency room with delirium, sweating, and hyperthermia due to alcohol withdrawal? O Encouraging psychiatric evaluation O Administering naltrexone (Vivitrol) O Administering disulfiram (Antabuse) O Assessing quickly for electrolyte and nutritional status

Assessing quickly for electrolyte and nutritional status Rationale Delirium, sweating, and hyperthermia are symptoms of alcohol withdrawal. Excessive fluid and electrolyte loss may occur through vomiting, sweating, and hyperthermia; therefore the nurse should quickly assess the patient's hydration and his or her electrolyte and nutritional status. A. patient who is taking methamphetamines should be encouraged to undergo a psychiatric evaluation because the drug may damage dopaminergic and serotonergic neurons in the brain, which may result in parkinsonism, depression, and anxiety. Naltrexone (Vivitrol) is used to maintain alcohol and opioid abstinence. Disulfiram (Antabuse) is prescribed to promote alcohol abstinence.

After assessing a patient with alcohol abuse, the nurse observes severe withdrawal symptoms and cravings. Which drugs would the nurse anticipate being prescribed by the healthcare provider? Select all that apply. O Naltrexone (ReVia) O Atenolol (Tenormin) O Conidine (Catapres) O Acamprosate (Campral) O Carbamazepine (Carbatrol)

Atenolol (Tenormin) Conidine (Catapres) Rationale Beta blockers such as atenolol (Tenormin) and alpha agonists such as clonidine (Catapres) may reduce cravings and decrease the severity of withdrawal symptoms in a patient suffering from severe alcohol abuse Naltrexone (ReVia) and acamprosate (Campral) are mainly prescribed to prevent relapse in patients with alcohol abuse. Carbamazepine (Carbatrol) is used to decrease seizure frequency and some of the psychiatric symptoms associated with alcohol withdrawal

The nurse is caring for a patient who is depressed and has complaints of insomnia. Which action by the patient would the nurse encourage to promote sleep? O Avoiding naps unless they are planned O Eating six small meals per day O Avoiding physical activity O Drinking diet soda

Avoiding naps unless they are planned Rationale Frequently a patient suffering from depression and insomnia should be encouraged to sleep at regular times. The nurse should encourage only planned naps for the patient. Encouraging the patient to eat six small meals per day would help the patient cope with imbalanced nutrition. However, it may not help improve sleep. The nurse should engage the patient in physical activities when awake, which may tire the patient and help the patient to sleep better. To prevent weight gain, depressed patients should not be encouraged to have a diet soda or other artificial sweeteners.

The nurse is teaching a group of student nurses about the risk for bladder cancer within various groups of the population. Which group does the nurse expect to have the highest risk for bladder cancer? O Black men who smoke O White men who do not smoke O Black women who do not smoke O White women who smoke

Black men who smoke Rationale Blacks are 35% more likely to develop bladder cancer compared with whites, and men are more likely to develop bladder cancer compared with women. According to the survey conducted by National Cancer Institute in 2008, it was found that cigarette smoking is the main cause of bladder cancers. According to the survey results, black men who smoke are at the highest risk for bladder cancer. White men are least likely to develop bladder cancer compared with other ethnic groups. White men who do not smoke are less likely to develop bladder cancer compared with white women and black women who do not smoke. Black women are less likely to develop bladder cancer compared with other groups on the population

which vital sign is most important to monitor in a client taking monoamine oxidase inhibitors? O Ego integrity Heart rate O Ego integrity Temperature O Ego integrity Blood pressure O Ego integrity Respiratory rate

Blood pressure

The nurse is caring fora patient with bulimia nervosa who reports episodes of overeating. The nurse learns that the patient lacks self-esteem and often feels guilty about overeating. Which nursing interventions can help this patient? Select all that apply. O Build a trusting relationship. O Measure the baseline vital signs. O Monitor the level of consciousness. O Help to explore the triggers of overeating. O Ask the patient to avoid frequent small meals.

Build a trusting relationship. Help to explore the triggers of overeating. Rationale Episodes of overeating, lack of self-esteem, and guilt are the symptoms of bulimia nervosa or binge eating. Building a trusting relationship with patients helps the nurse to understand the patient's reasons or stressful circumstances that may result in binge eating. Helping the patient to explore the triggers for binge eating facilitates avoiding these specific triggers. Measuring the baseline vital signs is general nursing care and not specific to binge eating. Patients with bulimia nervosa may not have cognitive impairment; therefore their level of consciousness need not be monitored. Patients with eating disorders are provided with frequent small meals to support their nutrition and control hunger triggers.

Which drug is used in opioid programs housed in practitioner offices in patients with opioid intoxication? O Haloperidol (Haldol) O Disulfiram (Antabuse) O Acamprosate (Campral) O Buprenorphine (Subutex)

Buprenorphine (Subutex) Rationale Buprenorphine (Subutex) is used in oploid programs in practitioner offices in patients with opioid intoxication. Haloperidol (Haldol) reduces the seizure threshold in patients with amphetamine toxicity. Disulfiram (Antabuse) and acamprosate (Campral) are used to prevent relapse in patients with alcohol toxicity.

A charge nurse in an end-of-life care unit is preparing an inservice on grief and loss for the nursing staff. Which essential information should be included as part of the presentation? A) Grief is objective in nature. B) Grief is an isolated episode. C) Individuals perceive loss differently. D) Loss is an actual, not a perceived, event.

C) Individuals perceive loss differently

Which one is not part of the small intestine? A. Jejunum B. Ileum C. Cecum D. Duodenum

C. Cecum

The enzyme pepsin is concerned primarily with the digestion of which of the following? A. Sugars B. Starches C. Proteins D. Fats

C. Proteins

There are risk factors that influence the musculoskeletal system associated with aging the nurse recognizes that with age A. Men have the greatest incidence of osteoporosis B. Muscle fibers increase in size and become tighter C. Weight-bearing exercise reduces the loss of bone mass D. Muscle strength does not diminish as much as muscle mass

C. Weight-bearing exercise reduces the loss of bone mass

The largest gland in the body is the: A. pituitary B. thyroid C. liver D. thymus

C. liver

Protein digestion begins in the: A. esophagus B. small intestine C. stomach D. large intestine

C. stomach

CAGE screening

C: Have you ever felt you ought to CUT down on drinking? A: Have people ANNOYED you by criticizing your drinking? G: Have you ever felt bad or GUILTY about your drinking? E: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (As an EYE OPENER)

Protein and Fat Sparing

Carbohydrates help to regulate both protein and fat metabolism. If dietary carbohydrate is sufficient to meet energy needs, protein does not have to be sacri ficed to supply energy. This protein-sparing action of carbohydrate protects protein for its major roles in tissue growth and maintenance; these are crucial func tions for which the other macronutrients cannot serve as a substitute. Likewise, with sufficient carbohydrate for energy, fat is not needed to supply large amounts of energy. This is significant, because a rapid break down of fat may result in the production of ketones, which are products of incomplete fat oxidation in the cells. Ketones are strong acids. The condition of acido sis or ketosis upsets the normal acid-base balance of the body and could result in cellular damage in severe cases. This protective action of carbohydrate is called its antiketogenic effect.

The licensed practical/vocational nurse (LPN/LVN) notices that the new nurse is the only nurse who administers pain medications to several of the patients during the night shift. During the medication pass, the LPN/LVN asks one of the patients about pain experienced during the night. The patient states that she has not had any pain at night for a long time. Which action by the LPN/LVN would be appropriate?

Contacting the nursing supervisor and relating any suspicions

Which nursing interventions should the nurse provide for the patient taking antipsychotic agents? Select all that apply. O Instruct the patient not to drive. O Check for extrapyramidal effects. O Explain the measures to avoid falling. O Stop the drug if side effects persist. O Suggest that the patient chew gum or candy.

Check for extrapyramidal effects. Explain the measures to avoid falling. Suggest that the patient chew gum or candy. Rationale Antipsychotic agents are used for the management of schizophrenia, the manic phase of bipolar disorder, and some organic mental disorders. Extrapyramidal effects are caused by antipsychotics due to dopamine blockade; therefore the nurse should check for extrapyramidal side effects caused by antipsychotic drugs. These agents may cause Parkinson-like side effects, which include tremors rigidity, and shuffling gait; therefore it is necessary to instruct the patient on measures to avoid falling. Dry mouth is a common side effect of these drugs. Patients being treated with these drugs are advised to chew sugarless gum or candy to avoid dry mouth. Antipsychotics don't cause drowsiness so the patient need not avoid driving during therapy. These drugs do have side effects, so the dose might be adjusted based on the amount and severity of side effects; however, the medication should not be stopped unless the provider prescribes it to be stopped.

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk

Which drug i a typical antipsychotic agent? Asenapine Lurasidone Aripiprazole Chlorpromazine

Chlorpromazine Rationale Chlorpromazine is a typical antipsychotic agent. Asenapine, lurasidone, and aripiprazole are atypical antipsychotic agents.

Cholesterol

Cholesterol is vital to membranes; it is a precursor for some hormones, and it plays other important roles in human metabolism. It occurs naturally in foods of animal origin. The main food sources of cholesterol are egg yolks, organ meats (e.g., liver, kidney), and other meats. To ensure that it always has the relatively small amount of cholesterol neces sary for sustaining life, the human body synthesizes endogenous cholesterol in many body tissues, particu larly in the liver as well as in small amounts in the adrenal cortex, the skin, the intestines, the testes, and the ovaries. Consequently, no biologic requirement for dietary cholesterol exists, and no DRI has been set for cholesterol consumption. The Dietary Guidelines for Americans and the DRIS recommend consuming a diet that is low in cholesterol.45 Although epidemiologic studies have found strong correlations between the dietary intake of trans fats with coronary heart disease, 13 the association with such risk factors and dietary cholesterol is less well-defined. Subsequently, the current recommendations to limit dietary choles terol intake to <300 mg/day are being challenged by lack of scientific support.

Which physical symptom is seen in a patient with depression? Chronic fatigue Slowed thinking Changed personality Retarded movement

Chronic fatigue Rationale Chronic fatigue is a common physical symptom seen in patients with depression. Slowed thinking is a cognitive symptom found in patients with depression. Patients with depression exhibit a change in personality because of emotional impairment. Retarded movement is a psychomotor symptom of depression.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? O Rubbing the application into the skin O Placing the area under a heat lamp for 20 minutes O Applying a dry sterile dressing over the affected area O Covering the application with a warm, moist dressing and an occlusive outer wrap

Covering the application with a warm, moist dressing and an occlusive outer wrap

Acamprosate (Campral), given for the treatment of alcohol abuse, works by which mechanism? O Cravings for alcohol are decreased. O The absorption of alcohol is blocked. O The sedative effects of alcohol are blocked. O It causes severe flushing of the face and hands with alcohol ingestion.

Cravings for alcohol are decreased. Rationale Acamprosate (Campral), an N-methyl-D-aspartate inhibitor, is used to reduce the craving for alcohol to extend periods of abstinence. Acamprosate (Campral) does not block the absorption of alcohol, block the sedative effects of alcohol, or cause severe flushing of the face and hands with alcohol ingestion.

The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?

Darken the room for the examination.

When communicating with an older adult patient who has difficulty hearing how should the nurse change her speech? O Speak very loudly O Speak rapidly O lower the toilet voice O raised a tone of voice

lower the toilet voice

Psoriasis Clinical Manifestations/Assessment

Clinical Manifestations/Assessment •Appear raised, erythematous, circumscribed, •White scales/patches •Primary lesion is popular becomes plaques •Located in scalp, elbows, chin & trunk. •Mild, moderate or severe •Mild pruritus, the feeling of depression, frustration & loneliness (self-conscious)

Which medicine does the nurse expect to find in the prescription of a patient with high blood pressure who reports a recent development of depression? Clonidine Serotonin Levodopa Progestins

Clonidine Rationale Clonidine is an antihypertensive known to contribute to depression. Serotonin is a neurotransmitter and not a drug. Levodopa is a medicine used by patients suffering from Parkinson's disease; it is not an antihypertensive drug. Progestins are hormones that may contribute to depression.

Which chemical is not a neurotransmitter? Clonidine Serotonin Acetylcholine Norepinephrine

Clonidine Rationale Clonidine is not a neurotransmitter, it is an antihypertensive drug. Serotonin, acetylcholine, and norepinephrine are neurotransmitters.

Which drug would be administered to decrease tremors and agitation in patients with opioid toxicity? O Naloxone (Narcan) O Clonidine (Catapres) O Atenolol (Tenormin) O Buprenorphine (Subutex)

Clonidine (Catapres) Rationale Opioid agonists such as clonidine (Catapres) are administered to decrease tremors and agitation in patients with opioid toxicity. Naloxone (Narcan) is used to prevent buprenorphine (Subutex) abuse. Atenolol (Tenormin) is used to reduce alcohol cravings and withdrawal symptoms. Buprenorphine (Subutex) is prescribed for opioid maintenance therapy.

General Postmortem Procedures

Close the client's eyes. Replace dentures. Wash the body and change bed linens if needed. Place pads under the perineum. Remove tubes and dressings. Straighten the body and place a pillow under the head in preparation for family viewing.

The nurse is assigned to care for a client with herpes zoster. Which characteristics should the nurse expect to note when checking the lesions of this infection?

Clustered skin vesicles

Which type of drug preparation is contraindicated for a patient taking disulfiram (Antabuse)? O Cough elixir O Laxative emulsion O Antacid suspension O Extended-release antihistamine

Cough elixir Rationale A cough elixir contains alcohol. Alcohol in any amount or form must be avoided by patients taking disulfiram (Antabuse) because of the intense interaction, which induces nausea, vomiting, and other symptoms. Antihistamines, antacids, and laxatives do not contain alcohol and are not contraindicated.

While examining the medical record of a patient diagnosed with a diabetic foot ulcer, the nurse notes that the patient has a diagnosed history of both alcohol and opiate abuse. The patient summons the nurse and complains that the pain medication administered 2 hours ago is "wearing off" and another dose, or perhaps a stronger medication, is needed. The nurse recognizes that pain management may be complicated by prior substance abuse. The patient's medication has been prescribed to be given every 4 hours as needed (prn). Which action by the nurse would be most appropriate? O Collecting thorough data regarding the patient's pain O Telling the patient that 2 hours is not that long and will pass quickly O Searching the prn medication prescriptions for an anxiolytic agent to help calm the patient O Notifying the health care provider to request an additional or stronger dose of pain medication

Collecting thorough data regarding the patient's pain Rationale Before contacting the provider, the nurse should collect thorough and complete data regarding the patients complaints of pain. Careful assessment of pain and observation of drug-seeking behavior are necessary for persons with a history of addiction: Dismissing the patient's complaint or telling the patient to wait are not acceptable approaches for pain management. Notifying the health care provider is indicated, but not until more information has been obtained. Administering an anxiolytic for a nonprescribed use is unacceptable.

Hematoma

Collection of extravasated blood trapped in the tissues or in an organ that results from incomplete hemostasis after surgery or injury

Which symptoms are likely to be observed in a patient with severe cocaine intoxication? Select all that apply. O Coma O Hallucination O Hyperpyrexia O Tonic-clonic seizures O Depression with suicidal ideation

Coma Hyperpyrexia Tonic-clonic seizures Rationale Severe intoxication with cocaine may lead to coma and death. The patient may also experience hyperpyrexia, tonic-clonic seizures, and respiratory depression Hallucinations are observed in patients with alcohol intoxication. Depression with suicidal ideation is associated with cocaine withdrawal, not intoxication.

Which subjective data does the nurse collect while assessing a patient with substance abuse? Select all that apply.

Complaints of nausea or pain The patient's drinking pattern The date and time of last drink

Which subjective data does the nurse collect while assessing a patient with substance abuse? Select all that apply. O Presence of tachycardia O Complaints of nausea or pain O The patient's drinking pattern: O The date and time of last drink O Presence of small scabs on the forearms

Complaints of nausea or pain The patient's drinking pattern: The date and time of the last drink Rationale The nurse should assess subjective data, such as complaints of nausea or pain because it will help to understand if there are any coexisting diseases. The patient's drinking pattern, as well as the date and time of the last drink, helps the nurse understand the severity of the addiction. The presence of tachycardia is objective data; it can be quantified and easily understood by the nurse without the patient's explanation. The presence of small scabs on the forearms indicates intravenous drug use, which is an objective datum.

Which subjective data does the nurse collect while assessing a patient with substance abuse? Select all that apply. O Presence of tachycardia O Complaints of nausea or pain) O The patient's drinking pattern: O The date and time of last drink O Presence of small scabs on the forearms

Complaints of nausea or pain) The patient's drinking pattern: The date and time of last drink Rationale The nurse should assess subjective data, such as complaints of nausea or pain, because it will help to understand if there are any coexisting diseases. The patient's drinking pattern, as well as the date and time of the last drink, helps the nurse understand the severity of the addiction. The presence of tachycardia is objective data; it can be quantified and easily understood by the nurse without the patient's explanation. The presence of small scabs on the forearms indicate intravenous drug use, which is an objective datum.

A patient is detached from family members and is having an emotional crisis because of unemployment. Which nursing action should be the primary intervention to help the patient during this crisis? O Encourage the patient to develop problem-solving and decision-making skills. O Explain the patient's emotional status to the health care provider. O Encourage the patient to recognize constructive aspects of mild or moderate anxiety. O Consult the health care provider to include other psychosocial professionals.

Consult the health care provider to include other psychosocial professionals. Rationale Identifying family supports and adequate coping mechanisms helps the nurse recognize family communication patterns. Dysfunctional relationships indicate a need to include other psychosocial professionals in an individual's care. The other interventions, such as encouraging decision-making skills, assessment of emotional status, and recognizing constructive aspects of anxiety, are common for all patients undergoing crisis.

The licensed practical/vocational nurse (LPN/LVN) notices that the new nurse is the only, nurse who administers pain medications to several of the patients during the night shift. During the medication pass, the LPN/LVN asks one of the patients about pain experienced during the night. The patient states that she has not had any pain at night for a long time. Which action by the LPN/LVN would be appropriate? O Contacting the nursing supervisor and relating any suspicions O Confronting the night shift nurse during the next day's narcotic count O Keeping the information private because there is no proof it's true O Telling all of the other nurses on the day and evening shifts so that they can be on the lookout

Contacting the nursing supervisor and relating any suspicions Rationale It is important for nursing colleagues to report suspected medication diversion or dependency, it is the duty of every nurse to uphold the standards of the profession. Reporting suspicions to the nursing supervisor would meet the obligation. Confronting an addicted nurse is not likely to stop diversion and does not meet the professional obligation. Reasonable suspicion is adequate to support reporting Proof of diversion is not required. Subsequent investigations by administrative staff or legal authorities can establish proof. Telling other nurses does not meet the professional obligation and may result in unexpected negative consequences.

The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion

When the patient with skeletal muscle spasms due to opioid abuse is admitted to the hospital, which drug does the nurse suspect will be prescribed? O Clonidine (Catapres) O Dicyclomine (Dicyclocot) O Methadone (Dolophine) O Cyclobenzaprine (Flexeril)

Cyclobenzaprine (Flexeril) Rationale Cyclobenzaprine (Flexeril) reduces skeletal muscle spasms in patients with opioid abuse. Clonidine (Catapres) is used to reduce tremors, sweating, and agitation. Dicyclomine (Dicyclocot) reduces gastrointestinal cramping and diarrhea. Methadone (Dolophine) reduces the severity of withdrawal symptoms of opioid poisoning

Which term is the milder form of bipolar illness? O Mania O Euphoria O Dysthymia O Cyclothymia

Cyclothymia Rationale Cyclothymia is a mild form of biplailless Its symptoms are episodes of depression and hypomania; note that these symptoms are not severe enough to meet the full criteria for bipolar disorder. Elation is characteristic of mania and distinct episodes of mania are seen in bipolar disorder. heightened mood (euphoria I a symptom of acute mania. Dysthymia is a unipolar disorder in which the patient suffers from chronic, ongoing symptoms of depression that last for at least 2 years.

A patient-facing death is experiencing pain. Which information, if found in the nurse's documentation, indicates that the goal related to pain has been achieved? A) Patient is exhibiting a decrease in mobility. B) Facial grimacing is noted as the patient paces in the hallway. C) The patient is crying and complaining of severe pain in the entire body. D) Patient reports that pain has decreased from 9 to 4 after taking pain medicine.

D) Patient reports that pain has decreased from 9 to 4 after taking pain medicine.

Which purpose of palliative care would be identified for a patient with a terminal illness? A) To place the patient in long-term care to receive 24-hour care B) To provide no treatment and let nature take its course by following a patient's do-not-resuscitate (DNR) status C) To take the patient's decision-making ability away and give it to the person with the power of attorney D) To provide prevention, relief, reduction, or soothing of symptoms of a disease without affecting a cure

D) To provide prevention, relief, reduction, or soothing of symptoms of a disease without affecting a cure

Vitamin D (Calciferol):

maintain calcium, phosphorus homeostasis acts like a hormone Food Source: sun exposure, milk, fish oils, cereals, Deficiency: Rickets (bones bend), osteoporosis

adolescence pt 2

Daydreaming can be developmentally appropriate and a useful safety valve for strong emotions. . By middle adolescence, career goals may become more practical and realistic. • In late adolescence, moral principles are based on the adolescent's own beliefs. Culture plays a role in how adolescents think and interact, and traditions can help stabilize identity. • It is important to allow adolescents to begin to behave independently and to make their own decisions. Peer groups have a major impact on the social and emotional growth and development of adolescents. • In late adolescence, intimacy with a peer can be sexual, intellectual, or social. • Effective health education and care include availability, visibility, high quality, confidentiality, affordability, and flexibility.

The nurse administers chlorpromazine (Thorazine) to a patient with bipolar disorder. The nurse observes that the patient is unable to most still Which changes in the medical plan of care should the nurse expect the health care provider to prescribe? Select all that apply. O Stop administering the drug. O Decrease the dose of the drug. O Follow up with the use of benztropine (Cogentin). O Administer diphenhydramine (Benadryl). O Administer St. John's wort.

Decrease the dose of the drug. Follow up with the use of benztropine (Cogentin). Administer diphenhydramine (Benadryl). Rationale Various abnormal neuromuscular symptoms (extrapyramidal symptoms) occur in association with antipsychotic medications, such as chlorpromazine (Thorazine) The extrapyramidal symptoms include akathisia, or an inability to still To combat these extrapyramidal effects,it is advisable to decrease the dose of the drug. The use of antiparkinsonian drugs, such as benztropine (Cogentin), after the use of the antipsychotic drug also decreases extrapyramidal symptoms. In addition, parenteral diphenhydramine (Benadryl) can be administered. It is not advisable to stop antipsychotic drugs immediately; they are gradually withdrawn. St. John's wort (Hypericum perforatum) is used to treat mild depression and is not effective in treating extrapyramidal symptoms.

Chloride:

maintain water & acidbase balance Food Source: table salt Toxicity: from severe dehydration

Which major change would the nursing instructor include in a discussion about the changes brought about by the introduction of psychotherapeutic drugs in the treatment of mental illness? O The development of electroconvulsive therapy O Deinstitutionalization of patients with psychiatric disorders O Reduction of funding for the mental health system O Establishment of the National Institute of Mental Health

Deinstitutionalization of patients with psychiatric disorders Rationale Psychotherapeutic drugs allow individuals to control their behavior and thus spend more time in the community, in the 20th century, the government started the movement of deinstitutionalization, the release of patients with psychiatric disorders from institutions to live and receive treatment in the community setting Mental health practitioners developed electroconvulsive therapy and insulin shock therapy to treat schizophrenia during the 1930s. The passage of the Omnibus Budget Reconciliation Act reduced funding for the mental health system. This information does not help in a discussion about the treatment of mental illness. The National institute of Mental health was established in the 1940s. This is irrelevant to the changes brought about by the introduction of psychotropic drugs.

Which condition is characterized by a false or irrational belief that is firmly held despite evidence to the contrary? Psychosis Delusion Hallucination Disorganized behavior

Delusion Rationale This is the correct definition of delusion. Psychosis does not have a single definition but is a clinical descriptor that means being out of touch with reality. Hallucinations are false sensory perceptions that are experienced without an external stimulus that seem real to the patient. Disorganized behavior is another common characteristic of psychosis. Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living such as organizing meals or maintaining hygiene.

A 45-year-old patient who lost a son in an accident is diagnosed with depression and has a risk of self-directed violence. Which outcome demonstrated by the patient does the nurse most likely expect if the nursing interventions are effective? O Interacts well with other patients O Denies having any suicidal thoughts O Sleeps at a scheduled time each night O Verbalizes ways of dealing with depression

Denies having any suicidal thoughts Rationale The patient has depression and suicidal thoughts. The nursing interventions are aimed at reducing the patient's risk of self-directed violence. If the patient denies having any suicidal thoughts, this indicates that the nursing interventions have been effective. Sleeping at a scheduled time and interacting with other patients are not common outcomes observed in all depressed patients. The patient verbalizing alternate ways of dealing with depression is a good outcome expected from a depressed patient who does not have suicidal thoughts. These outcomes are expected for a patient with depression, not necessarily for a patient who has suicidal thoughts.

Which assessment does finding indicate to the nurse that a patient is experiencing withdrawal from long-term use of dextroamphetamine (Dexedrine)? O Depression O Hypopyrexia O Hyporeflexia O Decreased respirations

Depression Rationale Depression, fatigue, lack of energy, loss of memory, and inability to manipulate information are symptoms of withdrawal from the amphetamine stimulant dextroamphetamine (Dexedrine). Respirations may increase with withdrawal from dextroamphetamine (Dexedrine). Hyperreflexia and hyperpyrexia, not hyporeflexia and hypopyrexia, may occur with withdrawal from dextroamphetamine (Dexedrine)

Which lessons would the nurse include to help a group of patients improve their mental health? Select all that apply.

Develop assertive communication skills. Recognize the power of positive thinking. Identify personal characteristics of anxiety. Incorporate progressive muscle relaxation.

Which lessons would the nurse include to help a group of patients improve their mental health? Select all that apply. O Develop assertive communication skills. O Recognize the power of positive thinking. O Seek help from family in decision making. O Identify personal characteristics of anxiety. O Incorporate progressive muscle relaxation.

Develop assertive communication skills. Recognize the power of positive thinking. Identify personal characteristics of anxiety. Incorporate progressive muscle relaxation. Rationale The nurse can help the individuals get through a crisis by providing accurate information that aids in realistic perception of the situation. Patients should develop assertive communication skills to improve mental health. The nurse should advise the patients to recognize the healing power of positive thinking. The patients should recognize their personal characteristics of anxiety. The nurse should encourage the use of muscle relaxation to reduce stress, Decision-making and problem-solving skills should be developed by the patients

Which drug enhances gamma-aminobutyric acid (GABA) activity that has been suppressed by chronic alcohol ingestion? O Diazepam (Valium) O Naltrexone (Vivitrol) O Clonidine (Catapres) O Disulfiram (Antabuse)

Diazepam (Valium) Rationale Benzodiazepines such as diazepam (Valium) are commonly used for detoxification because they enhance GABA activity that has been suppressed by chronic alcohol ingestion. Naltrexone (Vivitrol) is an opioid antagonist that is prescribed to block the pharmacologic effects of opioid and alcohol abuse. Clonidine (Catapres) is used to reduce tremors, sweating, and agitation associated with excess opioid ingestion. Disulfiram (Antabuse) helps reduce the desire for alcohol by inducing vomiting and nausea.

According to the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA Ar) protocol, which statement is true regarding the administration of diazepam? O Diazepam should be administered at regular intervals. O Diazepam should be administered according to a fired dosage regimen. O Diazepam should be administered when the patient shows withdrawal symptoms. O Diazepam should be administered in large doses on the second day of treatment.

Diazepam should be administered when the patient shows withdrawal symptoms. Rationale There are two approaches for benzodiazepine dosing for the treatment of alcohol withdrawal symptoms. The symptom-triggered schedule depends on the use of a rating scale such as the CIWA-Ar protocol, which indicates that benzodiazepines should be administered when the patient shows withdrawal symptoms. According to the fixed dosage regimen, benzodiazepine should be administered at specific intervals. According to the CIWA-Ar protocol, the drug should be administered when required but not according to fixed-dosage regimen. On the second day of treatment, small doses of benzodiazepines should be administered on a fixed schedule.

Ethnic Differences in Lipid Metabolism

Dietary patterns and habits form at an early age as a result of both family influence and environmental factors. The dietary fat intake of some individuals is much lower than that of others simply because of how the individuals were raised. However, since the unveiling of the human genome, we are learning that biologic differences also exist that may affect dietary patterns and determine the ways in which our bodies handle the nutri ents we eat. The prevalence of obesity has long been known to differ among ethnic and racial populations, but the exact cause remains uncertain.

The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure?

Discontinue the prescribed antihistamine 2 days before the test.

A young patient recently lost her father to prostate cancer and tells the nurse, "I took my father to the oncologist earlier, he would not have died."The nurse identifies the patient in which phase of mourning, according to Bowlby's theories of grief and mourning? Numbing Yearning and searching Disorganization and despair Reorganization

Disorganization and despair Rationale The patient is in the disorganization and despair stage. In this stage, the individual endlessly examines how and why the loss occurred. it is commonplace for the person to express anger. Gradually, the phase gives way to an acceptance that loss is permanent. Numbing is a period of intense emotion that serves to protect the body from the consequences of the loss and lasts from a few hours to a week or longer. The person may feel 'stunned" or "unreal." The yearning and searching phase arouses acute distress in most people. This painful phase is characterized by physical symptoms, such as tightness in the chest and throat, shortness of breath, a feeling of weakness and lethargy, insomnia, and anorexia. In the reorganization phase, the individual begins to accept unaccustomed roles, acquire new skills, and build new relationships.

Which disorder is associated with a loosening of associations? Delusion Hallucinations Disorganized thinking Disorganized behavior

Disorganized thinking Rationale Disorganized thinking is a thought disorder that may consist of a loosening of associations or a fight of ideas. This condition causes the speaker to jump from one idea or topic to another one in an illogical, inappropriate, or disorganized way. A delusion is a false or irrational belief that is firmly held despite obvious evidence to the contrary. Hallucinations are false sensory perceptions that are experienced without an external stimulus and seem real to the patient. Disorganized behavior is associated with difficulty in performing activities of daily living, such as organizing meals or maintaining hygiene.

When a patient with a history of alcohol abuse is undergoing long-term treatment, which agent does the nurse anticipate will be ordered for this patient? O Caffeine O Verapamil O Disulfiram O Buprenorphine

Disulfiram Rationale Disulfiram is indicated for long-term treatment of alcohol abuse. It prevents the patient from drinking alcohol by causing an unpleasant reaction if alcohol is consumed, Buprenorphine is used for maintenance opioid programs and is not indicated for long-term alcohol abuse. Caffeine is a stimulant and is not indicated for long-term alcohol abuse. Verapamil is used for the treatment of cocaine abuse and is not indicated for long term alcohol abuse.

Alcohol Abuse

Disulfiram (Antabuse) •Abstain at least 12 hours prior If you take anything before the 12 hours Adverse effects •Facial flushing, sweating, throbbing HA, neck pain, N/V, hypotension, tachycardia •Avoid alcohol •Cough medicines, vinegar, mouthwashes, aftershave lotions •Read labels

Which statements are true regarding disulfiram (Antabuse) therapy? Select all that apply. O Disulfiram (Antabuse) is contraindicated in patients with low creatinine clearance. O Disulfiram (Antabuse) is contraindicated in patients with liver disease who are on naltrexone (ReVia). O Disulfiram (Antabuse) must be used very cautiously in patients with diabetes mellitus or hypothyroidism. O Disulfiram (Antabuse) should not be administered until the patient has abstained from alcohol for at least 12 hours. O Patients who take disulfiram (Antabuse) should carry a patient identification card stating the use of the drug.

Disulfiram (Antabuse) must be used very cautiously in patients with diabetes mellitus or hypothyroidism. Disulfiram (Antabuse) should not be administered until the patient has abstained from alcohol for at least 12 hours. Patients who take disulfiram (Antabuse) should carry a patient identification card stating the use of the drug. Rationale Disulfiram (Antabuse) therapy must be used very cautiously in patients with diabetes mellitus or hypothyroidism because this drug may cause a disulfiram-alcohol reaction. The nurse should instruct the patient to avoid alcoholic beverages, and therapy should be started after at least 12 hours of abstinence because alcohol may aggravate the patient. The patient should be provided an identification card that states the use of therapy, the symptoms that may occur because of therapy, and the emergency contact. Acamprosate (Campral) is contraindicated in patients with liver disease who take naltrexone (ReVia) because it may cause an alcoholic reaction and intoxication. Acamprosate (Campral) is contraindicated in patients with a creatinine clearance of less than 30 mL/min.

Which statement by a nursing student indicates a need for further teaching about disulfiram? Select all that apply. O Disulfiram increases the effects of caffeine. O Disulfiram inhibits the metabolism of diazepam. O Disulfiram has no drug interactions with metronidazole.. O Disulfiram inhibits the metabolism of phenytoin. O Disulfiram inhibits the anticoagulant effect of warfarin.

Disulfiram has no drug interactions with metronidazole Disulfiram inhibits the anticoagulant effect of warfarin. Rationale Disulfiram is used to treat alcohol abuse and may enhance the anticoagulant effect of warfarin. Concurrent administration of disulfiram and metronidazole may result in psychotic episodes and confusion: therefore these drugs are not recommended in combination. The cardiovascular and central nervous system effects of caffeine may be increased by disulfiram. Disulfiram inhibits the metabolism of specific benzodiazepines such as diazepam and phenytoin.

When administering lorazepam, what precautions should be included in the nurse's plan of care? Select all that apply. Administer in the mornings Administer dosage with food Drowsiness usually disappears during continued therapy. Monitor vital signs Do not crush medications

Drowsiness usually disappears during continued therapy. Monitor vital signs

A patient with delusions, hallucinations, and disordered thinking is diagnosed with schizophrenia. Which therapy in the patient would yield a good response? Select all that apply. O Drug therapy O Phototherapy O Psychotherapy O Electroconvulsive therapy(ECT) O Play therapy

Drug therapy Psychotherapy Rationale Schizophrenia is a psychotic disorder with both positive and negative behavioral patterns. Delusions, hallucinations, and disordered thinking are characteristics o positive behavioral patterns. These types of behavioral patterns are associated with fewer changes in the brain and therefore respond better to drug therapy. Psychotherapy is also used to allow individual self-expression. Phototherapy is used to treat disorders caused by hormonal imbalances. Electroconvulsive therapy (ECT) is administered when a patient does not respond to drug therapy. Play therapy is a type of therapy used for children to express themselves.

dumping syndrome

Dumping syndrome is a condition that can develop after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. The condition can also develop in people who have had esophageal surgery. Rapid emptying of food into the intestine •Occur 5-30 minutes after eating •S/S: palpitation, diaphoresis, diarrhea, abdominal fullness and cramping, borborygmi, pallor, vertigo, desire to lie down •Eat a high-protein, low-CHO & moderate fat, small, frequent meals, Avoid consuming sugar, salt, milk, Avoid fluids with meals, low-fowler's position at least 30 minutes

Hydrocolloid (DuoDERM)

DuoDERM Extra Thin dressing is designed to reduce the risk of further skin breakdown & can be used as a primary hydrocolloid dressing for dry to lightly

Which assessment tool specifically describes the type of tardive dyskinesia and allows diagnoses to change over time? Clinical Global Impression (CGl) Brief Psychiatric Rating Scale (BPRS) Abnormal Involuntary Movement Scale (AlMS) Dyskinesia Identification System: Condensed User Scale (DISCUS)

Dyskinesia Identification System: Condensed User Scale (DISCUS) Rationale The DISCUS evaluation speically describes the type of tardive dyskinesia and allows diagnoses to change over time. The CGl and BPRS are used for baseline clinical evaluation. The AlMS rates dyskinetic movements, but it is not exclusively diagnostic for tardive dyskinesia.

A nurse is caring for an older adult resident in a long-term care facility. While the nurse is talking with this resident, the older adult reminisces about life, family, and career accomplishments. Based on Erickson's stages, you know this resident is in which stage of development? O Ego integrity versus despair O Intimacy versus isolation O identity versus role confusion O Generativity versus stagnation

Ego integrity versus despair

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

Tricyclic Antidepressants

Emitriptyline(Elavil) Imipramine (Tofranil) S/E: anticholinergic effects: dry mouth, urinary retention, constipation, sedation, restlessness Interventions •Monitor anticholinergic effect •Administer at bedtime •Tapered •Do not take w/ MAOIs •Hypertensive crisis

Which nursing intervention to help a patient with cancer frequently experiencing episodes of stress and depression is best? O Encourage the patient to develop adaptive patterns of behavior. O Encourage the patient to avoid events that may cause stress. O Offer the patient as much flexibility in visiting hours as possible. O Use therapeutic communication techniques, such as active listening.

Encourage the patient to develop adaptive patterns of behavior. Rationale The stress of being ill greatly influences a person's emotional well-being and coping ability. A person's reaction to a stressor can greatly affect the stress response. The nurse can serve as a resource in helping the patient develop adaptive patterns of behavior, which, in turn, reduce stress and depression. Developing adaptive patterns of behavior is more beneficial than avoiding stressors because this is not possible in daily life. Offering flexible visiting hours to patients' relatives is an effective intervention in helping patients who are going through crisis and patients who are dealing with dysfunctional family relationships. Therapeutic communication is a general intervention for all kinds of mental health disturbances.

A 74-year-old woman with stage 3 breast cancer is crying in her room. Which intervention should the nurse perform to help the patient through the grief process?

Encourage venting of feelings.

Which interventions would stimulate a patient to void after the removal of a urinary catheter? Select all that apply. O Running water in the sink O Having the patient drink cold milk O Encouraging the male patient to stand O Placing the patient's hands in warm water O Instructing the patient to void every 6 hours

Encouraging the male patient to stand Placing the patient's hands in warm water Running water in the sink Rationale If the patient complains of urinary retention, the nurse should try running water placing the patient's hands in water and pouring warm water on the perineum. The female patient should be encouraged to sit on a commode and the male patient encouraged to stand during urination. Drinking cold milk and having the patient void every 6 hours will not help a patient experiencing urinary retention

DIETARY REFERENCE INTAKES

Energy needs are listed as total kilocalories, and these amounts include caloric intake from fat and protein as well as carbohydrate. According to the most recent DRIS, 45% to 65% of an adult's total caloric intake should come from carbohydrate foods. This translates to 225 to 325 g of carbohydrates for a 2000 kcal/day diet. The recommended fiber intake can be achieved by choosing carbohydrate foods such as whole grains, legumes, vegetables, and fruits. In addition, the DRIS recommends limiting added sugar to no more than 25% of the total calories consumed. See the Clinical Applications box entitled "What Is Your Dietary Reference Intake for Carbohydrates?" to calculate your specific carbohydrate recommendation.

The nurse is caring for a patient who receives nasogastric (NG) tube feedings after a gastric surgery. What nursing interventions are required in order to ensure patient safety during feedings? Select all that apply. O Ensure patency of the tube. O Provide mouth care at least every 2 hours. O Advance the tube further by repositioning O Instruct the patient to avoid drinking water. O Lubricate the patient's nostrils and the tube with a water-soluble jelly.

Ensure patency of the tube. Provide mouth care at least every 2 hours. Lubricate the patient's nostrils and the tube with a water-soluble jelly. Rationale When a patient is inserted with an NG tube, the patient breathes through the mouth because of nasal occlusion by the tube. As a result, the patient's lips and tongue often become dry and cracked. The nurse should therefore provide mouth care at least every 2 hours to prevent discomfort. The nurse should ensure that the tube is free of any blockages to maintain patency of the tube. Lubricating the patient's nostrils and the tube with a water-soluble jelly helps prevent crusting of secretions. The patient is allowed to drink water to ease the gag reflex Repositioning of the NG tube can be done only by the health care provider if the patient has had gastric or esophageal surgery

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

A nurse obtains a urine culture specimen from a patient who acquired a urinary tract infection from frequent straight catheterizations. The nurse anticipates the culture will grow which organism? O Escherichia coli O Group B Streptococcus O Staphylococcus aureus O Streptococcus pneumoniae

Escherichia coli Rationale E coli is the most common cause of hospital-acquired urinary tract infections. Group B Streptococcus, S. aureus, and S. pneumoniae are not the most common causative organisms prevalent in the health care setting.

Which statement regarding patients with depression is correct? Levodopa, an antihypertensive, may contribute to depression. Excessive secretion of cortisol occurs in patients with depression. Patients with depression are two to three times more likely to commit suicide. Patients with major depressive disorder suffer from chronic symptoms of depression for at least 2 years.

Excessive secretion of cortisol occurs in patients with depression. Rationale About 45% to 60% of patients with depression have endocrine abnormalities. Such patients secrete excessive cortisol and abnormal thyroid-stimulating hormone. Levodopa, an antiparkinsonian medicine, may cause depression. Relatives of patients with depression are two to three times more likely to develop depression. Major depressive disorder is characterized by major depressive episodes that repair themselves for a period of greater than 2 years. Patients with dysthymia, not a major depressive disorder, are known to suffer from chronic symptoms of depression that last for at least 2 years.

While caring for a patient, a nurse learns that the patient lives in the same house as the patient's grandparents. What type of family is this considered?

Extended family

Which adverse effect is the most troublesome and the most common cause of nonadherence associated with antipsychotic therapy? Sedation Hypotension Anticholinergic effects Extrapyramidal symptoms

Extrapyramidal symptoms Rationale Extrapyramidal symptoms are the most troublesome adverse effects and the most common cause of nonadherence associated with antipsychotic therapy. Sedation, hypotension, and anticholinergic effects are adverse effects associated with antipsychotic medications, but these do not cause the most troublesome adverse effects of antipsychotic therapy.

Cell Membrane Structure

Fat forms the fatty center of cell membranes, thereby creating the selectively permeable lipid bilayer. Proteins are embedded within this layer and allow for the transport of various nutrients in and out of the cells. In addition, the protective myelin sheath that surrounds neurons is largely composed of fat.

Flavor and Satisfaction

Fat in the diet adds flavor to foods and contributes to a feeling of satiety after a meal. These effects are partly caused by the slower rate of digestion of fats as com pared with that of carbohydrates. This satiety also results from the fuller texture and body that fat gives to food and the slower emptying time of the stomach that it necessitates. The absence of satiation while an individual is consuming a low-fat/fat-free diet may contribute to overall dissatisfaction with such weight loss attempts that remove too much dietary fat.

Adipose Tissue

Fat that is stored in various parts of the body is called adipose tissue, from the Latin word adiposus, meaning "fatty." Weblike padding of fat tissue supports and protects vital organs, and a layer of fat directly under the skin is important for the regulation of body temperature. Protects internal organs

Essential fatty acid deficiency.

Fat-free diets may ea essential fatty acid deficiency with clinical man ifestations. Because essential fatty acids play an impor tant role in maintaining the integrity of biologic membranes, one indication of essential fatty acid defi ciency is dermatitis. Omega-3 fatty acids are especially required for normal function of the brain, the central nervous system, and the cell membranes. Inadequate intake of dietary essential fatty acids is linked to many health problems, such as hair loss, infertility, low blood platelet levels, impaired vision, compromised brain function, and growth retardation in children.

Fatty acids.

Fatty acids, the building blocks of lipids build the central fat substance that is necessary in all cell membranes promote the transport of fat-soluble nutrients throughout the body.

CLASSIFICATION OF FATTY ACIDS

Fatty acids, which are the building blocks of triglycerides, can be classified by their length as short-, medium-, or long-chain fatty acids. The chains contain carbon atoms with a methyl group (CH) on one end (also known as the omega end) and an acid carboxyl group (COOH) on the other end. Short-chain fatty acids have 2 to 4 carbons, medium-chain fatty acids have 6 to 10 carbons, and long-chain fatty acids have more than 12 carbons. Fatty acids can also be classified according to their saturation or essentiality, both of which are significant characteristics.

A nurse is caring for a patient who has anxiety attacks. Which symptoms would indicate that the patient is experiencing a severe anxiety attack?

Feeling of impending danger

A nurse is admitting a 65-year-old patient whose primary diagnosis is delirium. Which clinical conditions are possible causes of delirium? Select all that apply. O Fever O Azotemia O Liver failure O Drug intoxication O Congestive heart failure

Fever Azotemia Drug intoxication Rationale Possible causes of delirium include fever, azotemia (high levels of nitrogen in the blood), drug intoxication, pneumonia, malnutrition, and anesthesia. Congestive heart failure and liver failure do not cause delirium.

papules

Firm, raised areas such as pimples and the eruptions seen in some stages of chickenpox and syphilis.

The nurse in the clinic is examining the skin of a patient with plaque psoriasis. The nurse would expect to see which type of lesion? O Flat, nonpalpable macule O Deep, firm, well-defined lesion O Irregularly shaped cutaneous edema O Elevated lesion with a rough, flat top that is greater than O 1 cm in diameter

Flat, nonpalpable macule Rationale Plaque psoriasis is characterized by rough, flat-topped, elevated lesions. Flat, nonpalpable macules are patches. A nodule is a deep, firm, well-defined lesion. A wheal is an irregularly shaped area of cutaneous edema.

An adolescent has no recollection of any events that transpired after consuming alcohol the previous night. Which drug was most probably added to the adolescent's drink? O Alprazolam O Clonidine O Methadone O Flunitrazepam

Flunitrazepam Rationale Flunitrazepam is a benzodiazepine that causes amnesia and muscle relaxation in the patient. These effects are increased if the patient consumes it with alcohol. Alprazolam is used for the treatment of acute anxiety, Clonidine is used to reduce the withdrawal effects of opioids. Methadone is used to suppress withdrawal symptoms in morphine or heroin addicts.

Which drug gained notoriety in the 1990s, is associated with club drug use and is often called the "date-rape drug"? O Morphine O Opioid analgesic heroin O Flunitrazepam (Rohypnol) O Gamma-hydroxybutyrate (GHB)

Flunitrazepam (Rohypnol) Rationale Flunitrazepam (Rohypnol) has been misused in many sexual assaults and can have a lethal effect when combined with alcohol GHB, hemin, and morphine are often abused, but they are not considered the date rape drug

Which drug gained notoriety in the 1990s, is associated with club drug use, and is often called the "date-rape drug"? O Morphine O Opioid analgesic heroin O Flunitrazepam (Rohypnol) O Gamma-hydroxybutyrate (GHB)

Flunitrazepam (Rohypnol) Rationale Flunitrazepam (Rohypnol) has been misused in many sexual assaults and can have a lethal effect when combined with alcohol GHB, hemin, and morphine are often abused, but they are not considered the date rape drug

The nurse is reviewing the medical report of a l6-year-old patient suffering from congenital heart disease and major depressive disorder. Which medication does the nurse anticipate finding on the medication list of a patient who has congenital heart disease and major depressive disorder? Fluoxetine Paroxetine Phenelzine Tranylcypromine

Fluoxetine Rationale Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). This class of drugs does not have adverse cardiovascular effects. In addition, fluoxetine has been approved for use in treating depression in children and adolescents. Paroxetine, a type of SSRI, is not recommended for patients younger than l8 years. Fluoxetine is the only SSRI approved for use in treating depression in children and adolescents. Both phenelzine and tranylcypromine are monoamine oxidase inhibitors that can develop side effects related to the cardiovascular system.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluoxetine (Prozac) Paroxetine (Paxil) Citalopram ( Celexa) Escitalopram (Lexapro) Sertraline (Zoloft) S/E: nausea, CNS stimulation (restlessness, nervousness & agitation), insomnia, nausea Interventions:• Take in the morning •Monitor for orthostatic hypotension •Tapered •Effective after 2-4wks

Which first-generation antipsychotic drug is available as an elixir? Loxapine Haloperidol Fluphenazine Prochlorperazine

Fluphenazine Rationale Fluphenazine is available as an elxiar. Loxapine is available only in capsule form. Haloperidol is available in the form of tablets, concentrates, and injections. Prochlorperazine is available as tablets, injections, and suppositories.

Which points should the nurse discuss with a patient who was admitted for the treatment of acute depression before discharging the patient from the psychiatry unit Select all that apply. Follow-up plan Desired treatment outcome Enhancement of coping skills Availability o group activities Possible emergence of anxiety

Follow-up plan Desired treatment outcome Rationale The entire follow-up plan (including frequency of therapy sessions, prescribed medications, physician visits, and return-to-work goals) should be explained to the patient or the patient's family before discharge from the psychiatry unit. The nurse must also ensure that the patient and the family understand the desired outcome of the therapy. The discussions of the enhancement of coping skills, availability of group activities, and the possible emergence of anxieties would be discussed during the patient's stay at the hospital.

Full-Thickness Burns

Full-thickness burns (also classified as third-degree burns) involve destruction of the skin and underlying tissue, including fat, muscle, and bone. The area usually is charred, and healing is difficult.

Ulcer Stage 3

Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.

According to Piaget, during the adolescent stage of growth and development, an individual's cognitive function reaches maturity. What stage is this considered? O Peroperational O Formal operational O Formal operational thought stage O Concrete operational

Formal operational thought stage

The nurse is caring for a client on transmission-based precautions who has herpes zoster or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply.

Full-thickness skin necrosis can result. Lesions are very contagious when they are fluid-filled blisters. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. To reduce the risk of transmitting the virus to others, keep clients with lesions separated from other clients until lesions have crusted.

A 17-year-old female high school student presents to the emergency room and speaks to the nurse stating that she can't remember anything about a party she attended last night, including whether she was engaged in sexual activity. The nurse asks if the young woman consumed any drinks prepared by someone else at the party. The young woman states that she did. The primary care provider recommends a SANE (Sexual Assault Nurse Examiner) exam. For which medication will the young woman be screened during the exam? O Alprazolam O Gabapentin O Valproic acid O Gamma-hydroxybutyrate (GHB)

Gamma-hydroxybutyrate (GHB) Rationale GHB is a central nervous system depressant that has become the most commonly used substance in drug-facilitated sexual assaults (DFSAs) in the United States. Unconsciousness and amnesia are effects of the drug that make it desirable for use by sexual predators. The drug shows up in urine screens for only 6 to 12 hours after ingestion. Gabapentin and valproic acid are antiepileptics, which cause sedation and are not recognized for use in sexual assaults. Alprazolam is an anxiolytic that may cause some memory problems but is not known to cause amnesia.

A patient in the manic phase of bipolar disorder is taking lithium. The nurse identifies that the patient's lithium blood level is l.9mEq/L.Which action by the nurse would be the most appropriate? O Stop the drug until the serum lithium level is 0.4 mEq/L. O Continue the usual dose of lithium and note any side effects. O Hold the drug and notify the health care provider immediately. O Ask the health care provider to increase the dose because of a subtherapeutic range.

Hold the drug and notify the health care provider immediately. Rationale The therapeutic range for lithium is 0.4to l.3 mEq/l; the health care provider should be notified. Continuing the usual dose or asking the provider to increase the doseis unsafe. The ithium level is currently unsafe but does not need to drop to 0.4mEq/L before being restarted.

Liver

Glycogen stores in the liver provide a reservoir of available energy to ensure the whole body's energy needs are met. These reserves protect cells from depressed metabolic function and resulting injury. The liver regulates the amount of glucose entering the blood in response to pancreatic hormones.

Which term is used to document behavior that includes a patient stating loudy, " am God and I created the world.' Labile mood Heightened mood Cognitive symptoms Grandiose delusions

Grandiose delusionsed Rationale Patients with grandiose delusions believe that they are famous, omnipotent, wealthy, or otherwise very powerful. Two-thirds of patients in the manic state of bipolar disorder develop this symptom. When mood swings are observed, the patient is said to being a labile mood. A heightened mood is termed euphoria. Cognitive symptoms (such as the inability to concentrate, slowed thinking, confusion, and poor memory of recent events) are particularly common in older patients with major depressive disorder.

The nurse instructs a patient to take a monoamine oxidase inhibitor(MAOl) to avoid which food? Orange juice Egg salad sandwiches Ice cream Grilled cheese sandwiches

Grilled cheese sandwiches Rationale Patients taking MAOls should avoid tyramine-rich foods, such as cheese, because they may cause a hypertensive crisis. Orangejuice and milk products, such as ice cream, have not been shown to affect MAOls. Patients should not be concerned about eating eggs while taking MAOls.

The nurse is informing a pregnant patient about the effects of alcohol consumption during pregnancy. Which fetal effects does the nurse include in the education? Select all that apply. O Macrosomia O Growth disorders O Delirium tremens O Mental retardation O Craniofacial abnormalities

Growth disorders Mental retardation Craniofacial abnormalities Rationale Alcohol consumption during pregnancy affects the fetus and causes fetal alcohol syndrome. The infant may have mental retardation or a growth disorder after birth. There may be craniofacial abnormalities, such as wide-set eyes and a flattened face or malformed body parts. Macrosomia is excessive weight in an infant after birth, seen in infants born to diabetic patients. Delirium tremens is a psychotic reaction seen in patients due to abrupt cessation of alcohol.

Which objective data are included in the assessment of a patient with a dependence problem? Select all that apply. O Gum and tooth problems O Needle tracks on forearms O Positive blood sample for drugs O Drug quantity is taken by the patient O Height, weight, vital sign measurements

Gum and tooth problems Needle tracks on forearms Positive blood sample for drugs Height, weight, vital sign measurements Rationale Gum and tooth problems may indicate methamphetamine ("meth") use. Needle tracks on forearms indicate the use of intravenous drugs. A blood sample is objective data; if it is positive, the nurse may need to investigate further. Height, weight, and vital sign measurements are objective data. The drug quantity used by each patient differs and is a subjective datum.

When a patient being treated for methamphetamine intoxication develops seizures, which drug does the nurse suspect to have caused this? O Clonidine (Catapres) O Haloperidol (Haldol) O Naltrexone (ReVia) O Buprenorphine (Buprenex)

Haloperidol (Haldol) Rationale Haloperidol (Haldol) is an antipsychotic agent used in the treatment of methamphetamine intoxication. However, it may lower seizure threshold in patients already at high risk for seizures. Clonidine (Catapres) is used to decrease tremors and agitation in patients with opioid toxicity. Naltrexone (ReVia) along with psychosocial treatment may reduce alcohol craving in patients with opioid abuse. Buprenorphine (Buprenex) has ceiling effects on analgesia and reduces respiratory depression in a patient with opioid abuse. However, these drugs are not used for the treatment of methamphetamine intoxication and may not cause seizures.

Which drug should be used cautiously in patients with amphetamine toxicity because it decreases the seizure threshold in a patient? O Oxazepam (Serax) O Haloperidol (Haldol) O Acamprosate (Campral) O Buprenorphine (Subutex)

Haloperidol (Haldol) Rationale Haloperidol (Haldol) reduces the seizure threshold in patients with amphetamine toxicity. Oxazepam (Serax) is used to treat anxiety. Buprenorphine (Subutex) has been approved for maintenance of opioid programs. Acamprosate (Campral) is used to prevent relapse in patients who abuse alcohol.

A patient on a neurologic unit is experiencing a decrease in taste and smell distortion. Which intervention, if carried out by the nurse during meals, can assist the patient with neurologic deficits? O Have dietary prepare foods that are very attractive and colorful O Have family members provide all meals O Change the patient's diet to soft or puree O offer liquid nutritional drinks immediately before meals

Have dietary prepare foods that are very attractive and colorful

The nurse is caring for a terminally ill patient suffering from colon cancer. If the patient dies, which team member should break the bad news to the family members? O Health care provider O Nurse O Staff supervisor O Mortuary in charge

Health care provider Rationale Generally, the health care provider delivers the bad news to the family. However, the nurse accompanies the health care provider and remains with the family after the health care provider leaves. The staff supervisor and the mortuary in charge are not involved.

A student nurse has been assigned to the pediatric clinic. During the assessment, which set of data should the nurse expect to be considered normal when measuring the preschooler's vital signs? O Heart rate 90, respiratory rate 30, and blood pressure 82/64 O Heart rate 80, respiratory rate 23, and blood pressure 110/60 O Heart rate 120, respiratory rate 30, and blood pressure 50/60 O Heart rate 72, respiratory rate 20, and blood pressure 120/70

Heart rate 80, respiratory rate 23, and blood pressure 110/60

Rehabilitation Phase Burns

• Starts on admission • "Officially" begins when 20% or less of the TBSA remains burned • Rehabilitation • Promote independence and function • Promote mobility • Prevent contractures

When the nurse suspects withdrawal symptoms in a patient, which assessments would take priority? Select all that apply. O Hydration O Nutritional status O Electrolyte balance O Psychiatric symptoms Impairment of attention

Hydration Nutritional status Electrolyte balance Rationale a patient with withdrawal symptoms should be quickly assessed for hydration, nutritional status, and electrolyte balance. These changes are due to prolonged intake of alcohol. Psychiatric symptoms and changes) in air impairment of attention are related to intoxication.

Which statements by a patient indicate a need for further learning regarding precautions when taking disulfiram (Antabuse)? Select all that apply. O "I should avoid coffee." O "I Should avoid cough and cold elixirs for few days. O I should consume soups containing cooking sherry." O "I should use mouthwash regularly," O "I should wait at least 2 hours after taking the drug before consuming alcohol.

I should consume soups containing cooking sherry." "I should use mouthwash regularly," "I should wait at least 2 hours after taking the drug before consuming alcohol. So close! Rationale Disulfiram (Antabuse) is prescribed to promote abstinence in a patient who abuses alcohol. The patient should not consume soups containing cooking sherry because they may contain alcohol. Because mouthwashes mostly contain alcohol, the patient should be advised to avoid them. Because disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting if alcohol is ingested, the patient should avoid alcohol completely. Cardiovascular and central nervous system effects may be increased by disulfiram (Antabuse) and may lead to tachycardia and nervousness. Therefore the patient should be advised to avoid coffee. The patient should avoid cold and cough elixirs for some time because they may contain alcohol.

When monitoring a patient who began lithium therapy 3 weeks ago to treat bipolar disorder, which signs and symptoms potentially indicate serious adverse effects? Select all that apply. Hyperreflexia Excessive thirst Profuse diarrhea Gastric irritation Lethargy and weakness

Hyperreflexia Profuse diarrhea Lethargy and weakness Rationale Hyperrexiexia, profuse diarrhea, and lethargy, and weakness are serious adverse effects of lithium therapy that indicate impending toxicity. Excessive thirst is a common, mild adverse effect that generally resolves over time. Gastric irritation is a common adverse effect that can be addressed by taking the drug with food or milk.

For which dangerous side effect will the nurse monitor a patient who is taking phenelzine sulfate? O Agranulocytosis O Hypertensive crisis O Extrapyramidal side effects O Neuroleptic malignant syndrome

Hypertensive crisis Rationale Hypertensive crisis may result when patients who are taking a monoamine oxidase inhibitor(MAOl) eat food containing tyramine, such as red wine, beer, aged cheese. The neuroleptic malignant syndrome is associated with antipsychotics. Agranulocytosis is associated with clozapine, which is an antipsychotic, and lithium, which is an antimanic drug. Extrapyramidal side effects are also associated with antipsychotics.

The health care provider prescribes blood tests for a patient brought to the emergency room after a motor vehicle accident (MVA), including blood alcohol levels. When reviewing the results, which laboratory results does the nurse note to indicate long-term alcohol abuse? Select all that apply. O Hypoglycemia O Hyperglycemia O Increased liver enzymes O Increased urinary alcohol O Abnormal blood protein levels O Elevated magnesium and hemoglobin

Hypoglycemia Increased liver enzymes Abnormal blood protein levels Rationale Hypoglycemia, increased liver enzymes, and abnormal blood protein levels occur with alcoholism. Hyperglycemia is not a consequence of long-term alcohol abuse. Alcohol in the urine is an indicator of a recent ingestion of alcohol and not long-term use. Lower magnesium levels and anemia are associated with long-term alcohol use.

The nurse is performing the admission assessment of an elderly patient. On the assessment of the skin, the nurse notes full-thickness tissue loss over the right heel; however, bone is not exposed. The nurse would anticipate the diagnosis of which stage of a pressure ulcer? O I O II O III O IV

III Rationale An area of full-thickness tissue loss that does not expose bone is most likely a stage III pressure ulcer. If bone is exposed, it is a stage IV pressure ulcer. A stage pressure ulcer is characterized by an area of nonblanchable erythema. Partial-thickness loss characterizes a stage Il pressure ulcer

A seasoned nurse has been assigned a patient with cancer. The patient is highly upset that failing vision is preventing the reading of scriptures. Which immediate action, if taken by the nurse, would meet the patient's needs? If comfortable, offer to read the scripture for the patient. Medicate the patient and encourage a rest period Ask the nursing staff to come and have a church with the patient Notify members of the congregations to come and visit the patient

If comfortable, offer to read the scripture for the patient.

Erickson trust vs mistrust

If needs are dependably met, infants develop a sense of basic trust

Which tricyclic antidepressant is approved for treating enuresis in children 6 years of age and older? Clomipramine Trimipramine Imipramine Amitriptyline

Imipramine Rationale Imipramine is effective in treating enuresis in children aged 6years and older. Clomipramine is approved to treat obsessive-compulsive disorder. Trimipramine is not indicated for the treatment of enuresis in children. Amitriptyline has been shown to be effective in treating depression in older individuals.

pressure injury diagnoses

Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance

For a patient with excessive gastric bleeding, cold or iced solutions for a gastric lavage may cause which condition? O Dumping syndrome O Aspiration and gastric reflux O Impaired platelet production O Excessive blood clotting

Impaired platelet production Rationale Cold/iced solutions, if used for gastric lavage in patients with gastric bleeding, may cause impaired platelet production. This lowers the rate of blood coagulation and thereby increases the rate of bleeding. Thus the use of cold/iced solutions is contraindicated for gastric lavage in this case Dumping syndrome is caused by rapid infusion of concentrated solutions. Aspiration and gastric reflux are seen when the patient receives feeding through nasogastric tubing. Cold/iced solutions impair platelet production and therefore impair the clotting process

The nurse is caring for a patient diagnosed with major depression. Which outcomes would the nurse evaluate in the patient after providing effective nursing interventions? Select all that apply. O Improvement in sleep patterns O Improvement in social interactions O Improvement in verbal communication O Absence of relocation stress syndrome O Reduction in signs of self-directed violence

Improvement in sleep patterns Improvement in social interactions Improvement in verbal communication Reduction in signs of self-directed violence Rationale Major depression is characterized by apathy, pessimism, multiple physical complaints, anxiety, isolation, suicidal thoughts appetite disturbance, and limited attention span. Therefore the nursing interventions performed are directed toward the improvement of sleep patterns, social interactions, and verbal communication, and prevention of self-directed violence. The nursing interventions are said to be effective if there is an improvement in all these factors. Relocation stress syndrome is found in patients suffering from personality disorders.

Dietary Guidelines for Americans

In line with the current national health goal of health promotion through disease prevention by reducing identified risks of chronic disease, the Dietary Guidelines for Americans recommend the general control of fat in the diet, especially saturated fat and cholesterol. The following guidelines address dietary fat intake: • Consume less than 10% of calories from saturated fatty acids by replacing them with unsaturated fatty acids • Consume as little dietary cholesterol possible while consuming a healthy eating pattern. Keep trans-fatty acid consumption as low as possi ble by limiting foods that contain synthetic sources of trans fats (e.g., partially hydrogenated oils) and milk products. by limiting other solid fats. • Choose fat-free or low-fat milk and • Choose protein foods that are lean and nutrient dense. • Use oils to replace solid fats where possible.

An older patient who has been recently admitted to a long-term care facility has been staying in his room and not attending meals or activities since his son was killed in a car accident. Which concern would be the highest priority for this patient? O Grieving related to loss of son O Isolation related to loss of son O Grief related to relocation to a nursing home O Inability to cope related to the number of personal losses

Inability to cope related to the number of personal losses Rationale Losses occur with age. The number of losses and the rapidity with which they occur may affect the coping ability of the older person and result in anxiety, fear, or depression. Hopelessness related to relocation is not a priority; the patient is dealing with loss rather than relocation. Social isolation is not the highest priority. The patient is showing signs of depression as a result of his losses. The patient is not effectively grieving, so this concern would not be a priority at this

The infant

Infancy includes the period between 4 weeks and 1 year of age. Developmental tasks involve the goals of developing social competence and mastery of skills necessary for functioning in an environment. • Some developmental tasks of infancy include weaning, locomotion, self-feeding, and acquiring language. The development of a sense of trust begins in infancy. The infant's birth weight doubles by 6 months and triples by 1 year of age. • The infant is in Piaget's sensorimotor stage of development. Object permanence involves knowing an object is there even though it is not in sight. The infant is in Freud's oral stage of development. Sucking and exploring textures with the mouth are normal behaviors. Separation anxiety begins at 6 months of age when the infant protests if the parent leaves the room. • Language development involves both verbal language and body language. Verbal language involves expression and receiving (understanding) communication from others. Egocentric behavior is evidenced by the 1-year-old, who relates all toys to his or her own body.

Cellulitis

Infection of the skin characterized by heat, pain, erythema, and edema

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

Inflammatory or (lag) phase Maturation or (remodeling) phase Proliferative or (connective tissue repair) phase

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable.

Anxiety interventions

Interventions: •Decrease stimuli •Provide a calm & quiet environment •Setting realistic limits and controls •Recognize anxiety •Establish truss •Protect the client •Do not criticize coping mechanism •Provide creative outlets •Promote relaxation techniques •Medicate if necessary

Neuroleptic Malignant Syndrome

Interventions: •Notify PCP •Monitor VS •Initiate safety precaution •Seizure precaution •Administer antipyretics and or cooling blanket •Monitor nutrition, fluid, and electrolyte.

Small intestine

Intestinal enzymes and pancreatic amylase continue breakdown of simple carbohydrates. Brush border cells secrete specific enzymes for disaccharide hydrolysis: The monosaccharides are then absorbed and travel to the liver through portal blood circulation.

A do-not-resuscitate (DNR) order has been placed on the chart of a patient with cirrhosis of the liver. Which care will be withheld as a treatment option for this patient? Select all that apply. Hygiene Nutrition Intubation Medication Intravenous fluids Chest compressions

Intubation Chest compressions Rationale DNR means only not to resuscitate. It does not mean to withhold any other care such as hygiene, nutrition, fluids, or medication. The patient may choose to allow some parts of resuscitative efforts such as medication administration but to prohibit chest compressions or intubation.

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which condition in a patient is a sign of Wernicke's encephalopathy? O Involuntary eye movement O Hypoglycemia O Potential for violence O Increased serum magnesium levels

Involuntary eye movement Rationale Eye abnormalities such as nystagmus or paralysis of the lateral rectus muscles indicate Wernicke's encephalopathy. Hypoglycemia is not indicative of Wernicke's encephalopathy; however, administration of glucose-containing intravenous (IV) solutions to the patient may precipitate Wernicke's encephalopathy in a previously unaffected patient. Most patients with Wernicke's encephalopathy have decreased serum magnesium levels and other signs of malnutrition. Potential for violence is not related to Wernicke's encephalopathy.

A nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. Which symptoms would the nurse assess for with regard to tardive dyskinesia? O Migraine headache, hypertension O Abnormal respiratory rate and depth O Severe flushing, headache, and tremors O Involuntary movements of the mouth and tongue

Involuntary movements of the mouth and tongue Rationale Tardive dyskinesi i an extrapyramidal sign of pseudoparkinsonism characterized by involuntary movements, such as lip smacking or tongue protruding. Abnormal breathing, severe flushing, headache, tremors, and migraine headaches are not characteristics of dyskinesia.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is melanoma. Does the nurse understand that which describes a characteristic of this type of lesion? O Metastasis is rare. O It is encapsulated. O It is highly metastatic. O It is characterized by local invasion. O Lesion is a nevus that has changed in color.

It is highly metastatic.

FOOD SOURCES OF FAT

It is common that foods are classified as being a source of one type of fat or another. In reality, most foods contain a combination of different types of fats. For example, we generally think of olive oil as a "heart healthy" monounsaturated fat. significant source of monounsaturated fat, the actual composition of olive oil is 14% saturated fat, 9% polyunsaturated fat, and 77% monounsaturated fat Another prime example is beef fat. It is true that beer fat is mostly saturated fat (52% of the fat is saturated), but a hefty 44% is monounsaturated fat and 4% is polyunsaturated fat. Very few things in nutrition are all or nothing. Keep this in mind as you read the following section where fats are categorized accord ing to the predominant, but not exclusive, source of fat.

Which statement precisely describes moderate depression? It causes minor functional impairment. It significantly impairs daily functioning. It affects both symptomatology and functionality. It causes several symptoms that exceed the minimum diagnostic criteria.

It affects both symptomatology and functionality. Rationale Patients with moderate depression have an intermediate degree of impairment. This impairment affects both symptomatology and functionality. Mild depression causes minor functional impairment. Patients with severe depression often require hospitalization because their ability to manage daily functions is significantly impaired. Such patients also have several symptoms that exceed the minimum diagnostic criteria.

A young patient says that he gets annoyed when friends tell him that he drinks too much. He also reports that sometimes he thinks he should try and cut down a little on his drinking. The nurse in the clinic would draw which conclusion about the likelihood that the patient has alcoholism based on the CAGE questions? O It is probable that the patient has alcoholism. O The patient probably does not have alcoholism. O There is an increased risk to develop alcoholism. O The information provided is inadequate for making any determination.

It is probable that the patient has alcoholism. Rationale There are four CAGE questions. Two affirmative answers on the CAGE questions indicate probable alcoholism. The patient answered affirmatively to two of the questions. That is sufficient to indicate probable alcoholism. The CAGE questions do not indicate risk for developing alcoholism. Even though answers to only two of the four questions are revealed, those two answers are enough to make a determination.

Which statement regarding the effectiveness of electroconvulsive therapy for depression and bipolar illness is correct? It minimizes the rate of relapse. It prevents recurrences of mood disorders. It is safer for patients with cardiovascular disease. It is more effective in preventing the symptoms of mania than those of depression.

It is safer for patients with cardiovascular disease. Rationale Electroconvulsive therapy is a form of nonpharmacologic treatment for depression and bipolar illness that is more effective and safer for patients with cardiovascular disease than many drug therapies. After electroconvulsive therapy, drug therapy is done to minimize the rate of relapse. The aim of maintenance therapy (not electroconvulsive therapy is to prevent recurrences of the mood disorder. Lithium is more effective in preventing the signs and symptoms of mania than those of depression.

The purpose of the Clinical Institute Narcotic Assessment (CINA) rating scale is to perform which function? O it evaluates the patient's level of addiction. O It estimates the patient's degree of tolerance. O It determines the need for narcotics for pain relief. O It is used to assess patients undergoing opioid withdrawal.

It is used to assess patients undergoing opioid withdrawal Rationale The CINA rating scale is helpful in assessing and monitoring patients undergoing opioid withdrawal. The CINA rating scale is not used to determine the need for narcotics for pain relief, does not measure a patient's level of addiction, and does not estimate the patient's degree of tolerance.

What is the middle portion of the small intestine called? A. Jejunum B. Ileum C. Duodenum D. Cecum

Jejunum

The nurse is teaching a group of student nurses about the biological theories of aging. Which points should the nurse include in the teachings? O Aging is a chronological process and does not depend on lifestyle changes O Lipofuscin is a pigmented material that promotes aging in individuals. O Immunity is reduced with age because the thymus gland increases in size O Changes is elastin in the body can enhance flexibility in the elderly

Lipofuscin is a pigmented material that promotes aging in individuals.

The family member of an elderly patient living alone is concerned about safety. During family teaching, what should the nurse focus on to prevent accidents from occurring? O Taking all measure to prevent accidents from ever happening O Addressing any accidents after the occurrence O Knowledge and recognition of factors that can cause accidents O Manipulation of the environment to eliminate all accidents

Knowledge and recognition of factors that can cause accidents

The nurse administers haloperidol to a patient with a psychological disorder. For which side effect should the nurse monitor the patient? O Hypothermia O Renal impairment O Cerebral hemorrhage O Labile blood pressure

Labile blood pressure Rationale The neuroleptic malignant syndrome is a rare side effect of haloperidol. The symptoms include hyperthermia, muscle rigidity, and cardiovascular collapse. Therefore after administering haloperidol to a psychiatric patient, the nurse should monitor the patient for cardiovascular collapse, including blood pressure. Hypothermia involves reduced body temperature, which is unrelated to haloperidol. Renal impairment or kidney dysfunction is caused by other medications and is unrelated to haloperidol. Cerebral hemorrhage is observed in conditions such as trauma, and haloperidol has no effect on it.

A patient with the attention-deficit disorder has prescribed a drug that may cause abuse. Which withdrawal symptoms may be observed after discontinuation of the drug? Select all that apply. O Anxiety O Insomnia O Lack of energy O Lack of memory O severe depression

Lack of energy Lack of memory Severe depression Rationale Methamphetamine (Desoxyn) can be prescribed to treat attention-deficit disorder. Abrupt discontinuation of methamphetamine (Desoxyn) after long-term use may result in withdrawal symptoms including lack of energy, lack of memory, and severe depression. Anxiety and insomnia are chronic withdrawal symptoms of opioids.

Which statements concerning the use of medications in older adults are correct? Select all that apply. On average, the older adult takes up to 7 prescription medications. Laxatives and vitamin supplements are commonly used medications among older adults. The average older adult is currently taking 2 nonprescription medications. The use of multiple drugs may reduce the therapeutic benefits of the medications taken. Using more than one pharmacy to fill prescriptions will increase the risk factors associated with polypharmacy. The body's ability to absorb, transport, and eliminate medications is increased with age.

Laxatives and vitamin supplements are commonly used medications among older adults. The average older adult is currently taking 2 nonprescription medications. The use of multiple drugs may reduce the therapeutic benefits of the medications taken. Using more than one pharmacy to fill prescriptions will increase the risk factors associated with polypharmacy.

Which action should the nurse take if no urine return is visualized after inserting a urinary catheter in a female patient? O Obtain an order for an external female catheter O Remove the catheter and attempt to reinsert the same catheter. O Remove the catheter and obtain a new insertion kit. O Leave the catheter in place and insert a second catheter

Leave the catheter in place and insert a second catheter Rationale If the nurse inserts a urinary catheter into a female patient and does not see urine return, the balloon should be inflated and left in place. This action marks that the catheter is in the vagina and provides a landmark, thus helping avoid inserting the catheter again in the same opening. A new catheter should be obtained and Inserted into the urinary meatus. The nurse should not obtain an order for an external female catheter. The same catheter should not be reinserted after removal because this increases the risk of infection

The signs and symptoms of shock

Level of consciousness Skin: Cool and clammy Blood pressure Pulse Respirations: Increases Urinary output: Decrease Neuromuscular system Gastrointestinal system

Which antiparkinsonian medicine may cause depression? O Levodopa O Reserpine O Progestin O Methyldopa

Levodopa Rationale Levodopa is an antiparkinsonian medication that may contribute to depression. Reserpine and methyldopa are antihypertensive drugs that may cause depression. Progestin is a hormone that causes depression.

Lignin.

Lignin, which is the only noncarbohydrate type of dietary fiber, is a large compound that forms the woody part of certain plants. It binds the cellulose fibers in plants, thereby giving added strength andchelator a ligand that binds to a metal to form a metal complex

Unlicensed assistive personnel (UAP) is preparing to perform morning care on a dying patient. The UAP informs the nurse that the patient is complaining of severe fatigue. Which action should the nurse instruct the UAP to do? O Perform all grooming needs during a single visit. O Choose which tasks will be performed for the patient. O Limit care to essential tasks the patient wants to perform. O Have family members assume the responsibility of caring for the patient.

Limit care to essential tasks the patient wants to perform.

An unlicensed assistive personnel UAP) is preparing to perform morning care on a dying patient. The UAP informs the nurse that the patient is complaining of severe fatigue. Which action should the nurse instruct the UAP to do? O Perform all grooming needs during a single visit. O Choose which task will be performed for the patient. O Limit care to essential tasks the patient wants to perform. O Have family members assume the responsibility of caring for the patient.

Limit care to essential tasks the patient wants to perform. Rationale Needs and interventions for the dying patient include helping the patient identify desired tasks and helping the patient conserve energy for said tasks. Nursing care should be paced and timed, and rest periods should be provided. The family should not be asked to assume the responsibility of caring for the patient.

Lipoproteins

Lipoproteins, which are the major vehicles for lipid transport in the bloodstream, are combinations of triglycerides, protein (apoprotein), phospholipids, cholesterol, and other fat-soluble substances (e.g., fat soluble vitamins). Because fat is insoluble in water and because blood is predominantly water, fat cannot freely travel in the bloodstream; it needs a water soluble carrier. The body solves this problem by wrap ping small particles of fat in a covering of protein, which is hydrophilic (i.e., "water loving"). The blood then transports these packages of fat to and from the cells throughout the body to supply needed nutrients. A lipoprotein's relative load of fat and protein deter mines its density. The higher the protein load, the higher the lipoprotein's density. The lower the protein load, the lower the lipoprotein's density (Figure 3-5). Low-density lipoproteins carry fat and cholesterol to cells. High-density lipoproteins carry free cholesterol from body tissues back to the liver for metabolism. Circulating levels of lipoproteins are indicative of lipid disorder risks and with the underlying blood vessel disease atherosclerosis.

Proteins

•Builds & repair tissues •Regulate fluid balance •Maintain acid-base balance •Produce antibodies •Provide energy •Produce enzymes & hormones •Complete vs Incomplete proteins •Animal products & tofu

DIGESTION OF FATS Stomach

Little if any chemical digestion of fat occurs in the stomach. General muscle action continues to mix the fat with the stomach contents. No significant amounts of fat enzymes are present in the gastric secretions except gastric lipase (tributyrinase), which acts on emulsified butterfat. Although the primary gastric enzymes act on other proteins in the food mix, fat is isolated and prepared for its major, enzyme-specific breakdown in the small intestine.

cardiac sphincter

Located at the base of the esophagus and functions to prevent food materials from entering the esophagus from the stomach

Which intervention is a priority while providing care for an addicted patient being treated with chlordiazepoxide?

Monitoring the patient's intake and output

The infant pt

Major risk factors for heart disease begin developing in early childhood. Regular physical activity can help slow the development of these risk factors. • Infants should be placed in environments that stimulate movements and exercise. • A natural pattern of intermittent play is age-appropriate physical activity for infants. Breast milk is the best food for infants under 6 months of age, and mothers should be encouraged to continue to provide breast milk until 1 year of age. To prevent SIDS, infants should be placed on their backs to sleep. By 1 year of age, the infant eats table food three times a day. • At 1 year of age, whole milk can be introduced, but low-fat milk should not be provided to children under 2 years of age. • The most common type of dental caries in infants is nursing caries, which are preventable. • A childproof home is essential for preventing accidents.

Which nursing intervention is the priority when caring for a forgetful disoriented client with the diagnosis of dementia of the Alzheimer's type? O Ego integrity Restrict gross motor activity O Ego integrity Prevent further deterioration O Ego integrity keep the client-oriented to time O Ego integrity Manage the client's unsafe behavior

Manage the client's unsafe behavior

Which drug is the most commonly used illegal drug in the United States? O Cocaine O Marijuana O Phencyclidine (PCP) and lysergic acid diethylamide (LSD) O 3,4-methylenedioxymethamphetamine (MDMA; Ecstasy)

Marijuana Rationale Marijuana is considered a gateway drug and remains the most commonly used illicit drug used in the United States. Cocaine, MDMA, PCP, and LSD are often abused, but they are not the most commonly used illegal drugs in the United States.

Loss is a natural part of our lives Which type of loss is felt when one leaves home for college? Personal Perceived Situational Maturational

Maturational Rationale Maturational loss is a loss resulting from normal life transitions. Situational loss is defined as a loss occurring suddenly in response to a specific external event, such as the sudden death of a loved one. Perceived loss is a loss noted only by that individual. Personal loss is any significant loss that requires adaptation through the grieving process.

A patient with recurrent urinary tract infections (UTIS) is prescribed methenamine hippurate (Mandelamine). Which food and supplements would the nurse include in the patient's diet plan for the effective action of the medication: Select all that apply. O Vitamins K and D O Meat and plums O Vitamins Cand A O Milk and apples O Baked potatoes

Meat and plums Vitamins Cand A Rationale Methenamine hippurate (Mandelamine) is given to the patients with chronic recurrent UTIs as a preventative measure after the antibiotics have cleared the infection. To ensure the effective action of this medication, acid ash foods or acidifiers are used to acidify urine to a pH below 5.5. Acid-ash food includes meat, whole grains, eggs cheese, cranberries, plums, and prunes: Along with the acid ash foods, vitamins C and A should be given for the effective action of the medication. Vitamin K and Dare not related to the effectiveness of methenamine mandelate (Mandelamine) Milk and apples are alkaline ash foods that are used to increase the pH of the urine to the alkaline side of the pH scale. Baked potato is a potassium-rich food, usually given to patients taking diuretics

Which factors determine the sensorial function of a patient? Select all that apply. O Speech O Memory O Attention O Orientation. O impulse control

Memory Attention Orientation. Rationale Nursing assessments of a patient's emotional status make it possible to adjust the plan of care appropriately. Sensory function describes the patient's memory, attention, orientation, and ability to think abstractly. Speech patterns describe the patient's speech. Degree of impulse control is assessed to know the patient's potential for danger. Other factors in a patient's potential for danger indude the patient's potential for self-harm and previous history of violence or aggression toward others.

Which inference would the nurse make about a patient who is demonstrating maladaptive behavior and has lost contact with reality?

Mental illness

A patient on disulfiram (Antabuse) therapy is reported to have frequent psychotic episodes and confusion. Which medication is responsible for this condition? O Phenytoin (Dilantin) O Isoniazid (Nydrazid)) O Estazolam (ProSom) O Metronidazole (Flagyl)

Metronidazole (Flagyl) Rationale Disulfiram (Antabuse) is used in alcohol rehabilitation programs: Concurrent administration of disulfiram (Antabuse) and metronidazole (Flagyl) may result in psychotic episodes and confusion. Disulfiram (Antabuse) inhibits the metabolism of phenytoin (Dilantin), resulting in nystagmus, sedation, and lethargy. Disulfiram (Antabuse) inhibits the metabolism of isoniazid (Nydrazid), which results in alterations in mental status. Disulfiram (Antabuse) inhibits the metabolism of estazolam (ProSom), resulting in benzodiazepine toxicity.

A patient with anxiety who reports nausea and vomiting is exhibiting argumentative behavior. Which degree of anxiety is the patient experiencing? O Mild O Moderate O Severe O Panic

Moderate Rationale A patient's degree of anxiety is described in levels. Each level consists of certain behaviors. Moderate anxiety is characterized by feelings of tension, decreased perception, and some alertness in certain situations. Patients with moderate anxiety may tend to argue, tease, or complain. Headaches, diarrhea, nausea, vomiting, and low back pain are physical signs and symptoms exhibited by patients with moderate anxiety. Increased motivation is seen in patients with mild anxiety. Extreme terror and distortion of reality are seen in patients who are at the panic level of anxiety. Patients with severe anxiety feel fatigue.

patient with anxiety who reports nausea and vomiting is exhibiting argumentative behavior. Which degree of anxiety is the patient experiencing? O Mild O Moderate O Severe O Panic

Moderate Rationale A patient's degree of anxiety is described in levels: Each level consists of certain behaviors Moderate anxiety is characterized by feelings of tension, decreased perception, and some alertness in certain situations Patients with moderate anxiety may tend to argue, tease; or complain, Headaches, diarrhea, nausea, vomiting, and low back pain are physical signs and symptoms exhibited by patients with moderate anxiety. Increased motivation is seen in patients with mild anxiety Extreme terror and distortion of reality are seen in patients who are at the panic level of anxiety, Patients with severe anxiety feel fatigue.

The nurse is examining a patient who has been prescribed hormone replacement therapy (HRT). Which intervention should the nurse follow to ensure safe administration of the medication? Select all that apply. O Vision O Monitor for changes in the patient's breasts. O Monitor for changes in the patient's blood pressure. O Oral Cavity O Urine output

Monitor for changes in the patient's breasts. Monitor for changes in the patient's blood pressure.

Which nursing interventions should the nurse follow to prevent lithium toxicity in a patient who has been prescribed lithium carbonate? Select all that apply. O Monitor lithium levels in the patient. O Chart the presence of adverse effects. O Monitor changes in the patient's behaviors. O Suggest that the patient reduce salt intake. O Monitor the patient for symptoms of dehydration.

Monitor lithium levels in the patient. Chart the presence of adverse effects. Monitor changes in the patient's behaviors. Monitor the patient for symptoms of dehydration. Rationale Lithium levels should be monitored, and the adverse effects should be charted to help in the early identification of the symptoms of lithium toxicity. The nurse should monitor changes in the patient's behaviors to determine the therapeutic effects of lithium. Lithium leads to urinary frequency, which may result in dehydration; hence the symptoms of dehydration should be assessed. Salt intake should be increased to avoid lithium toxicity.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

A nurse is caring for a patient who is taking digoxin once a day for treatment of congestive heart failure. He now has a new prescription for spironolactone (Aldactone). Which nursing intervention is most appropriate for this patient? O Obtain a prescription for a potassium supplement O Monitor the patient for signs and symptoms of digoxin toxicity, O Encourage salt supplements to modify the adverse effects of the new medication. O Take blood pressure, pulse, and respiratory rate twice a day until the patient is stabilized on the new medication

Monitor the patient for signs and symptoms of digoxin toxicity, Rationale The appropriate nursing intervention would be to monitor the patient for signs and symptoms of digoxin toxicity. As a diuretic takes effect, there may be a resultant increase in the serum concentration of other medications that the patient is currently taking. Because this patient is taking digoxin, the nurse must carefully assess for development of digoxin toxicity, Obtaining an order for a potassium supplement would be inappropriate in this situation because spironolactone (Aldactone) is classified as a "potassium-sparing diuretic. These medications conserve potassium that is usually lost with diuretic agents. Salt should be discouraged in patients on diuretic therapy. The patient should be instructed to avoid overuse of salt in cooking or as a table additive. The health care provider might also place the patient on a restricted salt diet (c.g., 2 g/day).

Which nursing action is appropriate for a patient undergoing bupropion therapy in combination with nicotine replacement products to help with smoking cessation? Increase the dose of bupropion. Alert the patient that blurred vision may occur. Send the blood sample for a liver function test. Monitor the patient's blood pressure regularly.

Monitor the patient's blood pressure regularly. Rationale Coadministration of nicotine replacement products with bupropion may cause hypertension. Thus the nurse should monitor the patient's blood pressure on a regular basis. Cigarette smoking enhances the metabolism of tricyclic antidepressants, not bupropion. Before initiating selective serotonin reuptake inhibitor therapy, the nurse should check the patient's hepatic studies. This intervention is not required for bupropion therapy. If the patient undergoes monoamine oxidase inhibitor therapy, then the nurse should caution the patient that blurred vision may occur as a side effect.

Which intervention is a priority while providing care for an addicted patient being treated with chlordiazepoxide? O Avoiding between-meal snacks: O Monitoring the patient's blood reports. O Avoiding night-lights in the patient's room O Monitoring the patient's intake and output

Monitoring the patient's intake and output Rationale Chlordiazepoxide may cause urinary retention in the patient. The nurse must monitor the patient's intake and output so any change can be reported promptly to the health care provider. The patient may also suffer from loss of appetite; between-meal snacks are helpful to meet nutritional deficits. Blood reports are monitored for some medications, but not for chlordiazepoxide. The patient may experience disorientation at night, night lights should be used in the room, along with frequent visits by the nurse.

Which intervention is a priority while providing care for an addicted patient being treated with chlordiazepoxide? O Avoiding between-meal snacks: O Monitoring the patient's blood reports. O Avoiding night-lights in the patient's room O Monitoring the patient's intake and output

Monitoring the patient's intake and output Rationale Chlordiazepoxide may cause urinary retention in the patient. The nurse must monitor the patient's intake and output so any change can be reported promptly to the health care provider. The patient may also suffer from loss of appetite; between-meal snacks are helpful to meet nutritional deficits. Blood reports are monitored for some medications, but not for chlordiazepoxide. The patient may experience disorientation at night, night-lights should be used in the room, along with frequent visits by the nurse.

unsaturated fatty acid

Monounsaturated or polyunsaturated. •Usually have plant sources and are liquid at room temperature. •Are thought to have a blood cholesterol -lowering effect at moderate levels of intake. •Ex: Nuts, olive oil, avocado

Which is defined as a sustained emotional feeling perceived along a normal continuum of sad to happy that affects the patient's perception of the surroundings? O Mood O Mania O Dysthymia O Depression

Mood Rationale A mood is a sustained emotional feeling perceived along a normal continuum of sad to happy that affects our perception of our surroundings. Mania is an abnormally elated mental state characterized by feelings of euphoria, racing thoughts, talkativeness, and irritability. patient with chronic, ongoing symptoms of depression that last for at least 2 years is said to be suffering from dysthymia. Patients with depression display varying degrees of emotional, physical, cognitive, and psychomotor symptoms.

Over the years, several theories have evolved about the cause of alcoholism, and treatment modalities have changed in accordance with new information and understanding. The nurse who has worked for many years in the treatment of substance misuse and abuse based on which cause of alcoholism will have difficulty including the newer theories in his or her care? O Familial trait O Ethnic trait O Moral failing O Biologic cause

Moral failing Rationale The belief that alcoholism is a moral failing or is caused by moral fault provided the basis for much of the early treatment of alcoholic patients. The theory's influence on treatment modalities has largely been replaced by recognition of biologic influences, including familial and ethnic influences; those providers who base their regimen on the moral theory have difficulty assimilating the new biologic theories into their care.

flatulence

•Gas-producing foods •Carbonated beverages •Cabbages •Beans •Swallow excessive amount of air •Constipated •Abdominal surgery •Narcotic medications

malignant melanoma

Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised.

Which signs and symptoms, when exhibited by a patient receiving fluoxetine would indicate the potentially dangerous condition of serotonin syndrome? Select all that apply. O Miosis O Mydriasis O Confusion O Bradycardia O Tachycardia

Mydriasis Confusion Tachycardia Rationale Signs and symptoms of serotonin syndrome include altered mental status, autonomic dysfunction, and neuromuscular abnormalities. Examples of altered mental states include confusion, delirium, agitation, and mutism. Autonomic dysfunction can include blood pressure fluctuation, tachycardia, hyperthermia, marked pupil dilation (mydriasis), shivering, and diaphoresis. Neuromuscular symptoms include akathisia, ataxia, dystonia, dyskinesia, hyperreflexia, tremors, and seizures. Bradycardia and miosis (pupil contraction) are the opposite of what is typically seen in serotonin syndrome.

Side effects of Halperidol pt 2

NEUROLEPTIC MALIGNANT SYNDROME Occurs weeks to months after drug initiation Muscle rigidity, fever, unstable BP myoglobinuria TARDIVE DYSKINESIA 'Tardive' means 'late' -months to years after drug initiation Involuntary painless movements of face & upper limbs

An adolescent is admitted to the medical facility with severe respiratory depression and risk for coma. Which drug will be administered to the adolescent? O Naloxone O Diazepam O Flurazepam O Methadone

Naloxone Rationale Severe respiratory depression and a risk for coma are signs of opioid overdose. Naloxone is administered to the patient along with ventilation support. Diazepam and flurazepam are benzodiazepines that are used as anticonvulsants. Methadone is used to suppress withdrawal symptoms in morphine or heroin addicts..

An adolescent is admitted to the medical facility with severe respiratory depression and risk for coma. Which drug will be administered to the adolescent? O Naloxone O Diazepam O Flurazepam O Methadone

Naloxone Rationale Severe respiratory depression and risk for coma are signs of opioid overdose. Naloxone is administered to the patient along with ventilation support. Diazepam and flurazepam are benzodiazepines that are used as anticonvulsants. Methadone is used to suppress withdrawal symptoms in morphine or heroin addicts..

An adolescent is admitted to the medical facility with severe respiratory depression and a risk for coma. Which drug will be administered to the adolescent?

Naloxone- is a medication designed to rapidly reverse opioid overdose. It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids.

Which medication is prescribed to block the pharmacologic effects of opioids and alcohol? O Naltresone (ReVia) O Disulfiram (Antabuse) O Clorazepate (Tramene) O Acamprosate (Campral)

Naltresone (ReVia) Rationale Naltrexone (ReVia) is prescribed to block the pharmacologic effects associated with opioids and alcohol. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting. Clorazepate (Transene) is used for detoxification because it enhances gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Acamprosate (Campral) helps patients maintain alcohol abstinence.

Which order does the nurse anticipate from the health care provider for a patient with abdominal distention, nausea, vomiting, and absent bowel sounds who had abdominal surgery 3 days ago? O Suppository O Rectal tube insertion O Enteral tube feedings O Nasogastric tube insertion

Nasogastric tube insertion Rationale The patient is exhibiting signs of a bowel obstruction that requires gastric decompression via a nasogastric tube Insertion. A suppository treats constipation, not an obstruction. rectal tube prevents skin breakdown in patients with diarrhea. Enteral tube feedings will not move through the gastrointestinal tract when an obstruction is present

A patient with renal impairment with fluid overload is catheterized. The health care provider instructs the nurse to perform bladder irrigation. Which herb does the nurse refrain from using in the patient with renal impairment? O Echinacea O Nettle (Urtica dioica) O Cranberry (Cranberry Plus) O Sea holly (Eryngium campestre)

Nettle (Urtica dioica) Rationale Nettle is used to treat benign prostatic hypertrophy (BPH). It is also used to perform bladder irrigation. But it is contraindicated in patients with renal or cardiac impairment. Therefore, the nurse should not use nettle to perform bladder irrigation. Echinacea used to stimulate the immune system and to treat urinary tract infections (UTIS). It is unrelated to bladder irrigation. Cranberry is used to prevent UTIs, particularly in women. It is not used to perform bladder irrigation. Sea holly is used to treat UTIs and prostatitis. It has mild diuretic and antispasmodic effects. It is unrelated to bladder irrigation.

Which instruction would the nurse provide to a patient who is receiving oxygen via a transtracheal tube for the first time? O "Change the catheter every 3 months." O "Refrain from drinking fluids during use." O "Report small amounts of dear exudate! O lean the area every 4 hours with saline!

O "Change the catheter every 3 months." Rationale The transtracheal oxygen catheter should be changed a minimum of every 3 months because the catheter can become brittle over time. Patients can drink, eat, and talk while the transtracheal catheter is in place. Small amounts of clear exudate are normal; however large amounts of thick, colored exudate should be reported. The area should be cleaned with hydrogen peroxide two times a day.

Which instruction would the nurse give to a patient receiving oxygen to help increase air exchange? O "Humidify the oxygen." O "Perform deep-breathing exercises O "Perform regular oral hygiene." O "Lie on left side when sleeping

O "Perform deep-breathing exercises Rationale Patients on oxygen should be encouraged to perform coughing and deep breathing exercises to facilitate air exchange. Humidifying the oxygen prevents nasal dryness. Oral hygiene helps prevent any bad taste in the mouth. The patient should sit in Fowler's position, not lie on the left side, to maximize oxygenation.

Which instruction does the nurse give a patient when the patient reports irritation of the nares while receiving 2 L/min of oxygen via nasal cannula? O "Remove oxygen periodically! O "Use petroleum jelly on nares." O "Switch to a simple face mask." O "Apply a water-soluble lubricant."

O "Apply a water-soluble lubricant." Rationale The nurse would instruct the patient to apply water-soluble lubricant to the nares to treat irritation. Petroleum jelly should not be used, as petroleum-based products are combustible. Instructing the patient to remove oxygen could lead to hypoxia. Masks are used to deliver oxygen at rates greater than 4 L/min and would not be appropriate for a patient receiving 2 ymin.

A child has ingested furniture polish. Which instruction would the nurse give the mother? O "Call 911 for an ambulance O "Call the poison control center. O "Give ipecac syrup to induce vomiting. O Take the child to the emergency room.!

O "Call the poison control center. Rationale The mother should call the poison control center immediately to receive instructions regarding to what to do next. Taking the child to the emergency room or calling 911 for an ambulance would not be the first intervention because it could delay treatment. The mother should not give ipecac unless instructed to do so by the poison control center personnel. Inducing vomiting may not be the appropriate action for this type of poisoning

The nurse is providing educational packets to a patient before gallbladder removal surgery. Which question would the nurse ask to determine whether the patient can read and understand the material presented? O "Can you read this packet?" O "Do you understand what you are reading?" O "Can you please read to me the first paragraph of the packet?" O "Can you please tell me, in your own word, what you're reading in this packet?"

O "Can you please tell me, in your own word, what you're reading in this packet?" Rationale The nurse should ask the patient to present, in his or her own words, the information in the packet. If the patient cannot read, he or she is unlikely to admit it. Therefore, asking the patient if he or she can understand or read the packet would be unhelpful. Although the patient may be able to read what he or she sees in the packet, this is not the same as understanding what is in the packet

Which information would the nurse provide to a home care patient when teaching how to use humidified oxygen at 3 L/min? Select all that apply. O "Change the solution every 24 hours." O "Use bottled water in the chamber." O "Use humidification when wearing a face mask. O "Use distilled water in the chamber O "Wear gloves when touching the oxygen equipment."

O "Change the solution every 24 hours." O "Use distilled water in the chamber Rationale Distilled water should be the only type of water used in the humidification chamber. The water should be changed every 24 hours to prevent bacterial growth. Bottled or tap water should not be used. Gloves do not need to be worn. Humidification can be used, no matter which oxygen delivery device is being used.

Which instruction would the nurse give a patient before performing oropharyngeal suctioning with the Yankauer catheter? O "Lie back in the supine position." O "Cough to bring up any secretions." O "We need to check if your nostrils are blocked!" O "We need to turn up your oxygen supply to a higher amount."

O "Cough to bring up any secretions." Rationale Before oropharyngeal suctioning, patients should be encouraged to cough, which moves secretions from the lower airway into the mouth for suctioning. The patient should be sitting in semi-Fowler's or a higher position, rather than in the supine position, to prevent aspiration. The patency of the nostrils should be determined before nasopharyngeal, not oropharyngeal, suctioning. The nurse should not increase oxygen administration because this would not follow the health care provider's orders.

Which question will help determine the reason for a patient's stress urinary incontinence? O "Do you have incontinence when you sneeze or cough?" O "Have you tried performing Kegel exercises to control it?" O "When did you last experience the problem with incontinence?" O "Has your health care provider prescribed medication to control it?"

O "Do you have incontinence when you sneeze or cough?" Rationale Stress urinary incontinence occurs when a person laughs, coughs, sneezes, or lifts a heavy object. Kegel exercises and medications are treatments for urinary incontinence. Asking when the problem does not necessarily address the underlying cause.

Which statements by a patient recovering from alcoholism come from the 12 steps of Alcoholics Anonymous (AA)? Select all that apply. O "Take control of our lives. O "Admit that we have power over alcohol. O "Humbly ask Him to remove our shortcomings." O "Make a searching and fearless moral inventory of ourselves." O "Rely on ourselves to obtain power over the abuse of alcohol." O "Make amends to others wherever possible, except when to do so would injure them or others."

O "Humbly ask Him to remove our shortcomings." O "Make a searching and fearless moral inventory of ourselves." O "Make amends to others wherever possible, except when to do so would injure them or others." Rationale AA purports that individuals are powerless over alcohol. AA supports reliance on a higher power to restore one to sanity and to stop abusing alcohol. It puts the higher power in control, not personal control. It asks the higher power to remove shortcomings. The individual must make an inventory of one's self. Additionally, the individual must make amends to others unless doing so would injure them.

Which patient statement indicates further discharge teaching is needed for a patient with hemorrhoids? O "I should use witch hazel pads daily." O "I will drink fluid only when I am thirsty." O will add fiber-enriched food to my diet." O "I can sit in a bathtub of warm water twice a day."

O "I will drink fluid only when i am thirsty." Rationale The goal for patients with hemorrhoids is to decrease pain, prevent elimination problems, and prevent damage to the already swollen tissues. To facilitate this, it is necessary for the patient to maintain a proper diet high in fiber, ensure adequate fluid intake, and participate in regular exercise. If the hemorrhoids are particularly bothersome, localized heat such as from a sitz bath and witch hazel pads can be used. If the patient limits fluid intake, it is an indication of lack of understanding and the need for additional teaching,

Which statement by the patient demonstrates a clear understanding of how to use the patient-controlled analgesia (PCA) drug delivery system prior to surgery? O "I am going to push the button every 10 minutes." O "If I push the button, I will receive medication as long as it is not too soon." O I will stop breathing ifl push the button too much O I will only push the button when I am awake, and the nurse will push it when lam asleep."

O "If I push the button, I will receive medication as long as it is not too soon." Rationale The patient should be taught to use the PCA before surgery. The nurse should have the patient demonstrate use of the PCA delivery button. The most effective method to assess whether the patient understands how to use the machine is through return demonstration. Immediately after surgery the patient may not be capable of verbalizing pain relief, therefore this is not an effective option. Stating that the button can be pushed as often as needed for pain control demonstrates an accurate understanding of the system. The patient should understand and be able to verbalize that he or she should push the button any time that pain is felt. It is good for the patient to know the lockout time as well. There is a time frame in which the patient can press the button for pain meds. If the patient tries too soon, then the medication will not be dispensed. This will prevent the patient from having to keep track of the availability of pain medication. The patient does not understand the purpose of a PCA If he or she believes that the nurse will push the button when the patient is asleep. The patient can push the button every 10 minutes, but that is not using the PCA to full benefit. The patient should assess his or her own pain and hit the button as much as needed, prior to the pain becoming too high. The PCA is programmed and has a lockout mechanism that will not allow the patient to overdose.

Which statement about tertiary intention is correct? O "Initially, wounds should be left open. O It occurs when the skin edges are open. O "It begins during the inflammatory phase." O "The wounds are covered by a gauze dressing."

O "Initially, wounds should be left open. Rationale The wound-healing process is categorized into three types based on the severity of the wound. In the tertiary intention healing method, the wounds are left open and are closed only when the infection is controlled. This type of healing occurs when wounds are contaminated by microbes. Unlike primary intention, tertiary intention does not begin during the inflammatory phase of healing. The primary intention method of healing can be seen when the patient has a wound with minor scarring. The secondary intention of healing often is found in patients who have wounds with open skin edges. The health care professional should cover open wounds with gauze to prevent infection.

Which statement correctly explains why patients with ascending colostomies must wear bags instead of performing irrigation? O "I know the ostomy bag can be difficult to manage, but you will get the hang of it." O Colostomy irrigations can only be performed by family members who are nurses." O "All patients who have a colostomy must wear some form of an ostomy drainage pouch." O "Irrigations only work for descending or sigmoid colostomies because of stool being formed."

O "Irrigations only work for descending or sigmoid colostomies because of stool being formed." Rationale The only colostomies that can undergo successful irrigation are those formed in the descending and sigmoid colon because stool is more formed in these areas of the bowel. Telling a patient he or she will get used to the bag does not answer the question. Colostomy irrigations can be performed by anyone, it does not have to be done by a nurse. Patients who are able to irrigate only wear an ostomy cover and do not need to wear a drainage bag.

Which instruction would the nurse give the home care patient who is receiving oxygen at 3 L/min and uses extension tubing that is 50 feet long? O "Keep an eye on the tubing to prevent falls." O "Tie up any excess tubing to prevent injuries." O "Only use portable oxygen tanks while at home." O "Don't use more than 25 feet of tubing at home."

O "Keep an eye on the tubing to prevent falls." Rationale Long extension tubing for oxygen can increase the patient's risk of falling. Excess tubing should not be tied; if tubes become kinked, they may deliver too little oxygen, Portable tanks should be used when leaving the home but are not necessary when the patient is at home. Only using shorter tubing will limit mobility and the patient's independence while at home.

Which information on preventing skin breakdown does the nurse provide the family of an older patient who is wearing oxygen tubing? Select all that apply. O "Loosen the straps." O "Reposition the tubing." O "Add padding over the ears." O "Remove oxygen supply for 15 minutes every hour." O "Apply petroleum jelly to the areas."

O "Loosen the straps." O "Reposition the tubing." O "Add padding over the ears." Rationale The nurse should instruct family members to loosen the straps, reposition the tubing, and add padding over the patient's cars to prevent skin breakdown resulting from use of oxygen tubing. The family should not be instructed to remove the oxygen supply for any period because the patient can become hypoxic Petroleum jelly is combustible and should never be used near the oxygen

Which instructions would be given to a patient who will be using oxygen at home? Select all that apply. O "Maintain oxygen at prescribed settings!" O "Don't use electrical equipment near oxygen." O Place nasal prongs facing upward in the nares." O "Use extension cords if extra mobility is needed." O "Store oxygen cylinders near a heating vent to warm them.

O "Maintain oxygen at prescribed settings!" O "Don't use electrical equipment near oxygen." O Place nasal prongs facing upward in the nares." O "Use extension cords if extra mobility is needed." Rationale The nurse should instruct the patient to maintain oxygen at the prescribed settings, refrain from using electrical equipment near the oxygen, and to place the nasal prongs in the upward position in the nares. Oxygen cylinders should be stored in a cool, dry place; they do not need to be kept warm and should not be stored near a heat source. Extension cords should not be used. If additional mobility is needed, extension tubing can be used.

The school nurse is speaking to a group of adolescents about drug and alcohol abuse. When listening to the school nurse talk about drug and alcohol abuse, a student asks the nurse, "Why do people make such a big deal about drinking alcohol? Having a beer every now and then doesn't seem that dangerous. In France, there isn't even a legal drinking age. O " The school nurse correctly makes which response? O "It's my job to make a big deal about drug and alcohol abuse, that's why." O "A person must be 21 years of age to buy and consume alcohol in the United States." O "Alcohol carries the highest risk of dependence and addiction of all known substances." O "Many multidrug users began by abusing alcohol and progress to abusing other substances."

O "Many multidrug users began by abusing alcohol and progress to abusing other substances." Rationale Alcohol is considered a gateway drug, which may lead to the use and abuse of other substances. It is not the school nurse's job to make a "big deal" about drug and alcohol abuse. Although a person does need to be 21 years of age to buy and consu

Which information would be provided to a patient being discharged with a new colostomy? Select all that apply. O Insert the cone into the stoma during ostomy care." O "Sit in a chair to change the ostomy appliance. O "Measure the stoma opening before cutting the wafer." O "Change the ostomy appliance every 3 to 7 days O "Notify the health care provider of stoma color changes."

O "Measure the stoma opening before cutting the wafer." O "Change the ostomy appliance every 3 to 7 days O "Notify the health care provider of stoma color changes." Rationale Ostomy appliances should be changed every 3 to 7 days to prevent accidental dislodgment from the skin. The stoma will decrease in size over the first 6 to 8 weeks as inflammation subsides, therefore patients should measure the stoma opening before cutting the wafer. The nurse should instruct the patient to notify the health care provider of stoma color changes. The cone and sitting in the chair are steps in colostomy irrigation

A patient experiencing postoperative pain refuses to take analgesics and says that the pain is tolerable. Which instruction does the nurse tell this patient? O "Let me know at once if the pain is increasing or intolerable O You can let me know when you are ready to take the next dose O There are no adverse effects or problems if you delay medication O "Pain medication is more effective when taken at the onset of pain."

O "Pain medication is more effective when taken at the onset of pain." Rationale The nurse needs to inform the patient that it is inappropriate to delay analgesics until there is severe pain because the medications are more effective when taken at the onset of pain. It is not appropriate to tell the patient to inform the nurse only after the pain is intolerable. The nurse should instead encourage the patient to take medications as directed for effective pain management. Pain medications are administered as prescribed, and the nurse should not delay the dose according to the patient's readiness. The patient may need increased doses of pain medications if there is delay and the pain becomes intolerable later, which may cause side effects. Therefore, it is not appropriate to tell the patient that there will be no adverse effects

The nurse is caring for a patient who has nephritis. Which instructions would the nurse include while educating the patient about health promotion? O "Space out your activities to reduce the risk of edema." O "Increase the protein content in your diet." O Increase the sodium content in your diet. O "Report any incidents of hematuria and edema."

O "Report any incidents of hematuria and edema." Rationale Nephritis is characterized by inflammation of kidneys and manifests as edema over the face, especially eyes, anorexia, dysuria, and sanguineous urine. Increased serum creatinine, potassium, antistreptolysin-o titer, erythrocyte sedimentation rate (ESR), and red blood cells and protein in urine are found in the patient. The nurse should ask the patient to report any incidence of hematuria and edema. Reports of hematuria and edema help evaluate the effectiveness of the medication and the disease status. A patient with nephritis shows signs of edema and increased blood pressure. The patient should be instructed to rest until the edema and blood pressure are decreased. The patient should be instructed to perform some light activities to reduce fatigue, but only after the edema and blood pressure are decreased. The patient should be instructed to restrict protein and sodium contents in the diet because these may increase edema and blood pressure.

Four hours after surgery, a patient rings the call bell. When the nurse arrives, the patient states that the wound is infected. When the nurse assesses the wound, it is red, swollen, and warm to touch. Which statement would be the most appropriate response to the patient? O "You are correct: your wound is infected O "You are having an allergic reaction to your medication O "The wound is not infected; normal healing is occurring O "I will notify the health care provider of the infection.

O "The wound is not infected; normal healing is occurring Rationale During the appropriate inflammatory process, there is an initial increase in the flow of blood elements. This process causes the cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction. The wound is not infected because it has been only 4 hours since the surgery and this is a normal inflammatory response. This is not an allergic reaction but a part of the normal wound-healing process. There is no indication that the health care provider should be notified because this is a normal finding.

An elderly patient complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when the patient coughs. Which information does the nurse provide to the patient about the disorder? Select all that apply. O "This occurs due to local irritation." O "This is called stress incontinence." O "This is caused by nervous system disorders." O "This is caused by weakness of the muscles around the urethra." O "This occurs when intraabdominal pressure exceeds urethral resistance."

O "This is called stress incontinence." O This is caused by weakness of the muscles around the urethra." O "This occurs when intraabdominal pressure exceeds urethral resistance." Rationale Involuntary voiding of urine upon coughing, also called stress incontinence, occurs as a result of weakness of the muscles around the urethra. Stress incontinence occurs in older women when intraabdominal pressure exceeds urethral resistance. Local irritating factors and nervous system disorders usually lead to urge incontinence. Involuntary voiding occurs only when abdominal pressure rises above urethral pressure.

Which statement made by the licensed practical/vocational nurse (LPN/LVN) requires correction when teaching a patient with chronic obstructive pulmonary disease (COPD) about oxygen use at home? O"You can place padding over the ears to prevent skin breakdown." O "You can increase the liters of oxygen per minute if experiencing dyspnea." O "You should store the oxygen concentrator and tanks in a cool, secure location. O "You should refill the plastic humidifier battle with distilled water every 24 hours

O "You can increase the liters of oxygen per minute if experiencing dyspnea." Rationale The respiratory drive of a patient with COPD is based on increased carbon dioxide levels. Liters of oxygen per minute should not be increased in a patient with COPD because this will cause the respiratory drive to become diminished, and the patient will experience respiratory distress. Padding can be placed over the ears to prevent skin breakdown, oxygen should be stored in a cool, secure location, and the plastic humidifier bottle should be refilled every 24 hours with distilled water

During the immediate postoperative period, a patient with an external sequential compression device (SCD) wants to ambulate and then sit up for an hour or so without the device. Which statement by the nurse accurately addresses the patient's request? O "I think that will be okay if you feel up to it." O "You can, but only for 30 minutes, then we need to reconnect the SCD." O "I'm sorry, but when the SCD is being used, you are not allowed to get out of bed." O "Let's try having you sit on the edge of the bed first; if you do okay, then we can discuss it further.

O "You can, but only for 30 minutes, then we need to reconnect the SCD." Rationale An SCD device should not be disconnected for more than 30 minutes. The amount of time allowed out of bed when an SCD is being used is not based on whether the patient feels up to it. Patients with an SCD are not confined to bed. Regardless of how well the patient tolerates sitting on the side of the bed, the patient will not be allowed to get out of bed with the device disconnected for an hour.

Which statement by the nursing student regarding mouth-to-mouth ventilation to a patient with a normal pulse needs correction? O "You should initiate one breath every 15 seconds." O "You should utilize the head-tilt chin-lift maneuver." O "You should give one full breath lasting for 1 second! O "You should stop providing ventilation if the initial attempt fails.!

O "You should initiate one breath every 15 seconds." Rationale The statement made by the nursing student that needs correction is that there should be one breath every 15 seconds. When the patient has normal pulse, the nurse should provide one breath every 6 to 8 seconds to restore the patient's breathing capability. Giving the patient one breath every 15 seconds is inadequate because it amounts to only 4 breaths/min, which further promotes hypoxia. Tilting the head and chin helps provide effective mouth-to-mouth ventilation. If the initial attempt fails, the nurse should adjust the position of the head and chin and continue to try to provide ventilation to the patient. The nurse should take a deep breath and give two full breaths to the patient lasting 1 second each. This practice helps deliver an adequate amount of oxygen to the patient.

Which size suction catheter would the nurse select to perform suctioning in an adult? O 6-French (Fr) O 8-Fr O 10-Fr O 12-F

O 12-F Rationale The correct size for an adult nasotracheal suctioning catheter is 12-Fr or 14-Fr. The nurse should select either 6-Fr or 8-Fr to suction an infant. A child would require a 10-Fr or 12-Fr suctioning catheter.

A patient is diagnosed with an uncomplicated urinary tract infection (UTI). The nurse anticipates the provider will prescribe which medication regimen? O 10 days of ciprofloxacin (Cipro) O One-time dose of nitrofurantoin (Furadantin) O 3 days of amoxicillin O 3 days of sulfamethoxazole-trimethoprim (Bactrim)

O 3 days of sulfamethoxazole-trimethoprim (Bactrim) Rationale Many options for antibiotic therapy for UTIS are available. Three days of Bactrim is the common treatment. Cipro is also prescribed for 3 days, not 10 days. Furadantin or amoxicillin should be taken for 7 to 10 days.

A nurse is caring for an adult patient with severe burns covering the face. anterior of the chest, and anterior and posterior of both arms. According to the rule of nines, which percentage of the patient's body is burned? O 50% O 60% O 45 O 40.5%

O 40.5% Rationale According to the rule of nines, the face equals 4.5%, the anterior chest equals 18%, and the anterior and posterior of both arms equal 18% for a total of 40.5%. The extent of burns can be calculated according to the rule of nines.

Which wetting agent would the wound specialist advise the nurse to avoid due to it delaying the wound-healing process? O Acetic acid O Normal saline O Lactated Ringer's solution O Sodium hypochlorite solution

O Acetic acid Rationale Acetic acid is toxic to fibroblasts, and fibroblasts are necessary for the healing process. Therefore the nurse should not use acetic acid as a wetting agent. Normal saline and lactated Ringer's solutions are used as wetting agents because they do not delay the healing process. Sodium hypochlorite solution is used for wound débridement and is highly recommended for cleaning necrotic wounds because it does not delay the healing process.

Which recommendation will help promote normal bowel function in a patient with a history of constipation? Select all that apply. O Activity O High-fiber diet O Taking a laxative every day O Fluid intake 1000 mL/day O Establishing a routine schedule

O Activity O High-fiber diet O Establishing a routine schedule Activity, a high-fiber diet, and a normal elimination schedule help promote normal bowel movements. The daily use of laxatives can lead to dependence and is not recommended for most patients. Recommended fluid intake is between 2000 and 3000 mL/day, not 1000 mL/day, to help promote regular bowel elimination

A patient with diabetes reports drowsiness and seizures. The hematology and urinalysis reports show urinary output as low as 400 mL/24 hr and elevated blood urea nitrogen (BUN) and creatinine. Which measures must be taken to prevent any complications? Select all that apply. O Increase sodium and potassium contents in the patient's diet O Administer fluids and osmotic solutions to the patient. O Administer sodium polystyrenesulfonate (Kayexalate). O Administer antibiotics regardless of renal excretion O Perform frequent skin care of the patient with hot water

O Administer fluids and osmotic solutions to the patient. O Administer sodium polystyrenesulfonate (Kayexalate). O Administer antibiotics regardless of renal excretion Rationale Patients with acute renal failure show signs of drowsiness, seizures, urinary output as low as 400 mL/24 hr and elevated BUN and creatinine. Fluids and osmotic preparations should be administered to prevent decreased renal perfusion and restore the normal fluid and electrolyte balance. Sodium polystyrene sulfonate (Kayexalate) should be administered to remove potassium through the gastrointestinal tract. Antibiotics that are not dependent on renal excretion must be administered to prevent drug accumulation and toxicity. The patient has renal failure, which may cause retention of sodium and potassium. Therefore, the patient should limit the intake of sodium and potassium in the diet Frequent skin care of the patient should be performed with tepid water, not hot water, to remove the urea crystals.

Which is the priority nursing intervention for a patient with hypoxia who has an oxygen level of 78%, dyspnea, and confusion? O Administer oxygen O Obtain pulse oximetry. O Measure blood pressure. O Initiate telemetry monitoring

O Administer oxygen Rationale After the nurse determines a patient with hypoxia has a low oxygen level and is experiencing dyspnea and confusion, the initial nursing intervention should be to administer oxygen. Obtaining pulse oximetry, measuring blood pressure, and initiating telemetry are not the priority over delivering oxygen

The nurse observes that a burn wound in an elderly diabetic patient is taking a longer time to heal than a similar wound in a 10-year-old child. Which factors are known to cause delayed healing? Select all that apply. O Age O Body mass O Physique O Chronic illness O Affect

O Age O Chronic illness Rationale Age, infection, nutrition, and chronic illness are factors that affect the healing of wounds. Young children and adults have improved metabolism and heal more quickly than elderly patients. Patients with a chronic illness such as diabetes take a longer time to heal due to decreased metabolism. A wound free from infection heals faster; proper nutrition also helps the healing process. But in this case, age and illness are causing a delay in wound healing. Affect, body mass, and physique do not affect wound healing.

Which type of drug is the most commonly abused in the world? O Alcohol O Illegal drugs O Prescriptions medications O Over-the-counter medications

O Alcohol Rationale Alcohol, a central nervous system depressant, is the most commonly abused drug in the world. It is easily available and causes many adverse reactions and even death. Abuse of drugs is a major problem worldwide. Not only illegal drugs but also prescription and over-the-counter medications are abused. These drugs are currently not the most common ones abused, but this abuse is on the rise

A postoperative patient is instructed to avoid iced and carbonated beverages in diet to reduce gastrointestinal disturbances. However, the nurse observes that nausea and vomiting persists in the patient. Which order does the nurse expect from the health care provider? O Antiemetic medications O Six to eight ounces of fluids per hour O Nothing by mouth for 24 hours O Administration of intravenous fluids

O Antiemetic medications Rationale If nausea and vomiting persists even after limiting iced and carbonated beverages in diet, the patient is prescribed antiemetic medications, such as promethazine (Phenergan), benzquinamide (Emete-con), ondansetron (Zofran), or prochlorperazine (Compazine). The patient is encouraged to take six to eight ounces of fluids per hour when oral fluids are introduced after surgery. The patient needs to be on nothing by mouth (NPO) status at midnight before surgery to decrease the risk of intra- and postoperative vomiting and aspiration. Intravenous fluids are administered after the surgery until the patient is able to tolerate oral fluids. Intravenous fluids will not help prevent nausea and vomiting. Instead, antiemetic medications are given intravenously or rectally to stop nausea and vomiting.

if a patient with an abdominal incision and discomfort begins to cough, which intervention is the most appropriate? O Roll the patient to the left side. O Offer the patient a drink of water. O Sit the patient up in a semi-Fowler's position. O Apply a pillow to the incision with slight pressure.

O Apply a pillow to the incision with slight pressure. Rationale Applying a pillow will help reduce stress on the incision. The semi-Fowler's position helps facilitate breathing after surgery but is not the best intervention to help with a cough after surgery. Rolling to the side is encouraged to help a patient who has had abdominal surgery to rise to the sitting position. A drink of water after a coughing episode would help but not during the discomfort of coughing

A patient arrives at the emergency room (ER) with a penetrating, sucking chest wound. Which action should the nurse take first to ensure patient safety? O Assess the vital signs. O Locate the emergency room health care provider. O Medicate the patient. O Apply an airtight dressing.

O Apply an airtight dressing. Rationale If there is a sucking chest wound, the nurse should apply an airtight dressing. Any available material is acceptable-gauze, plastic wrap, clothing, or a hand. The vital signs should be taken, the health care provider located, and the patient medicated, but the dressing should be applied first because a pneumothorax can become a tension thorax if air continues to enter the open wound. Sometimes the fourth side will have to be untaped to allow air to escape. This will be assessed further once the airtight dressing is in place.

Which instruction would be included when teaching patients how to change an ostomy pouch? Select all that apply. O Cut the skin barrier a quarter inch larger than the stoma. O Rub the skin around the stoma with cold water. O Apply the protective skin barrier one-sixteenth of an inch from the stoma, O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change

O Apply the protective skin barrier one-sixteenth of an inch from the stoma O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change Rationale When providing teaching on care for ostomy pouches, the nurse should instruct patients to apply a protective skin barrier one-sixteenth of an inch from the stoma to create a good seal from the bag apply the pouch to the flange by compressing the faceplate to the bag, and cover the stoma with toilet tissue to prevent leaking during bag changes. The skin barrier should be cut one-sixteenth of an inch larger than the stoma; any larger allows stool to come in contact with the skin. Patients should gently cleanse the skin around the stoma with warm water, but never rub.

Which instruction would be included when teaching patients how to change an ostomy pouch? Select all that apply. O Cut the skin barrier a quarter inch larger than the stoma. O Rub the skin around the stoma with cold water. O Apply the protective skin barrier one-sixteenth of an inch from the stoma. O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change.

O Apply the protective skin barrier one-sixteenth of an inch from the stoma. O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change. Rationale When providing teaching on care for ostomy pouches, the nurse should instruct patients to apply a protective skin barrier one-sixteenth of an inch from the stoma to create a good seal from the bag, apply the pouch to the flange by compressing the faceplate to the bag, and cover the stoma with toilet tissue to prevent leaking during bag changes. The skin barrier should be cut one sixteenth of an inch larger than the stoma; any larger allows stool to come in contact with the skin. Patients should gently cleanse the skin around the stoma with warm water, but never rub.

Which instruction would be included when teaching patients how to change an ostomy pouch? Select all that apply. O Cut the skin barrier a quarter inch larger than the stoma. O Rub the skin around the stoma with cold water. O Apply the protective skin barrier one-sixteenth of an inch from the stoma. O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change.

O Apply the protective skin barrier one-sixteenth of an inch from the stoma. O Attach the pouch to the flange by compressing the two parts together. O Cover the stoma with toilet tissue to prevent leaking during bag change. Rationale When providing teaching on care for ostomy pouches, the nurse should instruct patients to apply a protective skin barrier one-sixteenth of an inch from the stoma to create a good seal from the bag, apply the pouch to the flange by compressing the faceplate to the bag, and cover the stoma with toilet tissue to prevent leaking during bag changes. The skin barrier should be cut one sixteenth of an inch larger than the stoma; any larger allows stool to come in contact with the skin. Patients should gently cleanse the skin around the stoma with warm water, but never rub.

A child has accidentally consumed floor cleaning liquid. Which actions should the nurse take? Select all that apply. O Give the specific antidote. O Call the poison control center. O Induce vomiting with ipecac. O Ask for the container of the substance. O Treat manifestations of shock.

O Ask for the container of the substance. O Treat manifestations of shock. O Call the poison control center. Rationale Calling the poison control center enables the nurse to provide better care before the medical care provider arrives. Asking for the container of the substance to check for the contents listed on the container is a useful action because it helps identify the chemical nature of the ingested substance(s). This will help provide the proper treatment based on the chemicals ingested. The victim may be in shock; the necessary steps should be taken to treat the patient. Specific antidote administration should be done only after consulting the primary health care provider. Inducing vomiting with ipecac is not advisable because it may lead to other complications, such as persistent vomiting, lethargy, and diarrhea. Because ipecac is a prescription drug, it should be used only if prescribed by a primary health care provider.

How does the nurse evaluate the effectiveness of a tracheal suctioning procedure? O Auscultate lung sounds O Assess ventilator settings O Examine sputum color and consistency O Determine need for supplemental

O Auscultate lung sounds Rationale Tracheal suctioning is performed to remove secretions and facilitate air movement within the lungs. Auscultating the patient's lung sounds will help the nurse determine the effectiveness of the suctioning procedure. Ventilator settings would be assessed to determine the accuracy of the health care provider's orders. Examining sputum color and consistency can determine if an infection is present. Oxygen levels are assessed to determine the need for supplemental oxygen.

In the operating room, a patient tells a circulating nurse that the cataract in the patient's left eye will be removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, which action should nurse perform first? O Notify the surgeon and anesthesiologist O Ask the patient to state his or her name O Assume that the patient is a little confused because of old age. O Check whether the patient has received preoperative medications

O Ask the patient to state his or her name Rationale Ensuring proper identification of a patient is the responsibility of all members of the surgical team, In a specialty surgical setting, where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses should not make assumptions in the care of their patients. The surgical team should perform a timeout where all the team members participate in the identification of the patient. The surgeon and the anesthesiologist are notified once the nurse has confirmed the patient's name and identity. The nurse should not assume that the patient is confused because of old age or premedication. Preoperative medications can be checked after identifying the patient. The patient should first be identified and then further procedures should be carried out

The nurse is providing care for a patient after a right hip replacement. The nurse knows it is vital to turn the patient every 2 hours while the patient is immobile; however, the patient refuses to turn in bed. Which nursing action is best? O Ask the patient why he refuses to turn in bed. O Ask the charge nurse to help turn the patient in bed. O Administer more pain medication because pain is keeping the patient from turning O Explain to the patient the risks associated with not changing position while immobile.

O Ask the patient why he refuses to turn in bed. Rationale The patient may refuse to turn in bed because he feels weak, is in too much pain, or is afraid to reinjure his hip. The nurse can base her interventions around his response. The nurse can ask the charge nurse to help her turn the patient once the patient has agreed and is prepared to turn. It may be necessary to provide more pain medication, but this is presumptive. Although it may be helpful to explain the risks of immobility to the patient, this may not be the best intervention at this time.

How should the nurse verify placement when inserting a nasogastric tube? Select all that apply. O Aspirate contents O Measure pH of contents. O Auscultate bowel sounds. O Irrigate tube with normal saline. O Listen for swoosh when injecting air.

O Aspirate contents O Measure pH of contents. O Listen for swoosh when injecting air. Rationale Ways to determine the placement of the nasogastric tube include aspirating gastrointestinal contents, testing the pH of these contents, and listening for a swoosh when injecting air through the nasogastric tube. Auscultating bowel sounds determine bowel function. Normal saline is used to irrigate the tube, not determine tube placement

Which step would the nurse take immediately after inserting a nasogastric tube? O Flush the tube with water. O Secure the tube to the patient's gown. O Aspirate gastric contents and test with pH paper. O Order a chest x-ray examination to confirm placement.

O Aspirate gastric contents and test with pH paper. Rationale The nurse should measure the pH of the aspirate with colored pH paper. Gastric aspirates have acidic pH values of 4 or less. This determines whether the tube is correctly placed in the stomach. Flushing the tube with water and securing the tube to the patient's gown should not be done until placement is verified. The primary health care provider and not the nurse will order X-ray examination to confirm that the tube has been correctly placed in the stomach.

The nurse is obtaining information regarding a patient's medication use before abdominal surgery. Which medication, if listed by the patient, would most concern the nurse? O Aspirin O Hydrochlorothiazide O Multivitamin O Acetaminophen

O Aspirin Rationale Aspirin can increase the risk of hemorrhage during and after surgery. The surgeon should be alerted immediately. Hydrochlorothiazide, multivitamins, and acetaminophen should be of less concern to the nurse.

The patient-controlled analgesia (PCA) device is being used after surgery. The patient has been pressing the button as instructed, but the nurse knows that an adverse reaction to narcotics is oversedation. Which measure should the nurse take to assess whether the patient is experiencing this adverse reaction? O Assess the patient's level of orientation frequently O Ask the family if the patient is able to converse with them. O Check the dosage and the functioning of the pump every 4 hours. O Determine whether the patient feels drowsy during assessment of vital signs.

O Assess the patient's level of orientation frequently Rationale The patient's level of orientation should be evaluated to determine whether the patient is experiencing oversedation. In caring for the patient with a PCA, the nurse should monitor the intravenous site and the PCA for proper functioning and correct dosage, but not every 4 hours. Asking the family to give input on this assessment is not appropriate; the nurse should communicate with the patient. It is normal for the patient to be drowsy because this is a normal side effect of the medication. The patient's perception may not be accurate; therefore, objective data such as the level of orientation are needed to verify the oversedation

The health care provider prescribes digoxin (Lanoxin) and potassium-sparing diuretics to a patient who has congestive heart failure. Which nursing interventions ensure safety of the patient? Select all that apply. O Assessing the patient for symptoms of digoxin toxicity O Including baked potatoes and raw bananas in the diet O Encouraging increased use of salt in the patient's diet O Assessing the patient's blood pressure, pulse, and respiration O Assessing blood urine BUN serum electrolytes and urine

O Assessing the patient for symptoms of digoxin toxicity O Assessing the patient's blood pressure, pulse, and respiration O Assessing blood urine BUN serum electrolytes and urine Rationale As the diuretics decrease the extracellular fluid volume, serum concentration of digoxin may increase, which leads to digoxin toxicity. Therefore, the nurse should assess the patient for the symptoms of digoxin toxicity. The patient's blood pressure, pulse, and respiration should be recorded four times a day to prevent any complications of fluid loss caused by the diuretics. The patient should be assessed for the levels of BUN, serum electrolytes, and urine for the symptoms of fluid overload. Baked potatoes and raw bananas are potassium-rich foods

Which finding indicates the need to perform suctioning for a patient? Select all that apply. O Drooling O Sneezing O Restlessness O Gurgling respirations O Oxygen saturation 92%

O Drooling O Restlessness O Gurgling respirations Rationale Physical signs that would indicate the need for suctioning include drooling, restlessness, and gurgling respirations. Sneezing can occur during the suctioning procedure. An oxygen Saturation of 92% alone does not indicate need for suctioning because it could result from other causes

a nurse has finished suctioning a patient who has had a tracheostomy. The nurse disposes of the catheter and performs hand hygiene. Which action should be performed by the nurse at this time? O Document the procedure. O Auscultate the patient's lungs O Place the call bell within reach O Place side rails in the up position

O Auscultate the patient's lungs Rationale After suctioning the patient and disposing of the catheter, the nurse should auscultate the patient's lungs to evaluate the effectiveness of the procedure. Documenting procedure placing the call bell within reach and placing the side rails in an upright position are all appropriate and should be done once the effectiveness of the procedure has been determined

When a patient with a history of alcoholism is admitted for treatment of alcohol withdrawal and is dehydrated, which vitamin would the nurse administer to the patient before administering IV glucose for rehydration? O A O B1 O D O E

O B1 O D O E Rationale A history of alcoholism may result in vitamin B1 (thiamine) deficiency, which is a factor in underlying alcohol-induced brain damage. Thiamine should be given before administering IV glucose to prevent Wernicke's encephalopathy. Vitamins A, D, and E are not given before administering IV glucose.

Which measures should the nurse take during the assessment of a wound? Select all that apply. O Be alert for signs of redness, swelling, and pain. O Ensure that the dressing is changed as prescribed by the health care provider. O Ensure that every abrasion, laceration, and incision is noted O Ensure that the location and appearance of the wound is documented every day. O Ensure the patient is free of pain.

O Be alert for signs of redness, swelling, and pain. O Ensure that the dressing is changed as prescribed by the health care provider. O Ensure that every abrasion, laceration, and incision is noted Rationale The nurse assesses all skin areas when inspecting a wound. The nurse ensures that every abrasion, laceration, and incision is noted. This helps in making a proper diagnosis of the wound. The nurse is also alert for signs of inflammation such as redness, swelling, or pain. The nurse documents the location and appearance of the wound every day as changes can occur rapidly. Freedom from pain is not realistic. Nurses complete most dressing changes, not the health care provider.

The nurse is placing a patient's arm in a sling. Which nursing action would enable venous return and facilitate reduction of edema? O Placing the forearm closer to the chest O Placing the apex of the sling behind the elbow O Bending the arm, ith the elbow slightly elevated O Tying the bandage around the neck, on the uninjured side

O Bending the arm, ith the elbow slightly elevated Rationale Placing the arm in an arm sling helps bend the arm to facilitate venous return, and elevating the elbow would facilitate reduction of edema. Placing the arm close to the chest would establish the proper position for the arm sling. Placing the apex of the sling's triangle behind the elbow of the injured arm facilitates usefulness of the sling. Tying the bandage connecting the neck and the uninjured side would help prevent pressure on the cervical spine.

A patient reports an inability to control alcohol cravings because of withdrawal symptoms. Which medications are beneficial to treat this condition? Select all that apply. O Beta-blockers O Alpha agonists O Opioid agonists O Narcotic antagonists O N-methyl-D-aspartate receptor (NMDA) antagonists

O Beta blockers O Alpha agonists Rationale Beta blockers block the beta-adrenergic receptor in the heart and alpha agonists show agonistic action on presynaptic alpha receptors; these drugs can be used to treat withdrawal symptoms and cravings associated with alcohol. Opioid agonists show antagonist properties that involve a ceiling effect on analgesia and respiratory depression. Narcotic antagonists are prescribed for opioid maintenance programs. NMDA antagonists are administered in alcohol rehabilitation programs for chronic alcoholic patients who want to maintain sobriety

A nurse is assisting a patient on the phone to perform cardiopulmonary resuscitation (CPR). In which groove would the nurse instruct the caller to place three fingers to palpate the pulse? O Under the chin O Inside of the thigh O Inside of the elbow O Between the throat and the neck

O Between the throat and the neck Rationale To determine pulselessness, the carotid pulse is the most reliable and accessible one to evaluate. The position of the head should be maintained, and the nurse slides three fingers into the groove between the trachea and the muscles on the side of the neck. The nurse should use terms that a layperson can understand. Therefore telling the patient to place the fingers in the groove between the throat and the neck can guide the patient to locate the carotid artery. The carotid artery is located on the side of the neck; therefore it is incorrect to instruct the caller to touch under the chin, the inside of the thigh, or the inside of the elbow

Which clinical manifestations of hypoxia are cardiac-related? Select all that apply. O Dyspnea O Bradycardia O Hypertension O Dysrhythmias O Apprehension

O Bradycardia O Hypertension O Dysrhythmias Rationale Cardiac-related signs of hypoxia include bradycardia, hypertension, and dysrhythmias. Dyspnea is difficulty breathing and is respiratory-related. Apprehension is a behavior-related clinical manifestation of hypoxia.

the nurse is caring for a patient who has recurrent, painful urinary tract infections and has been prescribed phenazopyridine (Pyridium). The nurse would inform the patient of which common side effect? O Black stools O Hypotension O Bright orange urine O Coffee-ground emesis

O Bright orange urine Rationale Pyridium, a urinary analgesic, can turn urine bright orange. Pyridium should not cause black stools, hypotension, or coffee-ground emesis.

A patient accidentally steps on an iron nail, which pierces deep into the foot. Which action should the nurse take first? O Remove the nail immediately. O Call the primary health care provider. O Give a tetanus booster vaccine. O Educate the patient about symptoms of sepsis.

O Call the primary health care provider. Rationale If the object is lodged firmly in tissue, do not attempt to remove it. Leave it in place, and the health care provider will remove it. Removal has the potential to cause significant bleeding or other types of complications that may necessitate emergency surgical intervention. If an iron nail pierces the foot it causes internal tissue damage and sepsis. The nurse should call the primary health care provider immediately. Removing the nail may cause a further increase in bleeding and may lead to an internal infection. Giving a tetanus booster may be considered a follow-up treatment for such injuries. Because the wound has been caused by a metal object, it may lead to sepsis. The nurse should educate the patient about the symptoms of sepsis after proper treatment has been given to the patient.

Which information would the preceptor stress to the graduate nurse about a vacuum-assisted closure (VAC) device? O The schedule for changing the device varies. O Negative pressure is applied to the wound by the device O Care must be taken to remove all materials from the wound. O The wound vacuum can be used for acute and chronic wounds.

O Care must be taken to remove all materials from the wound. Rationale During dressing changes, care must be taken to remove all sponges and remnants from the wound. Material left on the wound may cause delays in healing and abscess formation. It is important for the graduate nurse to understand that the schedule for changing the device varies, the device applies negative pressure, and the device is used for acute and chronic wounds; however, the importance of removing all material from the wound must be stressed because not doing so can affect the healing process,

The nurse notices that a patient with fever has erythema, pain, and tenderness over an area of the skin. Which infection does the nurse suspect in the patient? O Cellulitis O Impetigo O Herpes simplex O Pityriasis rosea

O Cellulitis Rationale The nurse would suspect cellulitis, an infection of the skin and underlying subcutaneous tissues. The affected areas become erythematous, edematous, tender, and warm to the touch. In impetigo, the lesions are small, flat blemishes that are flush with the skin surface and develop into pustulant vesicles, which rupture and form a dried exudate. Herpes simplex is identified when the patient develops cold sores. Pityriasis rosea is a single lesion, referred to as a scaly patch. It is a scaly area that is 1 to 3 inches in diameter with a raised border and a pink center that resembles ringworm (a fungal infection).

During colostomy irrigation, the nurse finds that the patient has a pressure sore in the area around the colostomy. Which intervention would be best? O Avoid giving colostomy care to this patient. O Change the irrigation solution for the colostomy. O Change the size of the ostomy appliance in the patient. O Avoid cleansing the skin with the irrigation sleeve on the stoma.

O Change the size of the ostomy appliance in the patient.

During colostomy irrigation, the nurse finds that the patient has a pressure sore in the area around the colostomy. Which intervention would be best? O Avoid giving colostomy care to this patient O Change the irrigation solution for the colostomy O Change the size of the ostomy appliance in the patient. O Avoid cleansing the skin with the irrigation sleeve on the stoma.

O Change the size of the ostomy appliance in the patient. Rationale The nurse must change the size of the ostomy appliance because an ill-fitting colostomy appliance can cause a pressure sore, which can lead to gangrene. Colostomy care should be done on a regular basis to prevent complications such as infection. Changing the irrigation solution for a pressure sore is not required because the pressure sore is not caused by the irrigation solution. It is necessary to cleanse the skin before placing the irrigation sleeve on the stoma. This reduces the risk for skin damage.

The nurse is caring for a patient with a urinary tract infection (UTI). Using the urometer connected to a drainage system, the nurse monitors the patient's urinary output and finds that it is 25 mL/hr. Which action should be the immediate response by the nurse? O Do nothing, and record the observation. O Administer the diuretic prescribed for the patient. O Immediately inform the health care provider O Check the placement and function of the drainage system.

O Check the placement and function of the drainage system. Rationale The nurse should first check the positioning of the drainage system to ensure that it is properly placed. A leak or improper placement of the drainage system will eventually show error in the urometer reading. Improper positioning of the drainage bag may result in erratic urometer readings. Therefore, rather than recording the observation, the nurse should first check the positioning of the urinary drainage bag. The nurse should administer only if ordered by the health care provider. The nurse should inform the health care provider only after making sure that the drainage system is properly in place and functioning.

A patient's lab reports indicate reduced bone marrow function and a decreased white blood cell count. Which type of medication does the nurse suspect the patient was most likely taking? O Antibiotic O Antihistaminic O Chemotherapy O Anti Inflammatory

O Chemotherapy Rationale Chemotherapy medications destroy rapidly dividing cancer cells but also reduce the function of bone marrow and decrease the white blood cell count by inhibiting cell division. Antibiotic medications destroy bacteria but do not affect the function of bone marrow. Antihistamines act by inhibiting the actions of histamine. Antiinflammatory medications reduce inflammation in tissues throughout the body and may suppress protein synthesis, wound contraction, and inflammation. These medications do not, however, affect the function of bone marrow or white blood cell count

A patient needs surgical removal of an inflamed gallbladder. Which screening tests does the nurse anticipate the surgeon will prescribe? Select all that apply. O Chest x-ray O Bone density scan O Blood sugar levels O Electrocardiogram (ECG) O Electroencephalography (EEG)

O Chest x-ray O Blood sugar levels O Electrocardiogram (ECG) Rationale The screening tests focus on the body systems that are likely to be affected by the surgery. A chest x-ray and ECG help determine the patient's heart and lung function. Blood sugar levels help determine postoperative wound healing and chances of infection. EEG is required for patients suffering from epilepsy and other brain-related disorders. A bone density scan is performed in females after menopause and is not required for this type of procedure.

A patient who is addicted to alcohol is undergoing detoxification in a drug treatment facility. Approximately 8 hours after admission, the nurse notes that the patient is experiencing tremors of the hands, nervousness, and restlessness, which are worsening. When the nurse contacts the provider, which prescriptions does the nurse expect from the primary care provider? O Naloxone or disulfiram O Haloperidol or risperidone O Furosemide or spironolactone O Chlordiazepoxide or lorazepam

O Chlordiazepoxide or lorazepam Rationale Chlordiazepoxide and lorazepam are benzodiazepines. They are classified as anti-anxiety medications or anxiolytics. They are frequently used to treat the tremors and heightened anxiety associated with alcohol withdrawal. Haloperidol and risperidone are antipsychotic agents used to treat schizophrenia and psychosis. Furosemide and spironolactone are diuretics used to treat congestive heart failure. Naloxone is the antidote to opiate overdose, and disulfiram is used as aversion therapy for patients to avoid

A patient who is addicted to alcohol is undergoing detoxification in a drug treatment facility. Approximately 8 hours after admission, the nurse notes that the patient is experiencing tremors of the hands, nervousness, and restlessness, which are worsening. When the nurse contacts the provider, which prescriptions does the nurse expect from the primary care provider? O Naloxone or disulfiram O Haloperidol or risperidone O Furosemide or spironolactone O Chlordiazepoxide or lorazepam

O Chlordiazepoxide or lorazepam Rationale Chlordiazepoxide and lorazepam are benzodiazepines. They are classified as antianxiety medications, or anxiolytics. They are frequently used to treat the tremors and heightened anxiety associated with alcohol withdrawal. Haloperidol and risperidone are antipsychotic agents used to treat schizophrenia and psychosis. Furosemide and spironolactone are diuretics used to treat congestive heart failure. Naloxone is the antidote to opiate overdose, and disulfiram is used as aversion therapy for patients to avoid a relapse of alcohol consumption.

On performing ultrasonography, the nurse finds that the patient has more than four cysts in each kidney. The nurse learns the reason for the development of cysts by examining the medical history of the patient. Which patient information does the nurse find in the patient's medical history Select all that apply. O Renal carcinoma O Horseshoe kidney O Chronic renal failure O History of urolithiasis O History of hemodialysis

O Chronic renal failure O History of hemodialysis Rationale Multiple cysts are common in patients having chronic renal failure, especially those who have undergone hemodialysis. Multiple cysts can be diagnosed by the presence of more than four cysts in each kidney on ultrasonography. The nurse finds that the patient has chronic renal failure, for which he or she has undergone hemodialysis. Renal carcinoma is the malignant tumor that is primarily seen in proximal convoluted tubules. Renal carcinoma is unrelated to multiple cysts. The horseshoe kidney is a developmental anomaly, in which the kidneys are fused together. Patients with horseshoe kidneys are at a higher risk for renal carcinoma. Urolithiasis is the formation of urinary calculi, when the minerals precipitate out to form stones in the urinary

Which interventions should the nurse implement while encouraging early ambulation in a postoperative patient? Select all that apply. O Clamp the nasogastric tube, if present, while the patient ambulates. O Encourage the patient to walk the same distance at each ambulation. O Maintain a tight hold while ambulating an unsteady patient receiving intravenous (IV) fluids. O Ask the patient to bend, lower, and press back knees hard against bed. O Ask the patient to sit on the side of bed before ambulating for the first time.

O Clamp the nasogastric tube, if present, while the patient ambulates. O Ask the patient to bend, lower, and press back knees hard against bed. O Ask the patient to sit on the side of bed before ambulating for the first time. Rationale If the patient has a nasogastric tube, it needs to be clamped during ambulation to prevent the stomach contents from draining out. The nurse asks the patient to perform muscle strengthening exercises, such as bending, lowering, and pressing back knees hard against the bed, to facilitate easy ambulation. The nurse asks the patient to sit on the side of the bed before ambulating for the first time to prevent fluctuation of the vital signs. The nurse encourages the patient to walk farther at each ambulation to improve stamina and functioning. To prevent any accidents, it is necessary to obtain help from another colleague while ambulating an unsteady patient receiving IV fluids.

The nurse is assessing a patient with a gangrenous leg. While collecting the patient's medical history, the nurse finds that the patient had developed the gangrene after lower-limb surgery. Which class of surgical wound does the nurse expect the patient has? O Class I O Class II O Class III O Class IV

O Class IV Rationale Surgical wounds are classified based on the level of contamination and infection. If the surgical wounds are not properly cared for, they may cause tissue necrosis. Tissue necrosis results in gangrene, and such wounds are classified as class IV. A clean surgical incision has the least chance of being infected and is categorized as a class (clean) surgical wound. Wounds that are at risk of being contaminated are categorized as class II (dean contaminated) surgical wounds. Wounds that are fresh without any pus formation and nonpurulent inflammation are categorized as class III (contaminated) wounds.

A nurse has received an order to obtain a urine culture from a patient with an indwelling catheter. The nurse uses two patient identifiers to determine the correct patient, performs hand hygiene, and dons gloves. Which action should the nurse perform next? O Use a clean syringe to withdraw urine from the tubing. O Pour urine from the drainage bag into the specimen cup. O Remove the indwelling catheter, and use a straight catheter to obtain the specimen O Clean the drainage port with alcohol, and use a sterile adapter and syringe to withdraw the urine specimen.

O Clean the drainage port with alcohol, and use a sterile adapter and syringe to withdraw the urine specimen. Rationale The urine culture specimen should be withdrawn from a clean port with a sterile adapter and syringe. A clean syringe is not appropriate for this laboratory specimen, Urine from the drainage bag is not considered sterile. It is not necessary to remove the indwelling catheter to obtain the specimen.

Which nursing action is an example of proper care for a transtracheal oxygen catheter site? O Cleaning the site with hydrogen peroxide O Washing the site with mild soap and water O Increasing oxygen flow before cleaning the site O Changing the transtracheal catheter every 4 months

O Cleaning the site with hydrogen peroxide Rationale The transtracheal catheter exit site should be cleaned with hydrogen peroxide. Soap and water should not be used. The patient should not alter the flow rate of the oxygen. The catheter should be changed every 3 months.

Which order of effective cleansing of the perineal area of a male patient would the nurse follow? O Cleansing the area around the meatus and then moving down the penis O Cleansing the top of the penis and then moving down in a circular motion O Cleansing the right end of the meatus and then moving left and down the penis O Cleansing the bottom portion of the penis and then moving up over the meatus

O Cleansing the top of the penis and then moving down in a circular motion Rationale The nurse uses forceps and cotton balls soaked in antiseptic solution while cleansing the external genitalia. The nurse first cleanses the top of the penis, and then moves down in a circular motion. The nurse also retracts the foreskin to cleanse the area properly. This is the standard procedure followed to promote effective cleansing of the perineal area. The meatus is the last part of the male genitalia to be cleansed. The nurse cannot start cleaning the male external genitalia by cleansing the area around the meatus. The sequence for cleansing the female perineal region is right of the meatus, left of the meatus, and then center over the meatus. The bottom portion of the penis is not the first part to be cleansed.

Which routine type of sedation might be used for a surgical procedure that does not require complete anesthesia but, rather, a depressed level of consciousness? O Bier block O Local anesthesia O Conscious sedation O Regional anesthesia

O Conscious sedation Rationale Conscious sedation is a routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but, rather, a depressed level of consciousness. A patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuli. Bier block, also known as intravenous regional anesthesia, is when an anesthetic agent is injected via an intravenous line into an extremity below the level of a tourniquet after blood has been withdrawn. Local anesthesia involves loss of sensation at the desired site. The anesthetic agent can be injected or applied topically. Regional anesthesia results in loss of sensation in an area of the body. The method of induction influences the portion of sensory pathways that is anesthetized.

Which action should the nurse take for a patient with full-thickness burns? O Break the blisters with forceps. O Apply antiseptics on the wound. O Apply a cold compress on the wound. O Cover the wounds with loose sterile dressing

O Cover the wounds with loose sterile dressing Rationale Full-thickness burns may result in large surface area exposed to the external environment, which increases the risk of infection. Therefore the burnt area should be covered with loose sterile dressing, which will absorb any draining fluid and also protect the wound from contamination. Vesicles (blisters) should not be broken intentionally, the burn should not be touched with anything except sterile dressings. It is not appropriate to apply antiseptics, ointments, sprays, or creams to the burn because they potentially may interfere with medical treatment and cause complications.

Which action performed by the nurse during tracheal suctioning can cause mucosal membrane injury? O Performing deep suctioning 20 to 25 seconds O Waiting 1 to 2 minutes between suction attempts O Angling the catheter down past nasopharyngeal area O Covering the hole of the suction catheter during insertion

O Covering the hole of the suction catheter during insertion Rationale The nurse should place the thumb over the hole of the suction catheter to facilitate the suction from the device during catheter removal, not during insertion. The nurse should only perform tracheal suctioning between 10 and 15 seconds. Suctioning any longer can lead to cardiopulmonary compromise. The nurse should also wait 1 to 2 minutes in between suction attempts to allow the patient to rest and regain oxygen supply. The nurse should angle the suction catheter downward once past the nasopharyngeal area.

Which complications are associated with surgical incisions in a patient? Select all that apply. O Cachexia O Singultus O Dehiscence O Evisceration

O Dehiscence O Evisceration Rationale After surgery, there is a risk for dehiscence or separation of a surgical incision or rupture of a wound closure within 3 to 14 days. It is associated with postoperative complications, such as distention, vomiting, excessive coughing, dehydration, or infection. Another complication related to surgical wounds is wound evisceration or protrusion of an internal organ through a wound or surgical incision. Cachexia refers to ill health, malnutrition, and wasting as a result of chronic disease, which may cause dehiscence in a patient 2 weeks after the surgery. Singultus is an involuntary contraction of the diaphragm followed by rapid closure of the glottis. Paralytic ileus refers to a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery

Five days after a patient's abdominal operation, the nurse observes an increase in the flow of serosanguineous drainage into the wound dressing. Which immediate risk to the patient will the nurse assess? O Dehiscence O Hematoma O Internal hemorrhage O Sloughing

O Dehiscence Rationale Dehiscence is the spontaneous opening of the incision a few days after the operation. Obesity, poor nutrition, excessive coughing, and multiple trauma are some of the risk factors that may cause dehiscence. An increase in the flow of serosanguineous drainage (a mixture of serum and blood) into the dressing indicates impending dehiscence. Hematoma is the pooling of blood under the skin. Internal hemorrhage is indicated by swelling around the wound. Sloughing is the shedding of dead tissue.

A nurse knows that the patient with urinary incontinence is at risk for which complication? O Immobility O Dehydration O Myocardial infarction O Cerebrovascular accident

O Dehydration Rationale Patients with urinary incontinence are likely to have decreased fluid intake, which can lead to dehydration. Incontinence does not increase a patient's risk for immobility, myocardial infarction, or cerebrovascular accident.

The nurse is providing preoperative teaching to a patient regarding dietary needs in the postoperative period. Which action is best on the part of the nurse? O Tell the patient to decrease intake of fats O Determine the patient's current eating habits, O Tell the patient to increase intake of carbohydrates. O Determine the patient's understanding of a healthy diet.

O Determine the patient's current eating habits Rationale The nurse should first determine the patient's current eating habits to help the patient understand how the diet should change in the postoperative period. The nurse can then educate the patient to increase or decrease intake of fats, carbohydrates, and proteins based on the patient's current diet. The patient's understanding of a healthy diet is important but does not apply at this time.

A patient is having trouble abstaining from alcohol. Which drug is often prescribed to encourage abstinence? O Disulfiram O Bupropion O Chlordiazepoxide O Chlorpromazine

O Disulfiram Rationale Disulfiram is the drug of choice if medication is given. It causes facial flushing, nausea, tachycardia, dyspnea, dizziness, and confusion. Chlordiazepoxide is an antianxiety drug. Chlorpromazine is an antipsychotic drug. Bupropion is an antidepressant drug.

A patient undergoing treatment for withdrawal symptoms of alcohol abuse complains of drowsiness, headache, and fatigue. Which drug may be responsible for the patient's condition? O Naltrexone (ReVia) O Clonidine (Catapres) O Disulfiram (Antabuse) O Acamprosate (Campral)

O Disulfiram (Antabuse) Rationale Disulfiram (Antabuse) is used to treat withdrawal symptoms of alcohol abuse and causes side effects such as drowsiness, headache, and fatigue. Naltrexone (ReVia) reduces the rewarding effects of alcohol; it does not cause drowsiness, headache, and fatigue. Clonidine (Catapres) is used to treat rigidity and tremors in patients with opioid abuse. Acamprosate (Campral) is prescribed to chronic alcoholic patients who want to maintain sobriety. It mainly causes diarrhea and suicidal tendencies.

Which outcome is expected in a patient using vacuum-assisted closure (VAC)? Select all that apply. O Drop in bacterial count in the wound bed O Reduced healing rate O Increased tissue growth O Opening of the wound O Decreased blood flow

O Drop in bacterial count in the wound bed O Increased tissue growth Rationale VAC is used to treat wounds that take a long time to heal. A suction device is attached to the dressing to remove fluid from the wound and facilitate blood flow. After this therapy, there is a drop in bacterial count in the wound bed. Tissue growth also increases due to the mechanical stretching of cells. The therapy speeds up healing by 40%. This therapy helps close the wound completely.

Which finding indicates a patient is experiencing onset of hypoxia (Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) ? Select all that apply. O Apnea O Dyspnea O Cyanosis O Lethargy O Bradycardia

O Dyspnea O Cyanosis O Lethargy Rationale At the onset of hypoxia, the patient displays dyspnea, cyanosis, and changes in level of consciousness, which can include lethargy. Apnea and bradycardia are later signs of hypoxia.

Which signs and/or symptoms are characteristic of complications in a patient with a transtracheal catheter? Select all that apply. O Pallor O Edema O Erythema O Clear exudate O Oxygen saturation 95%

O Edema O Erythema Rationale Signs of complications in a patient with a transtracheal catheter include edema and erythema. Pallor can indicate anemia but is not a complication of the catheter. Some clear secretions would be normal; however, any excessive or purulent exudate should be always be reported. An oxygen saturation level of 95% is a normal finding and does not need to be reported.

The nurse is caring for a patient before elective surgery. For which preoperative tasks is the nurse responsible? O Explaining the risks of the surgery O Discussing the benefits of the surgery with the patient O Educating the patient about postoperative care needs O Ensuring the consent form is signed O Determining the patient's current level of pain

O Educating the patient about postoperative care needs O Ensuring the consent form is signed O Determining the patient's current level of pain Rationale The role of the nurse in the preoperative period is to assess the patient's health status, educate the patient about postoperative care needs and expectations, and ensure the consent form has been signed, among other tasks. The nurse will also determine the patient's current level of pain. The operating health care provider should explain the risks and benefits of the surgery and have the patient sign the consent form.

When providing initial first aid, which actions should the nurse take to address a full-thickness burn on the right lower extremity? Select all that apply. O Elevate the right lower extremity O Apply an antiseptic ointment to the burn. O Apply loose sterile dressings to the burned area. O Attempt to cool the burn immediately by using cool compresses. O Monitor the victim frequently for edema, which may cause further constriction in the burn area

O Elevate the right lower extremity, O Apply an antiseptic ointment to the burn. O Monitor the victim frequently for edema, which may cause further constriction in the burn area

While caring for a patient with a fractured forelimb and continuous bleeding, the nurse places a clean cloth and applies firm pressure on the site of the bleeding. Then the nurse secures a bandage and adds an additional layer of cloth but does not remove the bandage applied previously. Finally the nurse raises patient's hand to a level above his or her heart. Which nursing action may harm the patient? O Elevation of the arm O Retention of bandage O Addition of a clean cloth O Application of direct pressure

O Elevation of the arm Rationale As the patient has a fracture on arm, elevating the arm above the heart may exacerbate the condition, so it should be avoided. Raising the bleeding part of the body above the level of the heart helps decrease blood flow and increase the victim's ability to clot at the injured site. This technique should be used only if there are no suspected or known fractures or conditions that may be exacerbated with use of this maneuver. It is acceptable to elevate a splinted fracture if no other contraindications are present. The nurse should retain the previous bandage, and only the primary health care provider should remove it while providing further treatment. More cloth can be applied if the bandage gets saturated with blood. This action may not cause any harm to the patient. Applying direct pressure helps decrease the flow of blood.

Which common postoperative complications are likely to be found in patients who are obese! Select all that apply. O Embolus O Atelectasis O Pneumonia O Hemorrhage O Electrolyte imbalance

O Embolus O Atelectasis O Pneumonia Rationale Patients who are obese are more susceptible to postoperative complications. Embolus forms from venous stasis in the lower extremities. Atelectasis and pneumonia occur because of immobility, reduced ventilatory function, increased secretions, and problems in lung expansion. Hemorrhage can happen in patients with bleeding disorders. A patient who is obese is not at any higher risk of electrolyte imbalances compared with a patient of normal body weight.

The nurse is caring for a patient with an intestinal obstruction. Suddenly, the patient becomes tachycardic, tachypneic, and hypotensive. On assessment, the nurse notes a boardlike abdomen and suspects an intestinal perforation. The nurse knows to prepare the patient for which type of surgery? O Urgent O Elective O Emergent O Transplant

O Emergent Urgent or emergency surgery - When a patient's condition is life threatening, surgery is considered emergent Rationale Bowel perforation is a medical emergency and must be surgically treated immediately to preserve life. This surgery would not be considered urgent or elective, and transplantation would not occur.

The nurse is caring for a postoperative patient. Which measures should the nurse take to prevent venous stasis and thrombus formation in the patient? Select all that apply. O Provide ample rest. O Administer antibiotics O Encourage early ambulation O Apply graded compression stockings. O Encourage patient to perform leg exercises.

O Encourage early ambulation O Apply graded compression stockings. O Encourage patient to perform leg exercises. Rationale Venous stasis and thrombus formation are serious circulatory complications after surgery. Measures should be taken to promote a healthy blood supply to the extremities. Early ambulation helps improve venous return and prevents stasis of blood. Graded compression stockings also help prevent stasis. Leg exercises are encouraged to promote normal venous return. Ample rest is not required after every surgery. Administration of antibiotics is a general precaution against infections and may not help avoid circulatory complications.

The nurse is caring for a patient 6 hours after arrival on the floor after an appendectomy. The nurse notes the patient has not urinated since before the surgery. Which action should the nurse do first? O Call the surgeon. O Place an indwelling catheter to gravity. O Perform straight or in-and-out catheterization O Encourage fluid intake

O Encourage fluid intake Rationale Anesthesia can lead to urinary retention, so it is important to monitor the patient's urine output. If the patient has not urinated 8 hours after surgery, the nurse should palpate for urinary retention and alert the health care provider. However, this patient only returned from surgery 6 hours ago, so the appropriate action is to encourage oral fluid intake. It may be necessary to catheterize the patient, but this requires a health care provider prescription and is not appropriate at this time.

A nurse is preparing to care for a patient with polycystic kidney disease (PKD). The nurse knows this patient is at risk for which fatal disease? O Liver failure O Bladder cancer O End-stage renal disease O Recurrent urinary tract infections

O End-stage renal disease Rationale PKD can progress to end-stage renal disease, which is fatal. Although PKD may cause recurrent urinary tract infections, these are not necessarily fatal. Liver failure and bladder cancer can be fatal, but neither these nor recurrent urinary tract infections are caused by PKD.

A 55-year-old man is admitted to the hospital with urinary retention. The patient is catheterized to relieve the retention. Which actions are necessary to prevent infection patient? Select all that apply. O Ensuring a closed drainage system O Monitoring the patency of the catheter O Hanging the drainage bag on the bed rall O Following good hand hygiene techniques O Ensuring that the spigot does not touch any contaminated surfaces

O Ensuring a closed drainage system O Monitoring the patency of the catheter O Following good hand hygiene techniques O Ensuring that the spigot does not touch any contaminated surfaces Rationale Bacteria grow quickly in pooled urine. Ensuring a closed drainage system prevents microorganisms from entering the system. Maintaining the patency of the catheter ensures that the urine does not pool. Hand hygiene measures should be followed to prevent the development and spread of infection. The spigot of the drainage system is a site at high risk for infection therefore, it should not be allowed to touch any contaminated surfaces. The drainage bag should not be hung on the bed rail because it could be accidently raised above the patient's bladder level, allowing backflow of urine. Backflow of contaminated urine can cause infection

Which physiologic change related to aging is most likely to lead to overdose in older adults? O Smell O Hearing O Eyesight O Weakness

O Eyesight Rationale The main physiologic change that may contribute to overdose in older adults is eyesight. Poor eyesight potentially leads to ingestion of the wrong medication. Anyone assisting with the care of an older adult should ensure that all medications and other substances are identified clearly by using large lettering. Older adults with hearing loss, chronic weakness, or an impaired sense of smell may still be able to read the labels to take medications appropriately.

A diet rich in which component is best for a patient with hemorrhoids? O Fiber O Proteins O Vitamins O Carbohydrates

O Fiber Rationale Hemorrhoids are a common problem associated with pregnancy and cause discomfort, pain, and elimination problems. Constipation is an important factor that can cause or aggravate hemorrhoids. Eating a fiber-rich diet prevents constipation. Diets rich in proteins, vitamins, and carbohydrates do not help in softening of stools. These foods would not be useful in controlling the discomfort or pain caused by hemorrhoids.

Which interval is usual at which nursing assessments, including vital signs, are monitored in the postoperative phase? O Four hours, followed by once a shift in O Thirty minutes times 4; every hour times 4; then every 4 hours O Fifteen minutes times 4: every 30 minutes times 4; every hour times 4; then every 4 hours O Five minutes times 4 every 10 minutes times 4; every 30 minutes times 4; then every hour

O Fifteen minutes times 4: every 30 minutes times 4; every hour times 4; then every 4 hours Rationale The usual interval at which nursing assessments, including vital signs, are monitored in the postoperative phase is every 15 minutes times 4, every 30 minutes times 4; every hour times 4; then every 4 hours. Four hours followed by once a shift is far beneath the standard of care generally accepted on postoperative units. Potential patient complications would be missed. This "times four" gauge is the maximum time that should elapse between assessments. Five minutes times 4 is not the typical interval of assessments routinely performed by nurses. Thirty minutes times 4 leaves too much time between assessments for optimal patient safety and monitoring of potential postoperative complications.

a nurse arrives on an accident scene and quickly recognizes that an individual is going into shock. In which position would the nurse place the patient? O Prone O Fowler's O Side-lying O Flat, with legs elevated

O Flat, with legs elevated Rationale It is essential to treat shock immediately. Priority interventions include establishing an airway; controlling bleeding, if present; and positioning the patient supine, with the legs elevated slightly above the head. In the prone position, the person is lying face down, in the side-lying position, the legs are not raised, and in Fowler's position, the person raises the head to a level higher than the legs, so this position is not appropriate for shock.

Which terminology would be documented in the medical record for an infection of a hair follicle? O A felon O Folliculitis O A furuncle O A carbuncle

O Folliculitis Rationale Folliculitis is an infection of a hair follicle, usually caused by Staphylococcus aureus. The infection may involve one or several follicles. It often occurs after shaving. A furuncle, also known as a boil, is an inflammation that begins deep in the hair follicles and spreads to the surrounding skin; it is often located in the posterior area of the neck, the forearm, the buttocks, or the axillae. A carbuncle is a duster of furuncles. It is an infection of several hair follicles that spreads to surrounding tissue. A felon occurs when the soft tissue under and around an area, such as the fingernail, becomes infected.

Which essential problems should be placed on the nursing care plan of a patient with a wound? Select all that apply. O Infection O Nutrition O Skin integrity O Respiratory distress O Altered mental status

O Infection O Nutrition O Skin integrity Rationale The patient with a wound is at risk for developing an infection and has an alteration in skin integrity; these are immediate concerns. In addition, nutrition is essential in wound healing. Unless the patient develops complications, altered mental status and respiratory distress are not immediately identified as problems.

Tinea capitis, Microsporum audouinii infection, tinea corporis, and tinea pedis are examples of which type of infection? O Viral skin infections O Fungal skin infections O Bacterial skin infections O Infections commonly acquired in health clubs

O Fungal skin infections Rationale Tinea capitis, M. audouinii infection, tinea corporis, and tinea pedis are all examples of fungal skin infections. These dermatophytoses are superficial infections. These are not bacterial in origin. (An example of a bacterial skin infection is cellulitis.) These are not viral in nature. (An example of a viral skin infection is herpes zoster.) Not all of these fungal infections are commonly acquired at health clubs. Tinea pedis, or athlete's foot, can be found between the toes of a person whose feet perspire heavily, it also can be spread from contaminated public bathroom facilities and swimming pools.

A patient reports a loss of appetite with severe headache and lethargy. On examination, the nurse finds that the patient has dry mucous membranes, the urinary output of 400 mL/24 hr, and elevated blood urea nitrogen (BUN) and serum creatinine. Which medications will the nurse expect in the patient's prescription? O Furosemide (Lasix) O Flutamide (Eulexin) O Doxazosin (Cardura) O Propantheline (Pro-Banthine)

O Furosemide (Lasix) Rationale Loss of appetite associated with severe headache and lethargy are the symptoms of acute renal failure. It is assessed by the presence of dry mucous membrane, decreased urinary output of less than 400 mL/24 hr. It is diagnosed with blood urea nitrogen (BUN) and creatinine test of the urinary sample. Furosemide (Lasix), a diuretic, is prescribed for acute renal failure to increase urinary output and prevent edema. Flutamide (Eulexin) is a nonsteroidal anti androgenic drug prescribed for prostate cancer. Doxazosin (Cardura) is prescribed for benign prostate hypertrophy (BPH). Doxazosin (Cardura) does not increase urinary output. Propantheline (Pro-Banthine) is prescribed for patients with hydronephrosis.

A child's x-ray report shows a bend and cracks in the bone of the left leg. The nurse would identify this as which type of fracture? O Communicated O Impacted O Compressed O Green stick

O Green stick Rationale A bend or crack in bone represents an incomplete break in bone. An incomplete break in bone is also called a green stick fracture. This type of fracture is more common in children because their bones are more pliable. Shattering of the bone into two or more pieces or fragments is called a communicated fracture. In an impacted fracture, the bone ends may jam together. This type of fracture mostly occurs as a result of trauma. Fracture to the vertebrae caused by pressure can be considered a compressed fracture:

Which interve. tion would the nurse implement in a child with an uncontrollable nosebleed? O Position the child flat with the legs elevated. O Have the patient lean forward, and apply pressure toe nose. O Place the child upright, hyperextend the neck, and pinch the nose. O Turn the child on the side, and place an emesis basin to promote drainage

O Have the patient lean forward, and apply pressure toe nose. Rationale The victim experiencing a nosebleed should be kept quiet in the sitting position and leaning forward. If this is not possible, the patient should be placed supine, with the head and shoulders elevated. The thumb and forefinger should be used to apply pressure for 10 to 15 minutes before releasing and an ice compress should be applied. The child should be made to sit upright, or if lying flat, the patient's shoulders and head should be elevated. The child should not hyperextend the neck but should bring it forward. Finally the child should not be turned on the side.

The nurse has received an order to irrigate a patient's wound using an antiseptic solution. Which action should the nurse take to reduce the risk of contamination? O Place the tip of the syringe against the area needing to being cleaned. O Instill the solution with force to remove any debris quickly from the wound. O Direct the solution from unhealthy tissue toward healthy tissue within the wound. O Have the solution flow from the least contaminated to the most contaminated area

O Have the solution flow from the least contaminated to the most contaminated area Rationale The irrigating solution needs to flow from the least contaminated to the most contaminated area to avoid contamination of clean tissue by exudates. Within the wound, the irrigating solution should be directed from healthy tissue and toward unhealthy tissue to reduce trauma to healthy tissue. The tip of the syringe should be placed approximately 1 inch above the area to be irrigated to avoid contamination. The irrigating solution should be instilled gently into the wound to minimize tissue damage, trauma, irritation, and bleeding.

The nurse assesses a patient who has collapsed in the waiting room and determines that the airway may be blocked. Which technique would the nurse use to open the airway? O Logroll O Head-tilt/chin-lift O Abdominal thrusts O Chest compressions

O Head-tilt/chin-lift Rationale The nurse ensures that the patient's airway is opened by performing the head-tilt/chin-lift maneuver. A logroll is used to align the body during movement. Abdominal thrusts and chest compressions are not used to open the airway during cardiopulmonary resuscitation.

The nurse is attending to an elderly patient scheduled for a hernia operation. The nurse understands that as a result of aging, the patient may have rigid blood vessel walls and a reduction in sympathetic and parasympathetic innervations to the heart. Which risks increase in this patient following surgery? Select all that apply. O Hemorrhage O Increased lung expansion O Increased systolic blood pressure O Increased diastolic blood pressure O Increased ability to eliminate drugs

O Hemorrhage O Increased systolic blood pressure O Increased diastolic blood pressure Rationale As the body ages, the blood vessel walls become rigid, causing a reduction in sympathetic and parasympathetic innervations to the heart. These changes may increase the risk of hemorrhage following surgery. The patient may also develop an increase in systolic and diastolic pressures. In postoperative patients, lung expansion may be reduced because of decreased strength of the respiratory muscles. After surgery, the patient may have decreased ability to eliminate drugs because of reduced renal function.

Which action by an unlicensed assistive personnel (UAP) when inserting of a rectal tube requires correction? O Places protective pad under patient O Inserts rectal tube about 8 to 10 inches O Applies water-soluble lubricant to tube O Positions patient in the left side-lying position

O Inserts rectal tube about 8 to 10 inches Rationale The rectal tube should only be inserted 4 to 6 inches. Inserting the tube 8 to 10 inches could cause colorectal trauma and requires correction. Placing a protective pad under the patient protects the linens: Applying a water-soluble lubricant to the tube facilitates easy insertion. The patient should be placed in the left side-lying position.

A nurse is assessing a patient who underwent a surgical procedure. The nurse notices a decrease in blood pressure; rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness. Which complication does the nurse suspect? O Depression O Hemorrhage O Electrolyte imbalance O Obstructive sleep apnea

O Hemorrhage Rationale A drop in blood pressure, rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness are symptoms of hemorrhage. Postoperative hemorrhage may lead to a loss of intravascular volume l toeading to a drop in blood pressure and a weak, thready pulse. Heart rate and respiratory rate increase to compensate for the low intravascular volume to maintain tissue perfusion. Depression is not an immediate postoperative complication unless the patient has a history of depression. Electrolyte imbalances may occur in the immediate postoperative period but would not display these symptoms. The symptoms of obstructive sleep apnea would be drowsiness, apneic periods, and somnolence,

Which finding indicates effective intermittent suctioning for a patient with a nasogastric tube? O pH of aspirate of 3.5 O Hissing sound at air vent O Bowel sounds in all four quadrants O Gurgling sounds when injecting air

O Hissing sound at air vent Rationale After connecting a nasogastric tube to intermittent suction, the nurse should be able to hear a hissing sound at the air vent. This determines the suction's patency. The pH of the solution and gurgling sounds auscultated when injecting air are signs used to verify tube placement. Bowel sounds present in all four quadrants indicates good bowel function, suctioning would not be required.

A student nurse is caring for a patient with a wound that is not healing. Which factors in the patient's health history could negatively affect the healing process? Select all that apply. O History of heart disease O Diabetic for 10 years O Smokes a pack of cigarettes daily O Eats three well-balanced meals per day O Physically active with no history of illnesses

O History of heart disease O Diabetic for 10 years O Smokes a pack of cigarettes daily Rationale Healing is affected by age, nutritional status, and physical well-being and medication therapies Lifestyle factors such as smoking can impede healing Alterations in health, including diabetes, cancer, and heart disease, can slow the body's healing process. The fact that the patient eats three well-balanced meals per day will help with the healing process. When the patient is active with no history of illness, the nurse would anticipate normal healing

Which patient conditions would indicate that the patient is in shock? O Polyuria O Bradycardia O Hypothermia O Low oxygenation

O Hypothermia Rationale A patient who has undergone shock usually has cool and clammy skin, and hypothermia may develop. A patient who is at a risk of vasodilatory shock does not have polyuria. Oliguria develops as a result of decreased circulation of fluids, which in turn, results in decreased urine output. The patient has an increased pulse rate. Therefore the patient may be at risk of tachycardia, or heart rate greater than 100. The patient may not be at risk of bradycardia (reduced heart rate). Vasodilatory shock may not develop in a patient with low oxygenation.

The nurse observes that there is swelling at the intravenous (IV) site in a postoperative patient. The nurse also finds that the site is cool to the touch. Which condition does the nurse suspect? O Dehydration O IV solution infiltration O Fluid overload O Pulmonary edema

O IV solution infiltration Rationale Swelling at the IV site which is also cool to touch indicates that the IV solution has become infiltrated. Infiltration may occur because of movement or inadvertent dislodgment of the needle when the patient ambulates. Dehydration may be seen in the patient if the patient's fluid intake and output has reduced considerably. Fluid overload may be indicated if there is swelling in the legs and arms. Difficulty breathing, anxiety, and pale skin are symptoms of pulmonary edema.

A student nurse is asked about the structures involved in urinary elimination. Which details about the urethra are correct? Select all that apply. O In women the urethra is 4 to 6.5 cm long. O In men the urethra is about 4 inches long O The urethra is attached to the base of the bladder O The urethra goes to the urinary meatus behind the clitoris O The urethra extends from the bladder to the outside of body,

O In women the urethra is 4 to 6.5 cm long. O The urethra is attached to the base of the bladder O The urethra goes to the urinary meatus behind the clitoris O The urethra extends from the bladder to the outside of body, Rationale The urethra is 4 to 6.5 cm long in women. The urethra goes to the urinary meatus located beneath the clitoris, between the folds of the labia. The urethra is attached to the base of the bladder and extends to the outside of the body. In men, the urethra is about 8 inches long and goes through the penis, ending at its tip, the glans penis

With which initial respiratory pattern would a patient with hypoxia present? O Increased rate and depth of res rations O Decreased rate and depth of respirations O Periods of apnea during normal respirations O No changes in the respiratory rate and pattern

O Increased rate and depth of resprations Rationale A patient with hypoxia will initially display an increase in respiratory rate and pattern. As hypoxia progresses, the respiratory rate and depth will decrease. If the hypoxia is not corrected, the patient will eventually develop periods of apnea. Respiratory rate and pattern in a patient with hypoxia would not present as normal.

The nurse is performing a preoperative assessment on a patient and notes that the patient appears anxious. The nurse understands that preoperative anxiety can have which effect on the patient postoperatively? O Increased recovery time O Decreased pain medication needs O Increased risk for hemorrhage O Decreased anesthesia requirements

O Increased recovery time Rationale Anxiety before surgery can lead to increased length of recovery after surgery, increased pain medication requirements, and increased anesthesia needs. Preoperative anxiety has not been shown to increase risk for hemorrhage.

Which stage of general anesthesia includes the administration of anesthetic agents and endotracheal intubation? O Stage IV O Induction O Emergence O Maintenance

O Induction Rationale Induction is the stage of general anesthesia that includes the administration of anesthetic agents and endotracheal intubation. Stage IV begins with the cessation of respirations and must be avoided, or it will necessitate the initiation of cardiopulmonary resuscitation and may lead to death. During the emergence phase of anesthesia, anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of currently used anesthetic agents, emergence may occur in the operating room. The maintenance phase of anesthesia includes positioning the patient and preparing the skin for incision, and the surgical procedure itself.

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which condition in a patient is a sign of Wernicke's encephalopathy? O Involuntary eye movement O Hypoglycemia O Potential for violence O Increased serum magnesium levels

O Involuntary eye movement Rationale Eye abnormalities such as nystagmus or paralysis of the lateral rectus muscles indicate Wernicke's encephalopathy. Hypoglycemia is not indicative of Wernicke's encephalopathy; however, administration of glucose-containing intravenous (IV) solutions to the patient may precipitate Wernicke's encephalopathy in a previously unaffected patient. Most patients with Wernicke's encephalopathy have decreased serum magnesium levels and other signs of malnutrition. Potential for violence is not related to Wernicke's encephalopathy.

Which action by a patient performing intermittent straight catheterization could lead to repeated urinary tract infections? O Using a new disposable catheter each time O Taking prescribed antibiotics on a daily basis O Irrigating catheters with sterile saline after use O Performing hand hygiene before and after procedure

O Irrigating catheters with sterile saline after use Rationale If supplies must be reused, patients should be instructed to boil rubber catheters for 20 minutes and wrap in a clean cloth. Irrigating catheters with sterile saline will not eliminate microorganisms that can cause urinary tract infections. Using new disposable catheters, taking prescribed antibiotics, and performing hand hygiene diminish the risk for infection

The nurse would use a Venturi mask as an oxygen delivery device when observing which finding in the patient? O Discomfort O Has a mustache O Is a mouth breather O Requires humidified oxygen

O Is a mouth breather Rationale A patient who is a mouth breather will be best served by a Venturi mask, which covers the mouth and nose to deliver better oxygen than a nasal cannula (which only delivers oxygen through the nares). Patient oxygen needs, not comfort, will determine the oxygen delivery system. Having a mustache affects sleep apnea treatment systems, not oxygen delivery. Humidified oxygen can be delivered through any device.

Which method is most appropriate to open the airway of a patient with a suspected neck injury? O Jaw-thrust/chin-lift O Head-tilt/chin-lift O Flexed position O Modified head-tilt/chin-lift

O Jaw-thrust/chin-lift Rationale If a neck injury is suspected, the jaw-thrust/chin-lift is used. If neck injury is suspected, the head-tilt/chin-lift produces hyperextension of the neck and could cause complications. A flexed position is an inappropriate position to open the airway.

A nurse is assessing an elderly female patient experiencing urinary incontinence. Which physiologic changes does the nurse expect to see in this patient? Select all that apply. O Lower estrogen levels O Urinary tract infection O Temperature elevation O Enlargement of prostate gland O Decreased bladder muscle tone

O Lower estrogen levels O Decreased bladder muscle tone Rationale Lower estrogen levels in females result in tissue atrophy in the vagina, urethra, and the bladder and may cause urinary incontinence. Urinary incontinence may also be caused by decreased bladder muscle tone Decreased muscle tone interferes with the external urinary sphincter and causes incontinence. A urinary tract infection is caused by urinary retention. A urinary infection causes temperature elevation. Enlargement of the male prostate gland causes pressure on the urethra, which results in urinary retention

Which physical attribute would be associated with darker skin tones or freckles in patients? O Melanin O The dermis O Sudoriferous glands O Stratum germinativum

O Melanin Rationale Highly specialized cells called melanocytes in the epidermis give rise to the pigment melanin that is responsible for the skin color. Higher concentrations of melanin result in darker skin tones. The dermis is the true skin and varies in thickness throughout the body. The sudoriferous glands are sweat glands, which excrete sweat and cool the body's surface. The stratum germinativum is the inner layer of the epidermis that provides a constant new supply of cells for the upper layer and enables the skin to repair itself after an injury.

Which disease condition can be found more in fair-skinned patients than in those with more pigmentation in their skin? O Keloids O Melanoma O Nevus of Ota O Traction alopecia

O Melanoma Rationale Fair-skinned people are more prone to developing melanoma compared with people with more pigment in their skin. People with darker skin have an increased amount of melanin pigment produced by melanocytes. This increased melanin forms a natural sun shield for darker skin and results in a decreased incidence of skin cancer in these individuals. However, individuals with dark skin may have a higher incidence of keloids, Nevus of Ota, and traction alopecia.

The nurse is caring for a patient with a deep stab wound. Which foods does the nurse advise the patient to include in the diet to facilitate faster healing? Select all that apply. O Milk and eggs O Baked potatoes O Dark green vegetables O Seafood and red meat O Gelatin dessert

O Milk and eggs O Baked potatoes O Dark green vegetables O Seafood and red meat Rationale A diet rich in proteins; carbohydrates, lipids; vitamins A and C; thiamine, pyridoxine; and minerals such as zinc, iron, and copper are required for wound healing. Milk and eggs provide proteins. Baked potatoes provide vitamin C. Dark green vegetables provide Vitamin A. Seafood and red meat provide zinc. Gelatin dessert lacks the nutrition required for healing

Which catheter is used to drain urine from the renal pelvis of the kidney? O Coudé catheter O Robinson catheter O Mushroom catheter O Whistle-tip catheter

O Mushroom catheter Rationale A mushroom catheter or Malecot and de Pezzer catheter is used to drain urine from the renal pelvis of the kidney. When it is placed near the ureter or in an area of the kidney, it facilitates the drainage of urine from the renal pelvis. The coudé catheter is used when the enlargement of prostate gland is suspected. The Robinson catheter is used when intermittent drainage is required. During renal surgery, complete drainage of urine is required. The whistle-tip catheter is used when there is blood in urine.

Which oxygen delivery system would be used to apply 2 L/min of oxygen to an ambulatory patient with chronic obstructive pulmonary disease (COPD)? O Venturi mask O Nasal cannula O Simple face mask O Nonrebreathing mask

O Nasal cannula

How many attempts can the nurse make to perform tracheal suctioning at one time? O Only one O No more than three O As many as needed to complete the suctioning O The nurse is not permitted to perform tracheal suctioning

O No more than three Rationale The nurse can only perform tracheal suctioning three times during the suctioning procedure More than one attempt at suctioning may be needed, but the nurse should not exceed three suctioning procedures at one time. It is within the scope of nursing practice to perform tracheal suctioning.

The nurse lists the goal of maintaining the closed urinary drainage system on the care plan. Which data would lead the nurse to conclude that the patient goal has been achieved? O Complaints of burning during urination O Urine is yellow and cloudy in appearance O Discharge with a foul odor from the perineum O No signs and symptoms of a urinary tract infection

O No signs and symptoms of a urinary tract infection Rationale The urinary drainage system should not be opened after it is in place except to irrigate, and then only with a specific order. It is important to maintain a closed system to prevent urinary infections. Burning on discharge, urine that is cloudy in appearance, and a discharge with a foul odor are signs of a possible urinary or bladder infection and indicate that the system may not have been maintained.

The nurse is preparing to care for a patient who has undergone cardiothoracic surgery (treats conditions in the heart, lungs, and chest). During the immediate postoperative period, the nurse would assess which area of the skin for pressure-related breakdown? O Patella O Ventral foot O Occipital skull O Anterior pelvis

O Occipital skull Rationale The patient undergoing cardiothoracic surgery is on his or her back on a hard surface for an extended period. Therefore, the patient should be assessed for skin breakdown on the occiput, olecranon, calcaneus, sacrum, coccyx, and other dependent areas. This patient would not be at risk for breakdown on the patella, ventral foot, or anterior pelvis.

Anursing instructor would share with students which statements regarding the effects aging on the renal system? Select all that apply. O A Urinary incontinence is Inevitable with aging O Older men are at risk for urinary retention because of prostatic hypertrophy O I Excessive fluid intake can increase the risk of urinary tract infections in the older adult O Older Women are at risk for stress incontinence because of weakened pelvic musculature O Urinary tract infections in older adults are often associated with diabetes, neurologic disorders, and procedures (eg catheterization)

O Older men are at risk for urinary retention because of prostatic hypertrophy O Older Women are at risk for stress incontinence because of weakened pelvic musculature O Urinary tract infections in older adults are often associated with diabetes, neurologic disorders, and procedures (eg catheterization) Rationale Older men are at risk for unitary retention because of prostatic hypertrophy. An enlarged prostate restricts urinary out by narrowing the lumen of the urethra, this contributes to urinretention Older wionen are it risk for stress incontinence because of weakened pelvic musculature This can be related to earlier childbearing Another contributing factor for stress incontinence in the older woman is hormonal changes that occur With aging Uninary truct intections in alder adults are often associated with diabetes neurologic disorders, and procedures (egcathetenzation). Any time an invasive procedure is performed, there isa sk of bacter being Introduced, and the older adult s especially susceptible to this threat because of age related dedine in immunity

The nurse is caring for a patient who will have surgery in 3 hours, and the patient's morning medications are due now. Although most medications will be held before surgery because the patient has a prescription for nothing by mouth (NPO), the nurse anticipates administering which medication(s)? Select all that apply. O Oral multivitamin O Oral phenobarbital O Intravenous morphine O Oral digoxin (Lanoxin) O Subcutaneous enoxaparin (Lovenox)

O Oral phenobarbital O Intravenous morphine O Oral digoxin (Lanoxin) Rationale The nurse would plan to administer oral anti seizure and cardiac medications with a small sip of water the morning of the surgery. Intravenous morphine would be given to manage pain because this is not an oral medication. Oral multivitamins would be held before the surgery. Although the enoxaparin (Lovenox) is a subcutaneous medication, it would most likely be held the day of the surgery because of an increased risk of bleeding during the operation.

A patient diagnosed with urinary tract infection caused by Escherichia coli is prescribed nalidixic acid (NegGram). Which interventions by the nurse would ensure safety of the patient? Select all that apply. O Performing a premedication assessment for any renal impairment O Hydrating the patient to produce a urinary output of about 1500 mL O Performing a postmedication assessment for any visual disturbances O Instructing the patient to stop the medication when symptoms subside including alkali ash foods, such as milk and vegetables, in the patient's diet

O Performing a premedication assessment for any renal impairment O Performing a post medication assessment for any visual disturbances Rationale Nalidixic acid (NegGram), a quinolone antibiotic, is effective against urinary tract infections (UTIS) caused by gram-negative bacteria, such as Escherichia col. As nalidixic acid (NegGram) is contraindicated in patients with renal impairment, the patient should be checked for any renal impairment. The medication, if administered to the patient, may result in visual disturbances. Therefore, the nurse should assess the patient regularly for any visual disturbances. During antibiotic therapy patients must be hydrated enough to have a urinary output of 2000 mL. The nurse should hydrate the patient to maintain the normal viscosity of blood, Acid-ash foods should be included in the diet of the patient taking nalidixic acid (NegGram) to reduce the pH of urine to 5.5. On discontinuing the antibiotic therapy, the targeted pathogens may develop resistance to the antibiotic. Therefore, the nurse should instruct the patient to complete the full antibiotic therapy, even if the symptoms

Which action during suctioning would increase a patient's risk of cardiopulmonary compromise? O Performing suctioning for 20 to 25 seconds O Having the patient rest for 1 to 2 minutes between suction attempts O Using a water-soluble lubricant on the catheter O Angling the catheter downward after initial upward insertion

O Performing suctioning for 20 to 25 seconds Rationale Suctioning should only be performed for 10 to 15 seconds with each pass to prevent cardiopulmonary compromise. The nurse should allow 1 to 2 minutes rest in between suctioning attempts. The catheter should be lubricated with water-soluble lubricant to facilitate passage. The catheter should initially be angled up and then downward to follow the normal anatomy

A 50-year-old patient has a prostate-specific antigen (PSA) level of 6 ng/mL. The nurse knows this patient should be evaluated for which condition? O Prostate cancer O Polycystic kidney disease O None, this is a normal value O Human immunodeficiency virus (HIV)

O Prostate cancer Rationale An elevated level of PSA is indicative of prostate cancer. However, it can also be elevated with benign prostatic hyperplasia. The normal value is 0 to 4 ng/mL. Elevated PSA level is not indicative of polycystic kidney disease or HIV.

A young teen with an incision calls the nurse. The patient states to the nurse, "I feel like something gave way in my wound." The nurse assesses the patient and suspects a possible wound dehiscence. Which action should the nurse take first? O Medicate the patient for pain. O Notify the health care provider. O Instruct the patient to lie in Sims position O Place a warm, moist sterile dressing over the area.

O Place a warm, moist sterile dressing over the area. Rationale When wound layers separate, resulting in dehiscence, some patients report feeling that something has given way or broken. If the wound is not covered and dehiscence occurs, the patient should be made to remain in bed and not cough. A warm moist sterile dressing should be placed over the wound. The patient is to remain on nothing by mouth (NPO) status in case surgery is needed to fix the problem. Once the gauze has been placed and the patient's condition is stable, the nurse notifies the health care provider. The patient may be medicated, but it is not a priority, pain is not stated and level is not given. Placing the patient in the Sims position is not appropriate.

The nurse is preparing to care for a patient who has just returned from major abdominal surgery. Which intervention by the nurse in the immediate postoperative period will best prevent cardiovascular complications? O Encourage the patient to restrict movement of legs. O Assist the patient to turn, cough, and deep breathe. O Encourage the patient to get out of bed as soon as possible. patient's legs. O Place sequential compression devices (SCDS) on the legs

O Place sequential compression devices (SCDS) on the legs Rationale In the immediate postoperative period, the nurse should place the SCDs on the patient's legs to promote venous blood return while the patient is immobile. The nurse should facilitate the movement of the patient's arms and legs, not restrict it. Turning, coughing, and deep breathing are important interventions for the respiratory system. Although the patient should ambulate as soon as possible, this is not the best action in the immediate postoperative period.

Which action is correct when administering a soap suds enema to an adult patient? O Warms solution to 85°F O Instills 1250 mL solution O Places patient in Sims position O Administers enema while the patient is on toilet

O Places patient in Sims position Rationale The patient should be positioned in Sims, or left side-lying position, not on the toilet. Sims position allows solution to flow with gravity along the natural anatomy. The solution should be 105°F and between 750 and 1000 mL for an adult.

An emergency tracheostomy was performed on a patient. Which primary intervention would the nurse carry out in the immediate postoperative period? O Offering a soothing back rub O Providing discharge teaching O Arranging for spiritual guidance O Placing a communication board at the bedside

O Placing a communication board at the bedside Rationale The primary nursing responsibilities for maintaining a tracheostomy tube are to keep the airway clear, keep the inner cannula clean, prevent impairment of surrounding tissues, and provide the patient with a means of communication. Because the procedure was done on an emergency basis, the nurse must provide a communication board or pencil and paper for the patient, who will be unable to speak after having had a tracheostomy. It is essential to provide discharge teaching, but it should not be done immediately after surgery. A soothing back rub will help the patient, and spiritual guidance may be needed, but these are not as important as establishing communication with the patient in an effort to address needs in the immediate postoperative period.

Which nursing action needs to be corrected during the insertion of the urinary catheter? O Keeping the collecting bag above the floor O Keeping the urometer in the drainage system O Performing proper care of the catheter twice a day O Placing the drainage bag above the catheter level

O Placing the drainage bag above the catheter level Rationale The nurse should avoid placing the urinary drainage bag above the level of the catheter insertion. This will avoid allowing the urine to reenter the drainage system and contaminate the urinary tract. The nurse should keep the collecting bag above the floor to avoid the patient acquiring an infection from an external source. The nurse should keep the urometer in the drainage system to get precise levels of urinary output. The nurse performs catheter care twice a day and inspects the insertion site for blood or exudate because this indicates infection or trauma.

Which nursing actions are part of managing an airway obstruction for an unconscious patient? Select all that apply. O Some correct answers were not selected O Placing the patient in the supine position O Initiating cardiopulmonary resuscitation (CPR) O Performing a blind finger sweep of the oral cavity O Opening the airway and attempt to ventilate O Performing abdominal thrusts on the patient

O Placing the patient in the supine position O Opening the airway and attempt to ventilate O Performing abdominal thrusts on the patient Rationale It is necessary have the patient in the supine position when managing airway obstruction to facilitate ventilation. Abdominal thrusts are performed on an unconscious patient (who cannot cough spontaneously) to facilitate removal of an obstructing object in the airway. The nurse would also open the airway and attempt to ventilate, a maneuver known as rescue breathing. CPR becomes necessary only if spontaneous breathing is not restored and the patient no longer has a pulse. Blind finger sweeps are no longer recommended; only attempt to remove an object from the victim's mouth if the object is visible.

Which intervention does the nurse expect the health care provider to prescribe for a patient with a critically elevated serum potassium level? O Soap suds enema O Rectal tube insertion O Nasogastric tube insertion O Polystyrene sulfonate (Kayexalate) enema

O Polystyrene sulfonate (Kayexalate) enema Rationale A critically elevated potassium level can lead to life-threatening cardiac dysrhythmias. The health care provider will prescribe a polystyrene sulfonate (Kayexalate) enema to lower the potassium level. A soap suds enema is used to alleviate constipation. A rectal tube prevents skin breakdown from uncontrolled diarrhea. A nasogastric tube alleviates gastric distention caused by bowel obstruction.

The patient with acne vulgaris is prescribed isotretinoin. The nurse anticipates that which test will be performed before the patient begins taking the prescribed medication? O Vitamin D O Pregnancy test O Kidney function O Fasting blood glucose

O Pregnancy test Rationale Isotretinoin can cause severe birth defects and should not be taken if there is a chance a woman might be pregnant. Kidney function, vitamin D, and blood glucose are not affected by the drug

An elderly male patient has been admitted to the hospital for a urinary tract infection, Which physiologic changes in the urinary system does the nurse teach the patient about? Select all that apply. O Prostate enlargement decreases urinary frequency O Prostate enlargement may lead to urinary retention O Urinary retention increases the risk of urinary infection O infective bladder contraction leads to urinary retention

O Prostate enlargement may lead to urinary retention O Urinary retention increases the risk of urinary infection O infective bladder contraction leads to urinary retention Rationale Prostate enlargement may lead to urinary retention by obstructing the low af unine Unnary retention Increases the risk for bacterial growth and the development of urinary infection: Because the bladdencannot contract effectIvely, an older adult often retains urine after võiding The older adult often experiences noctura, Prostate enlargement increases urinary frequency as a result of incomplete voiding

The health care provider instructs the nurse to administer preoperative medication before transferring a patient to the surgical suite. Which interventions should the nurse implement after administering the medication? Select all that apply. O Provide a quiet environment. O Encourage the patient to void. O Place the bed in a low position O Raise the side rails of patient's bed. O Monitor the patient every 15 to 30 minutes.

O Provide a quiet environment. O Place the bed in a low position O Raise the side rails of patient's bed. O Monitor the patient every 15 to 30 minutes. Rationale The patient may experience mild discomfort after receiving the preoperative medication Therefore, the nurse supports the patient by providing a quiet environment. The patient may experience drowsiness or vertigo, so the nurse places the bed in a low position to prevent falls. The side rails of the bed are also raised to provide safety from falls. The nurse monitors the patient every 15 to 30 minutes to ensure that there are no complications. The nurse encourages the patient to void before administering the medications because the patient needs to be in bed after the medications are given.

What can be used to determine the presence of hypoxia in a patient experiencing dyspnea? Select all that apply. O Sputum color O Pulse oximetry O Peripheral pulses O Level of consciousness O Respiratory rate and pattern

O Pulse oximetry O Level of consciousness O Respiratory rate and pattern Rationale Obtaining pulse oximetry readings, determining the level of consciousness, as well as respiratory rate and pattern can determine if a patient has hypoxia. Sputum color indicates possible infection. The peripheral pulses are assessed to determine circulation.

A nurse is admitting a patient to the unit who has been diagnosed with a urinary tract infection (UTI). The patient is acutely ill, with a temperature of 102.5°F (39°C) and chills. She is grabbing on to her left side and complaining of severe pain. The urine specimen appears concentrated with a cloudy appearance and the nurse knows that this symptom is most associated with which type of UTI? O Cystitis O Urethritis O Prostatitis O Pyelonephritis

O Pyelonephritis Rationale This patient appears acutely ill and probably has pyelonephritis: Pyelonephritis is inflammation of the structures of the kidney-the renal pelvis, the renal tubules, and the interstitial tissue-usually caused by Escherichia coli. Pyelonephritis can lead to kidney damage because of destruction of nephrons. Cystitis is inflammation of the wall of the bladder, usually caused by urethrovesical reflux, introduction of a catheter or similar instrument, or contamination (e.g, from feces). It is more common in women because of the short urethra: Signs and symptoms include dysuria, urinary frequency, and pyuria. Urethritis is an inflammation of the urethra. Assessment findings are more localized to the area and include inflammation of the urethra with pus formation in the mucus-forming glands, discomfort, and burning on urination.

Which interventions should the nurse implement while providing care for a postoperative patient who is unconscious? Select all that apply. O Raise the side rails of the bed. O Place a pillow under the head. O Keep the call light within reach. O Raise the bed to a 45-degree angle. O Assess blood pressure and heart rate.

O Raise the side rails of the bed. O Keep the call light within reach. O Raise the bed to a 45-degree angle. O Assess blood pressure and heart rate. Rationale The level of consciousness in a postsurgical patient is altered. Therefore, the nurse raises the side rails of the bed to prevent falls. The nurse also keeps a call light within the patient's reach to help the patient inform the nurses about any complications immediately. The nurse raises the bed to a 45-degree angle to reduce the chances of aspirating vomitus. The nurse assesses blood pressure and heart rate frequently as postoperative complications can occur suddenly. The nurse does not place a pillow under the patient's head until the patient has regained complete consciousness because doing so may cause the tongue to obstruct the airway.

The nurse observes that a postsurgical patient is experiencing symptoms of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung). Which intervention does the nurse implement before reporting to the health care provider? O Raises the head of the bed O Rolls the patient to one side O Administers pain medications O Provides simple carbohydrates

O Raises the head of the bed Rationale Dyspnea is a symptom of atelectasis that can be relieved by raising the head of the patient's bed. The nurse rolls the patient to one side only if there is a risk for aspiration of vomitus and not to relieve dyspnea Pain medications are not a priority in this case. Instead, oxygen therapy needs to be initiated. Simple carbohydrates are helpful in treating hypoglycemia but will not help to relieve the symptoms of atelectasis.

Five days after surgery, a patient calls the nurse and states that the wound is bleeding. After assessing the wound of the patient, the nurse notes that there is no drainage on the bandage at that time. Which other sign may indicate that the patient's wound is bleeding? O Even respirations O Rapid thready pulse O Increased urinary output O Increased blood pressure

O Rapid thready pulse Rationale If hemorrhage results internally, the dressing may sometimes remain dry while the abdominal cavity collects blood. The nurse should be attuned to less obvious signs of internal bleeding including restlessness, rapid thready pulse, decreased blood pressure, decreased urinary output, and cool and clammy skin. Even respirations are normal. The urinary output decreases and the blood pressure decreases when a patient is hemorrhaging

Which equipment is used to humidify the oxygen being delivered to a patient with a tracheostomy? O T-tube O Obturator O Inner cannula O Pilot balloon valve

O T-tube Rationale The T-tube is a "T"-shaped piece of equipment that allows for administration of humidified oxygen to a patient with a tracheostomy. An obturator is used to insert a tracheostomy tube. The inner cannula is a part of the tracheostomy tube. A pilot balloon valve keeps the tracheostomy cuff inflated.

The nurse is caring for a patient who has undergone abdominal surgery. Following the daily assessment, the nurse finds that the patient has an internal hemorrhage. On the basis of which finding did the nurse make such a conclusion? Select all that apply. O Rapid, thready pulse O Skin hot to the touch O Abdominal distension O Low blood pressure O High urinary output

O Rapid, thready pulse O Abdominal distension O Low blood pressure Rationale A patient who has undergone abdominal surgery may have an internal hemorrhage due to trauma, Internal hemorrhage is characterized by a rapid, thready pulse; abdominal distension; and low blood pressure. This is caused by increased abdominal pressure and vasodilatation. The patient may have cool and clammy skin because of reduced blood pressure. Internal hemorrhage causes reduced blood volume, which causes reduced urinary output. Therefore, increase in skin temperature and urinary output do not indicate internal hemorrhage.

An older adult presents with urinary frequency caused by cystitis. Which nursing advice is helpful to this patient? Select all that apply. O Recommending drinking cranberry Juice O Providing information about the usefulness of indwelling catheters O Encouraging the patient to increase fluid intake O Discouraging drinking coffee, tea, cola, and alcohol O Encouraging complete urination before and after meals

O Recommending drinking cranberry Juice O Encouraging the patient to increase fluid intake O Discouraging drinking coffee, tea, cola, and alcohol Rationale Cranberry juice decreases bacterial infections of the bladder and urinary frequency caused by cystitis. Patients should be encouraged to increase fluid intake to at least 6 to 8 glasses a day unless medically contraindicated. Bacterial growth is minimal in diluted urine. Incomplete urination tends to increase frequency as well as the risk of infection. Coffee, tea, cola, and alcohol intake should be discouraged because these have a diuretic effect and may increase urinary frequency Routine use of indwelling catheters should be avoided because it may cause urinary infection. Restricting fluid intake does not decrease urinary incontinence severity or frequency

Which action does the vacuum-assisted closure (VAC) device provide for a wound? O Reduces edema and increases circulation O Increases bacterial count after several days O Decreases blood flow and encourages healing O Facilitates positive pressure and wound closure

O Reduces edema and increases circulation Rationale The wound VAC applies negative pressure to wounds. Healing of the wound is facilitated during this process by an increase in blood flow, improved or increased fluid drainage, and enhanced wound closure as the pressure draws the edges of the wounds together. The use of negative pressure removes fluid from the area, decreases edema, and, as a result of decreased edema, increases blood flow. The blood flow is increased and not reduced. Bacterial count is reduced; it does not increase bacterial count. The wound VAC uses negative pressure and not positive pressure to heal.

a newly postoperative patient is transferred to the postanesthesia care unit (PACU). When the nurse reassesses the bandage, bleeding is evident. Which action should the nurse perform next? O Reinforce the bandage. O Increase the intravenous fluid. O Gall the surgeon for additional instructions. O Remove the original bandage and replace with gauze.

O Reinforce the bandage. Rationale Initial surgical dressings may require reinforcement if soiled. Increasing the intravenous fluid is not a nursing function and requires a prescription. The surgeon may eventually be called if bleeding does not stop after reinforcement. The original surgical bandage is not removed but is reinforced with a pressure dressing.

For removing staples from a surgical incision, which intervention is most appropriate? O Remove all the staples. If the edges pull apart, apply Steri-Strips. O Remove every other staple; then wait several days to remove the rest. O Remove the middle staples first, then proceed to the outer edges and apply the dressing O Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed.

O Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed. Rationale Routinely, every other staple is removed first and replaced with Steri-Strips, unless the orders are different. You would want to monitor that the incision remains closed during the procedure. Unless contraindicated by orders, all the staples are removed at the same time. Starting in the middle of the incision would not reduce the stress on the edges of the incision. Removing all the staples at once will put more stress on the incision, causing an increased risk for the edges to pull apart.

A hunter has been bitten by a snake and is brought to the emergency room. Which measures should the nurse implement? Select all that apply. O Remove restrictive clothing O Assess the patient for shock. O Suction the toxins from the site. O Exercise the limb with the snake bite O Place affected area above the level of the heart.

O Remove restrictive clothing O Assess the patient for shock. Rationale Emergency care for bites from reptiles, such as snakes, includes restricting movement of the affected limb and keeping it below the level of the heart, as well as removing restrictive clothing and jewelry. The patient must be monitored for shock. The toxins are not generally suctioned in the emergency room. This intervention may have been attempted by the patient. This is not a nursing intervention. Exercise should not be done, and the extremity should be kept below the level of the heart.

Which action should the nurse take when a male patient's foreskin retracts during a catheter insertion? O Continue with the procedure. O Repeat the cleansing process. O Notify the health care provider O Briefly discontinue the procedure.

O Repeat the cleansing process. Rationale If the foreskin retracts or the nurse lets go of the penis during the cleansing procedure, the area will become contaminated. Therefore new antiseptic solution should be obtained and the area cleaned again. The nurse should not continue the procedure until the area has been cleaned again. It is not necessary for the health care provider to be notified. The nurse should briefly discontinue the procedure if an erection occurs.

A nurse is caring for a patient with benign prostatic hypertrophy (BPH) that has been refractory to treatment with medicines. The nurse anticipates the patient will undergo which procedure? O Transurethral needle ablation O Transurethral microwave thermotherapy O Photoselective vaporization of the prostate O Transurethral resection of the prostate (TURP)

O Transurethral resection of the prostate (TURP) Rationale TURP is considered the gold standard for BPH treatment. Although transurethral needle ablation, transurethral microwave thermotherapy, and photoselective vaporization of the prostate are all used to treat BPH, TURP is the preferred method.

Which indications are possible with poisoning? Select all that apply. O Respiratory distress O Nausea and vomiting O Hyperthermia O Seizures O Hypothyroidism

O Respiratory distress O Nausea and vomiting O Seizures Rationale Acute signs and symptoms of poisonings are sometimes delayed for hours. The following are possible indications of poisonings: respiratory distress, pulmonary edema; bronchospasm; severe nausea, vomiting, or diarrhea; seizures, twitching, or paralysis; decreased level of consciousness or unconsciousness; restlessness, delirium, agitation, or panic; color changes; pale, flushed, or cyanotic skin; signs of burns or edema around the mouth or other areas of the body; pain, tenderness, or cramps on swallowing characteristic odor on the breath; unusual urine color (red, green, bright yellow, black, bronze); slow, labored breathing or wheezing: abnormal constriction or dilation of pupils; abnormal eye movements, such as nystagmus (constant, involuntary, cyclic movement of the eyeball); skin irritation, erythema, or edema; and shock or cardiac arrest. Hyperthermia is not a sign and symptom of poisoning. Hypothyroidism occurs when the thyroid gland is underactive, and this does not pertain to poisoning

Which action when performing an oropharyngeal suctioning of a 12-year-old patient requires correction? O Using 100 mm Hg wall suction O Moving the Yankauer catheter around mouth O Selecting a 14-French (Fr) suction catheter O Placing the thumb over the end of the connector

O Selecting a 14-French (Fr) suction catheter Rationale The nurse should select a 10- to 12-Fr suction catheter for a child because trauma to the oral mucosa can occur if too large a catheter or too much suction is used. The appropriate suction pressure for a child is 100 to 120 mm Hg. The Yankauer catheter should be moved around the mouth and a thumb placed over the end of the connector to gather secretions.

Which blood test is done to evaluate for impaired renal function, which is affected very little by dehydration, malnutrition, or hepatic function? O Serum creatinine. O Blood urca nitrogen (BUN) O Creatinine clearance O Prostate specificantigen

O Serum creatinine. Rationale The blood test done to evaluate for impaired renal function which is affected very little by dehydration malnutrition, or hepatic function, is known as blood creatinine or serum creatinine. This test measures the amount of creatinine-a catabolic product of creatine which is used in skeletal muscle contraction in blood. BUN isa laboratory test used to determine the kidney's ability to rid the blood of the nonprotein nitrogen (NPN) waste and urea resulting from catabolism BUN, however, is affected by dehydration, malnutrition, or hepatic function. The creatinine clearance test involves testing of blood and urine over a 24-hour period. Elevated serum levels accompanied by a decline in urine levels indicate renal disease Prostate-specificantigen is a blood test that is performed to assess for prostate cancer, prostate hypertrophy, and prostatitis

A patient has come to the postanesthesia care unit (PACU) after hip replacement surgery. What nursing concern would the nurse anticipate to be the highest priority? O Nutrition O Hydration O Skin integrity O Tissue perfusion

O Skin integrity Rationale The existence of hip replacement means there is a wound, which clearly indicates impaired skin integrity; interventions need to be developed to promote wound healing. More information is needed about tissue perfusion, nutrition, and hydration status before those can be identified as higher priorities. Tissue perfusion needs interventions directed toward supporting wound repair if there are circulatory problems. Nutrition is a concern in addition to skin integrity if the patient is having problems with nutrition intake and needs intervention directed toward supporting wound repair. Hydration is a concern in addition to skin integrity if there are problems with fluid balance and needs intervention directed toward supporting wound repair.

Which findings does the nurse expect in a diabetic surgical patient who is taking longer than usual to heal O Increased oxygen to tissues O Small blood vessels that impair tissue circulation O Increased ability of the body to fight infection O Decreased temperature due to healing mechanisms

O Small blood vessels that impair tissue circulation Rationale Wounds in diabetic patients take a longer time to heal. This occurs due to small blood vessel disease that impairs tissue perfusion and hemoglobin fails to release oxygen to tissues. This decreases the oxygen to the tissues. An elevated temperature would suggest an infection and is not due to healing. Diabetes decreases the ability of the body to fight infection.

Three days postoperative, the nurse is ordered to remove a patient's sutures but notices a thick liquid oozing from the suture site. Which action should the nurse take next? O Reapply the removed sutures. O Use.a wetting agent and dress the wound. O Stop the process and leave the remaining sutures intact. O Continue the process and apply Steri-Strips all over.

O Stop the process and leave the remaining sutures intact. Rationale If the nurse observes a thick liquid oozing from the suture site while removing sutures, the nurse should immediately stop the process. Oozing could indicate that the wound is not completely healed. The nurse should not suture back the removed stitches or simply dress the wound. Instead, the nurse should let the wound remain open for a period of time, which helps to prevent further injury, and avoid wetting the wound. The nurse should not completely remove the sutures because doing so may cause infection due to incomplete healing. The nurse may be advised to dress the wound, but the next action the nurse should take is to notice the complication and stop.

In caring for a patient with hydronephrosis, which nursing interventions would be appropriate? Select all that apply. O Restricting fluids O Strictly recording intake and output O Encouraging a diet high in fiber O Assessing and managing pain O Observing for signs and symptoms of infection

O Strictly recording intake and output O Assessing and managing pain O Observing for signs and symptoms of infection Rationale Appropriate nursing interventions for a patient with hydronephrosis include strict recording of intake and output, assessing and managing pain, and observing for signs and symptoms of infection: It is important to determine that output is adequate and proportional to fluid intake because this disorder is caused by obstructions in the urinary tract Severe, stabbing pain may be present in the patient with hydronephrosis. Nausea and vomiting may be caused by a reflex reaction to the pain and will usually subside once the pain is under control. Infection can cause prolonged pressure in the region, which can result in fibrosis and loss of function in affected nephrons. If the condition is left untreated, the kidneys can be destroyed. Appropriate nursing interventions for a patient with hydronephrosis do not include restriction of fluids. Rather, fluids are encouraged to avoid concentrated urine. A high-fiber diet will have no impact on the diagnosis of hydronephrosis

The nurse is caring for a patient 12 hours after abdominal surgery. How can the nurse best facilitate controlled coughing in the postoperative patient? O Instruct the patient to control and prevent coughs by drinking water O Teach the patient to splint the incision with a pillow to help prevent pain. O Hold pain medication to ensure the patient is awake enough to participate O Instruct the patient to take shallow breaths to prevent pain while coughing.

O Teach the patient to splint the incision with a pillow to help prevent pain. Rationale The nurse should teach the patient to splint the incision to prevent pain and protect the incision while coughing. The patient should not prevent coughs. The nurse should ensure that the patient's pain is well controlled. A patient with uncontrolled pain is less likely to perform the necessary postoperative exercise to prevent complications. The patient should take several deep breaths before coughing.

A patient tells the nurse, "I'm worried that my urine is a different color." Which questions will the nurse ask the patient to determine the cause of the color change? Select all that apply. O Tell me more about your diet. O "What medications have you been taking?" O "Do you void on awakening in the morning?" O "Do you sleep through the night without võiding" O "How many glasses of water do you drink every day?"

O Tell me more about your diet. O What medications have you been taking?" O How many glasses of water do you drink every day?" Rationale Urine color changes if a patient consumes food containing water-soluble dyes or consumes medications. Therefore, the nurse asks the patient about dietary changes as well as medications. The urine color also darkens if it is more concentrated. Therefore, the nurse determines whether the patient's fluid intake is normal. Asking the patient if the patient voids in the morning is a question related to urinary elimination. Asking the patient about nighttime voiding is more specific to urinary incontinence. It is not related to urine color

The nurse on the preoperative floor is asked to act as witness for the signing of the surgery consent form. The nurse knows that by providing the signature, the nurse is verifying which information? O The consent was voluntary. O The patient was competent at the signing of the consent form. O Proper education was provided before the consent form was signed O The patient understood the procedure before signing the consent form.

O The consent was voluntary. Rationale The witness verifies only that the consent was voluntary and the identity of the person signing the form. It is the surgeon's responsibility to determine the patient's competency, education, and understanding before having the patient sign the form

A nurse is teaching about kidney function to a group of nursing students. Which statements about kidney function indicate that the students are learning effectively? Select all that apply. O The kidneys produce several substances vital to banc mineralization. O A nephron is a functional unit of the kidney and helps produce urine O The kidneys filter the waste products of metabolism and excrete them in urine. O The kidneys produce several substances vital to white blood cell (WBC) production O The kidneys produce several substances vital to the maintenance of blood pressure

O The kidneys produce several substances vital to banc mineralization. O A nephron is a functional unit of the kidney and helps produce urine O The kidneys filter the waste products of metabolism and excrete them in urine. O The kidneys produce several substances vital to the maintenance of blood pressure Rationale The kidneys produce several substances vital to bone mineralization, Nephron is the functional unit of the kidney and helps manufacture urine. Kidneys filter the waste products of metabolism and excrete them in urine. The kidney also produces rennin that aids in the maintenance of blood pressure. Kidneys produce substances vital for the production of red blood cells (RBCS), not WBCS.

The nurse decides to provide external cardiac compression on a patient who is short of breath and has a normal pulse. Which event would occur as a result of this intervention? O The patient may be injured. O The patient's respiratory rate would be restored. O The patient's blood pressure would become normal O The patient would become unconscious as a result of cerebral injury

O The patient may be injured. Rationale External cardiac compression should be given to the patient who has pulselessness. The intervention helps increase the rate of blood circulation to the heart, lungs, brain, and rest of the body. Because it may cause potential injury, this method should be avoided in the patient who has a normal pulse. Respiratory rate will become normal by providing artificial respiration to the patient. External cardiac compression helps maintain normal pulse rate and blood pressure in the patient who has pulselessness. It is not performed in patients who have a normal pulse. This intervention does not cause injury to the brain. Therefore unconsciousness resulting from cerebral injury does not occur in this patient.

The nurse notices that a patient's urine specimen is cloudy. Which conclusion does the nurse draw from this finding? O The patient has diabetes. O The patient's urine contains bilirubin. O The patient's urine contains bacteria. O The patient's fluid intake is inadequate.

O The patient's urine contains bacteria. Rationale if the urine specimen is cloudy it indicates that the patient's urine contains bacteria or large amounts of protein Cloudy urine does not indicate that the patient has diabetes because diabetes cannot be confirmed before testing the patient's urine. If the patient's urine contains bilirubin, its color will be a very dark amber. If fluid intake is inadequate, the patient's urine will be more concentrated. In that case, the patient's urine will be dark, not cloudy.

Which statement regarding preoperative medication is true? O After surgery, all preoperative medications are automatically resumed for the patient. O The patient who has received an opioid analgesic usually requires a larger amount of anesthetic once in surgery. O The preoperative phase is the optimal time to introduce the concept of patient-controlled analgesia (PCA) to the patient. O After receiving preoperative medication, the patient is generally encouraged to ambulate on the nursing unit to encourage deep breathing.

O The preoperative phase is the optimal time to introduce the concept of patient-controlled analgesia (PCA) to the patient. Rationale An introduction to PCA preoperatively is advantageous because the patient is better able to comprehend the concept and operation of the equipment. Surgery cancels all medications prescribed before surgery except for conditions of longstanding duration, such as phenytoin (Dilantin) for seizure control. The surgeon will prescribe medication again, as necessary, after surgery. The nurse institutes safety procedures, such as keeping the bed in low position and the side rails up and monitoring the patient every 15 minutes until the patient leaves for surgery. The patient who has received an opioid analgesic usually requires a smaller amount of anesthetic once in surgery. After receiving preoperative medication, the patient must remain in bed.

The nurse is teaching a group of student nurses about performing renal angiography: Which statements by a student nurse indicate the need for further teaching? Select all that apply. O The puncture site is assessed for bleeding and hematoma. O The pressure dressing is removed immediately after the procedure O The patient's oral intake is withheld the night before the procedure O The patient is advised not to lie in the supine position after the procedure." O The circulatory status of the involved extremity is assessed every 24 hours

O The pressure dressing is removed immediately after the procedure O The circulatory status of the involved extremity is assessed every 24 hours Rationale Renal angiography is performed to evaluate the blood supply to the kidneys assess masses, and detect any complications after kidney transplantation. The pressure dressing should be maintained at the site of the puncture to prevent bleeding. Therefore, the nurse should not remove the pressure dressing immediately after the procedure. The circulatory status of the involved extremity should be assessed every 15 minutes for 1 hour, and then every 2 hours for the next 24 hours. This intervention helps detect any possible bleeding or hematoma. After the procedure, the puncture site should be assessed carefully for any bleeding. The patient should not be given with any food or fluids by mouth the night before the procedure because radiopaque dye will be used in the procedure.

The medical team has arrived to take the patient to surgery. Which observation, if made by the nurse, would prompt the nurse to "stop the line" and prevent the patient from being taken to surgery? O The patient's jewelry has been removed. O The patient's dentures have not been removed. O The surgery "timeout" has not been performed. O The site for the surgery has not been marked

O The site for the surgery has not been marked Rationale The nurse should call a halt to the process and report that the site of the surgery has not been marked to prevent wrong-site surgery. The patient's jewelry should be removed before surgery. Depending on the surgery, the dentures may be allowed to remain in the patient's mouth. The surgery timeout usually occurs in the operating room immediately before the surgery.

Which statement regarding the anatomy and physiology of the renal system is true? O The outer covering of the kidney is the medulla O The functional unit of the kidney is the glomerulus O The three phases of urine formation are filtration, reabsorption, and secretion. O Blood is delivered to the glomerulus by the efferent arteriole and exits through the afferent arteriole.

O The three phases of urine formation are filtration, reabsorption, and secretion. Rationale The three phases of urine formation are filtration, reabsorption, and secretion. Filtration occurs in the glomerulus of Bowman capsule. Reabsorption of water, glucose, and ions occurs in the proximal convoluted tubules, the loop of Henle, and the distal convoluted tubules. Secretion of ions, waste products, and drugs occurs primarily in the distal convoluted tubule. The outer covering of the kidney is called the renal capsule, a strong layer of connective tissue. The functional unit of the kidney is the nephron. Each kidney contains more than 1 million nephrons, which are responsible for filtering blood and processing urine. Blood is delivered to the glomerulus by the afferent arteriole and exits through the efferent arteriole,

A critical care nurse is preparing to suction a patient who has a tracheostomy. Which nursing action may result in damage to the mucosa? O The catheter is inserted until resistance is met O The patient is allowed to rest between each suction effort. O The cannula is rinsed with a solution before the patient is suctioned. O The thumb is placed over the suction control while the catheter is being advanced.

O The thumb is placed over the suction control while the catheter is being advanced. Rationale During tracheostomy suctioning, the thumb should be removed from the suction control before the catheter is advanced because the thumb would prevent suctioning while the catheter is introduced, and this has the potential to damage the mucosa. Inserting the catheter until resistance is met, allowing the patient to rest between efforts, and rinsing the cannula with a normal saline solution before the first suction are appropriate actions.

Which assessment finding would indicate that the patient has a stage Il ulcer? O The ulcer involves full-thickness tissue loss, and subcutaneous fat is visible. O The ulcer is a localized area of skin that is intact with nonblanchable redness. O The ulcer is a shallow red-pink wound bed with partial thickness loss of dermis O The ulcer involves full-thickness tissue loss, with exposed bone, tendon, or muscle.

O The ulcer is a shallow red-pink wound bed with partial thickness loss of dermis Rationale A stage Il pressure ulcer involves partial-thickness loss of dermis. It appears as an open ulcer, usually shiny or dry, with a shallow red-pink wound bed without slough or bruising. A stage III pressure ulcer involves full-thickness tissue loss, in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full thickness tissue loss, with exposed bone, tendon, or muscle. A stage I pressure ulcer is a localized area of skin over a bony prominence that is intact with nonblanchable redness.

Which statement regarding informed consent is true? O Informed consent occurs when the nurse discusses the surgical procedure, risks, and alternatives with the patient. O If the patient's life is in danger and the family members cannot be located, the surgeon may not legally perform surgery O The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was voluntary consent. O The best time to have the patient sign the consent form is after the patient has received the preoperative medication because the patient will be more relaxed.

O The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. Rationale The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. Informed consent occurs when the surgeon discusses the surgical procedure, risks, and alternatives with the patient. If the patient's life is in danger and the family members cannot be located, the surgeon may legally perform surgery. The witness (often a nurse) is not verifying that the patient understands the procedure. Consent should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives.

The nurse expects fluvoxamine to be prescribed for a patient with which condition? Pruritus related to an allergic reaction Postoperative nausea and vomiting (PONV) Obsessive-compulsive disorder(OCD) Short-term anxiety

Obsessive-compulsive disorder(OCD) Rationale Fluvoxamine is used to treat OCD when obsessions or compulsions cause marked distress, are time-consuming, or interfere substantially with social or occupational responsibilities. Hydroxyzine (Vistaril is used to control PONV and pruritus associated with allergic reactions. Meprobamate (Miltown) is used for short-term relief of anxiety and as a mild skeletal muscle relaxant.

The nurse is assessing gastrointestinal function in a postoperative patient. Which assessment finding would indicate that there is normal peristalsis? O Bowel sounds are absent in the patient. O The patient is able to turn every 2 hours. O The patient experiences flatus after consuming food. O There are 5 to 30 gurgles in the abdomen per minute.

O There are 5 to 30 gurgles in the abdomen per minute. Rationale If the nurse hears 5 to 30 gurgles in the abdomen per minute, it indicates that the patient has normal peristalsis and the patient can consume foods and fluids, An absence of bowel sounds may indicate a decrease in or absence of intestinal peristalsis, which needs to be reported immediately. Ability to turn every 2 hours will not indicate that the patient has normal gastrointestinal function, but the turning exercise aids gastrointestinal functioning. Experiencing flatus after consuming food indicates the presence of intestinal gas, which is relieved by limiting iced beverages and offering warm liquids,

Three weeks after surgery, an African-American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding? O This may be normal for this patient. O The wound has dehisced and is now repairing itself. O There is a need to call the health care provider for additional prescriptions is O The patient must be taught to monitor for signs that indicate the infection

O This may be normal for this patient. Rationale Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of the wound, forms during the maturation phase. The tissue is elevated, round, and firm. African Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. This is a normal finding for an African-American patient. There is no need to call the health care provider as this is a normal finding in this situation. Dehiscence would be evident by the wound opening and drainage being present. The extra tissue does not indicate that there is an infection or it is spreading

Three weeks after surgery, an African-American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding? O This may be normal for this patient. O The wound has dehisced and is now repairing itself. O There is a need to call the health care provider for additional prescriptions. O The patient must be taught to monitor for signs that indicate the infection is spreading

O This may be normal for this patient. Rationale Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of the wound, forms during the maturation phase. The tissue is elevated, round, and firm. African Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. This is a normal finding for an African-American patient. There is no need to call the health care provider as this is a normal finding in this situation. Dehiscence would be evident by the wound opening and drainage being present. The extra tissue does not indicate that there is an infection or it is spreading

While administering oxygen to a patient with respiratory distress, the nurse places a nasal prong into each of the patient's nostrils in the direction that the prongs are curved. Why does the nurse use ensure the prongs are positioned this way? O To prevent drying of the nasal mucosa O To allow maximum expansion of the lungs O To ensure adequate supply of oxygen O To direct the flow of oxygen into the upper respiratory tract

O To direct the flow of oxygen into the upper respiratory tract Rationale Placing a nasal prong into each nostril in the direction that the prongs are curved facilitates direct entry of oxygen into the upper respiratory tract. This ensures improvement in oxygen saturation levels in the patient. Administering oxygen through the nose can cause dryness of the nasal mucosa. This can be prevented by humidification. Administering oxygen through nasal prongs does not facilitate maximum expansion of the lungs. Maximum lung expansion can be achieved by performing deep breathing exercises. The patency of the nasal cannula and the flowmeter ensures adequate supply of oxygen. Prongs are a part of the nasal cannula which enables direct flow of oxygen into the upper respiratory tract.

A patient with a herpes viral infection has frequent outbreaks of cold sores and is prescribed suppressive therapy with valacyclovir. The nurse finds that the patient is also prescribed ibuprofen for which purpose? O To manage chronic pain O To prevent pneumonitis O To provide topical relief O To manage inflammation

O To manage inflammation Rationale The patient is prescribed ibuprofen to manage inflammation that may be caused by cold sores. Systemic analgesics, such as codeine and acetaminophen, are given for pain management Pneumonitis cannot be prevented but can be treated with intravenous acyclovir. Local anesthetics, such as lidocaine, provide topical relief from discomfort.

While performing the closed intermittent method of catheter irrigation, why would the nurse inject the irrigating solution slowly? O To reduce the spread of microorganisms O To prevent accumulation of solution in the bladder O To prevent bladder spasms while dislodging clots in the catheter O To decrease injury and reduce the duration of hospital stay

O To prevent bladder spasms while dislodging clots in the catheter Rationale Injecting the solution into the catheter slowly helps prevent bladder spasm while dislodging clots, sediments, or any other material from the catheter. Accumulation of the solution in the bladder can be prevented by clamping on the irrigation tubing. This prevents bladder distention and injury. Reducing the spread of microorganisms is done by cleansing the end of the catheter with an antiseptic swab. Performing this procedure using strict aseptic technique will help decrease the patient's duration of hospital stay.

Why would the nurse dress a wound after cleaning it with warm water? Select all that apply. O To protect the wound O To absorb drainage O To maintain temperature O To reduce discomfort O To eliminate risk of infection

O To protect the wound O To absorb drainage O To reduce discomfort Rationale Dressings are placed on wounds and used as protective coverings. They apply pressure on the wound to control bleeding and absorb any drainage from the wound Dressings stabilize or support surrounding tissue to reduce the discomfort caused by the wound. Dressings do not affect the temperature of the body. Proper wound care helps reduce the likelihood of infection but does not eliminate infection risk.

Which statement by the nurse about alcohol withdrawal syndrome indicates effective learning? O "Gastrointestinal bleeding can occur if a heavy drinker abruptly quits drinking." O Tremors are seen in a patient who abruptly quits drinking." O "Seizures occur in the patient a few days after alcohol cessation." O "Younger people are more at risk for alcohol withdrawal syndrome."

O Tremors are seen in a patient who abruptly quits drinking." Rationale Abrupt cessation of alcohol in an alcoholic patient may cause withdrawal symptoms such as tremors, agitation, and hallucinations. The tremors can occur in the hands and may also be seen in the tongue, the chin, the trunk, and the feet, 6 to 48 hours after the last drink. Gastrointestinal bleeding can occur as a result of chronic alcohol use, rather than abruptly stopping ingestion. Seizures can occur 12 to 24 hours after alcohol cessation. Withdrawal symptoms are seen more often in older adults, those who have suffered from delirium tremens, and those who have another acute illness or are malnourished.

A patient had a closed fracture of the arm. Which type of bandage would the nurse apply? O Compress O Gauze O Triangular O Butterfly

O Triangular Rationale The triangular bandage, as the name indicates, is a triangular piece of doth that is useful in the case of bone injuries (fractures). In this case, the nurse can use a triangular bandage to immobilize the fractured bone and to prevent further injury to the arm. A compress bandage is useful to treat bleeding, as with open compound fractures. In this case, this bandage cannot be used because the arm has a closed fracture. In this case, a gauze bandage cannot be used because it is used as a part of wound dressing or while applying pressure. The arm fracture requires that the limb be kept in position until medical assistance arrives. Hence pressure cannot be applied. A butterfly bandage is used to keep the wound closed in the case of deep cuts that require stitches: closed fractures do not involve external wounds, and therefore a butterfly bandage is not used for closed fractures.

Which task would be assigned to a nurse rather than to unlicensed assistive personnel (UAP)? O Perineal cleaning and care O Urinary catheter irrigation O Obtaining a clean urine sample O Urinary output measurement

O Urinary catheter irrigation

patient reports to the nurse, "I frequently feel the urgent need to urinate, but I'm unable to urinate completely." Upon palpation, the health care provider observes an egg-shaped urinary bladder arising suprapubically. Which prescription will the nurse expect from the health care provider? O Urinary catheterization O Collagen implant injection O Bethanechol (Urecholine) O Phenazopyridine (Pyridium)

O Urinary catheterization

The nurse is caring for an elderly patient with decreased bladder and muscle tone. Which physical effect does the nurse expect in the patient? O Cystitis O Dysuria O Oliguria O Urinary incontinence

O Urinary incontinence Rationale Decreased bladder muscle tone interferes with the external urinary sphincter, which may lead to urinary incontinence. Cystitis is the inflammation of the bladder caused by irritation of highly concentrated urine or pathogenic bacteria. Dysuria is caused by infection or trauma. Oliguria is caused by kidney failure or a blockage or retention of the urine.

A licensed practical/vocational nurse (LPN/LVN) is reading over the nursing care plan for a newly admitted female patient. One nursing concern noted is impaired urinary elimination. The LPN/LVN is not certain exactly what that means, but on further reading of the care plan, the LPN/LVN discovers nursing interventions, including "Remind patient to perform Kegel exercises four times per shift" and "Assist patient to toilet every 2 hours." Considering the care plan information, which condition is the patient most likely experiencing? O Urinary incontinence (UI) O Urinary tract infection (UTI) O Neurogenic bladder: flaccid type O Neurogenic bladder spastic type

O Urinary incontinence (UI) Rationale This patient probably is experiencing UI. Ul is the involuntary loss of urine from the bladder. It may be permanent or temporary. Although it affects all age groups, it affects older adults more frequently. Kegel exercises and scheduled toileting are two of the interventions that might help the patient achieve continence. UTI is the presence of microorganisms in the urinary tract structure. Medical care will focus on treating the patient with the correct antibiotics, whereas the primary focus of nursing care of the patient with a UTI maintaining adequate hydration and hygiene. The patient with a neurogenic bladder has a lesion of the central nervous system (CNS), interfering with normal nerve conduction to the urinary bladder. In the flaccid type, which is caused by a lower motor neuron lesion, the bladder continues to fill and distend, with pooling of urine and incomplete emptying. Because of loss of sensation, the patient may not even be aware that he or she has a distended bladder. The patient with a neurogenic bladder has a lesion of the CNS, interfering with normal nerve conduction to the urinary bladder. In the spastic type, which is caused by a lesion above the voiding reflex arc, loss of sensation to void and loss af motor control occur, There is resultant bladder wall atrophy and diminished capacity. The bladder releases urine on reflex with little or no conscious control

A patient visits the clinic complaining of urinary frequency and dysuria. The nurse anticipates which test will be performed? O Urine culture O Blood culture O O Pelvic examination Papanicolaou (Pap) smear

O Urine culture Rationale The patient's symptoms reflect a likely urinary tract infection, and a urine culture will be performed. A blood culture is unnecessary. A pelvic examination and a Pap smear may be performed if the provider suspects a sexually transmitted infection.

Which intervention should the nurse perform for a patient with chronic lung disease presenting with impaired oxygenation caused by inability to clear the airway? Select all that apply. O Allow frequent rest periods. O Use of incentive spirometer O Administer cough expectorants. O Provide paper for communication

O Use of incentive spirometer O Administer cough expectorants. Rationale The nurse would encourage coughing and use of the incentive spirometer and administer cough expectorants to a patient with impaired oxygenation who is not effectively able to clear the airway. Allowing for frequent rest periods is an intervention for a patient with activity intolerance: A patient with compromised verbal communication as a result of a tracheostomy or ventilator use would require an alternative form of communication, such as writing.

Which intervention is most effective to prevent skin breakdown in a patient with incontinence? O Providing bladder training O Inserting a Foley catheter O Using the Crede maneuver O changing undergarments and pads frequently

O changing undergarments and pads frequently Rationale Urine and feces are highly irritating to the skin. Skin that is continuously exposed becomes inflamed and irritated quickly. To help prevent skin impairment, the patient's undergarments or underpants should be changed frequently and the area washed with soap and water after each episode of incontinence. Inserting a Foley catheter is not a nursing function and places the patient at risk for infection. Bladder training may take some time and is not an immediate method of preventing skin impairment. The Crede maneuver is used to promote bladder elimination and is not appropriate,

Which approach is the most appropriate way to cleanse the wound and surrounding area for a sterile dry dressing change? O Use a sterile swab to soak up any drainage; then apply a clean dressing. O Using an aseptic swab, start on the side of the wound closest to you and apply one stroke per swab. O Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. O Using an aseptic swab, start at the top of the incision, using the same swab until dirty: then get a clean swab.

O Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. Rationale Using an aseptic swab and starting from the incision outward helps to remove bacteria from the wound area and prevents contaminating a previously cleaned area. The wound needs to be cleaned with aseptic solution to prevent contamination before application of a dressing. In cleaning the wound, a new swab needs to be used for each stroke to prevent wound contamination. When cleaning a wound, you need to start on the side farthest from you to prevent contaminating an area already cleaned. The wound needs to be cleaned before a clean dressing can be applied. The same swab is not used until it is dirty, only one stroke per swab.

A patient sustains a first-degree burn after being splashed with hot water. Which treatment would be effective for the nurse to provide? Select all that apply. O Soaking the burned area with ice water O Using cold compress to reduce pain O Giving oral rehydration therapy O Applying a sterile dressing on the burn O Using a specific antiseptic solution

O Using cold compress to reduce pain O Applying a sterile dressing on the burn Rationale When hot water is spilled on the skin, it causes first-degree burns. Using a cold compress can reduce the pain caused by the burn. A sterile dressing should be applied to the burn to prevent infection. Soaking the burned area with ice water is to be avoided because it may cause further damage to the tissue by causing frostbite. Oral rehydration therapy is advisable in the case of second and third-degree burns because these burns may result in fluid loss. As first-degree burns result in erythema and pain, but not blisters, application of an antiseptic solution is not necessary

Which action will decrease tissue trauma to the skin surrounding a wound? O Removing the bandage slowly O Using the thumb to retract skin away from the tape O Applying petroleum jelly on the skin around the wound O Soaking the skin with alcohol before removing the bandage

O Using the thumb to retract skin away from the tape Rationale Using the thumb to retract the skin from the tape minimizes skin trauma and decreases patient discomfort. Removing the bandage slowly may not prevent trauma to the skin. Unless prescribed, petroleum jelly is usually not applied to the skin. Alcohol may be irritating to the skin:

Which statement about the effect of the transtracheal method on oxygen flow rate is true? O Usually this method does not affect the oxygen flow rate in any patients. O Usually this method requires less oxygen flow compared with other systems in some patients. O Usually this method requires more oxygen flow compared with other systems in all patients. O Usually the same amount of oxygen flow is achieved as with other systems.

O Usually this method requires less oxygen flow compared with other systems in some patients.

Under which conditions would a nurse avoid giving cardiopulmonary resuscitation (CPR)? Select all that apply. O When the nurse is scared O When the nurse is confused O When the patient is able to breathe O When the nurse is exhausted O In an unsafe place

O When the patient is able to breathe O When the nurse is exhausted O In an unsafe place Rationale Once the nurse starts performing CPR, it is necessary to continue it till the patient is able to breathe. If the nurse is exhausted while performing CPR, then it is necessary to stop because the nurse may suffer from shortness of breath. An unsafe place increases the risk of infection and injury, so CPR should be immediately stopped, and the patient should be evacuated from there. CPR should be resumed after the patient is moved to a safe place. CPR should be stopped after the patient recovers and breathes properly without any assistance. The nurse instructor should motivate students to not be scared or confused while giving CPR because it is an important lifesaving measure.

When assessing a patient's surgical dressing, the nurse finds separation of the wound edges and pale red, watery discharge on the gauze, and the nurse requests an NPO order (receive nothing by mouth). Which condition could be the possible reason for requesting NPO? O Cellulitis O An abscess O Extravasation O Wound dehiscence

O Wound dehiscence Rationale Dehiscence is caused by a rupture of sutures and is characterized by separation of the wound edges as well as pale red discharge on surgical dressings. In this case, to prevent further damage, the patient is instructed to have bed rest, and nothing is given by mouth. Cellulitis is an infection of the skin and is characterized by heat, pain, and erythema. An abscess is a localized infection characterized by the formation of pus and the presence of inflammation around the wound. Excavation is characterized by the passage of fluids into the blood from subcutaneous tissue.

Which action should the nurse take when performing nasotracheal suctioning a patient with a respiratory infection? O Apply a water-soluble lubricant on the catheter. O Use antimicrobial ointment during suctioning O Flush the secretions from the catheter with sterile saline. O Wrap the catheter around the gloved hand, and then remove the glove.

O Wrap the catheter around the gloved hand, and then remove the glove. Rationale After performing the suctioning procedure, the nurse should wrap the suction catheter around the gloved hand and then remove the glove, leaving the catheter contained inside the glove, to prevent transmission of microorganisms. A water-soluble lubricant is used during insertion to facilitate passage of the catheter. Antimicrobial ointment may occlude the catheter and should not be used. Secretions are flushed from the catheter with normal saline to maintain patency if the patient requires additional suctioning

A nurse is caring for a patient scheduled to undergo a cystoscopy. The patient expresses anxiety regarding the pain associated with the scope being inserted into the urethra. Which response is best from the nurse? O "Don't worry, you won't feel a thing! O "It only hurts while the scope is initially inserted." O "The doctor will prescribe pain medication, if necessary O You will feel pressure during insertion of the scope

O You will feel pressure during insertion of the scope Rationale The nurse should inform the patient that only pressure will be felt. The nurse should not tell the patient not to worry. Telling the patient it hurts only while the scope is being inserted is not helpful or true. Although the patient should know the health care provider will prescribe pain medication, if necessary, this does not address the patient's concerns about the procedure.

Which precautions does the nurse take to ensure appropriate wound healing of a thigh laceration? Select all that apply. O checks that the surrounding skin is clean and dry O Ensures therapeutic body position is maintained O Ensures dressings and drains are positioned correctly O Provides appropriate nutrition for faster healing O Decreases fluids to decrease the amount of drainage

O checks that the surrounding skin is clean and dry O Ensures therapeutic body position is maintained O Ensures dressings and drains are positioned correctly O Provides appropriate nutrition for faster healing Rationale The nurse takes adequate precautions to ensure appropriate wound healing in the patient. The nurse ensures that the surrounding skin and tissue are clean and dry to avoid bacterial infection. The nurse ensures that the patient is lying in the correct position so that the wound is not disturbed and there is no undue pressure on the wound. The nurse ensures that dressings, compression stockings, and drains are placed correctly to avoid contamination. The nurse also ensures that the patient receives adequate nutrition that helps with faster healing. Fluids should not be decreased; patients should be offered fluid at least every hour.

Which information does the nurse include while preparing instructions for a patient who has undergone prostatectomy? Select all that apply. O The patient should rest for 24 hours to prevent postoperative bleeding O Administer aspirin (Ecotrin) in case of postoperative pain. O observe for signs and symptoms of urinary tract infection (UTI), O Ensure oral fluid intake of 2000 to 3000 mL per day. O Avoid use of antibiotics until bleeding completely stops.

O observe for signs and symptoms of urinary tract infection (UTI), O Ensure oral fluid intake of 2000 to 3000 mL per day. Rationale The nurse should monitor the postprostatectomy patient for possible signs and symptoms of urinary tract infections. To prevent the occurrence of infection and to maintain urinary continence, the patient is advised to maintain the oral fluid intake of 2000 to 3000 mL per day. The patient is instructed to rest for 48 hours after prostatectomy., Aspirin (Ecotrin) is avoided after prostatectomy because it increases bleeding. Antibiotics, as prescribed, should be administered to prevent urinary infections.

Transrectal ultrasonography is used to view which structure? O Rectum O Bladder O Kidneys O Prostate

O prostate Rationale Transrectal ultrasonography is a diagnostic test that is performed to look at the prostate. With this test, the health care provider can differentiate between prostate enlargement and prostate cancer. A biopsy also can be performed to obtain tissue samples from various areas of the prostate. Transrectal ultrasonography is not used to look at the rectum, although the rectum is the area in which the ultrasound probe is inserted. Transrectal ultrasonography is not used to look at the bladder. Ordinary ultrasonography-use of a probe on the outside of the skin, would be better suited for visualization of the bladder. Transrectal ultrasonography is not used to look at the kidneys. Ordinary ultrasonography-use of a probe on the outside of the skin would be better suited for visualization of the bladder.

Which patient statement regarding how to address frequent epistaxis would the nurse correct? O "Ice compresses applied on my nose may help control the bleeding.' O should tilt my head slightly backward to help stop the flow of the blood." O "I should apply steady pressure to the bridge of my nose for 10 to 15 minutes." O "I need to breathe through my mouth when I have a nosebleed, so I can spit out any blood."

O should tilt my head slightly backward to help stop the flow of the blood." Rationale To manage epistaxis, the patient should tilt the head slightly forward. Ice compresses, steady pressure to the bridge of the nose, and breathing through the mouth to expectorate any blood are all appropriate approaches to manage epistaxis.

In which position would the nurse place a patient who has been admitted with major trauma-related blood loss and is becoming restless and anxious, has a rapid heart rate, is vomiting, and has cool and clammy skin? O side lying O Trendelenburg's O Supine with legs slighter higher than the head O Sitting with head and shoulders elevated and legs stretched out

O side lying Rationale The patient is displaying signs of hypovolemic shock, because the patient is vomiting, he or she should be placed on the side to allow the airway to dear and encourage drainage Trendelenburg's position is no longer used for the treatment of shock. If the patient is not unconscious or vomiting, he or she should be positioned supine, with the legs slightly higher than the head. If the patient is having trouble breathing he or she should be made to sit, with the head and shoulders elevated and legs stretched out

A chronic alcoholic patient reports an inability to control alcohol cravings and the nurse plans to admit the patient into an alcohol rehabilitation program. Which medication is beneficial to treat this condition? O Alpha agonist O Opioid agonist O Narcotic antagonist O ON-methyl-D-aspartate receptor (NMDA) antagonist

ON-methyl-D-aspartate receptor (NMDA) antagonist Rationale NMDA antagonists are administered in alcohol rehabilitation programs to chronic alcoholic patients who want to maintain abstinence from psychoactive drug use. Alpha agonists are prescribed to reduce cravings and treat alcohol withdrawal symptoms. Opioid agonists show antagonist properties that involve a ceiling effect on analgesia and respiratory depression. Narcotic antagonists are prescribed for opioid maintenance programs.

Trans-fatty acids.

Observed effects of diets that are high in trans-fatty acids include an increase in low density lipoprotein (LDL) cholesterol levels, a reduction in the protective high-density lipoprotein (HDL) cholesterol levels, an increase in the atherogenic index and endothelial dysfunction, and an increased production of atherosclerotic inflammatory cytokines. In response to these growing health concerns, beginning in 2003 the FDA required all food manufacturers to identify the amount of trans fats on the nutrition facts label, thereby making the identification of these products much easier (see Figure 3-7). This act motivated the food industry to develop alternative fats and oils to avoid the use of trans fats and to improve the fatty acid composition with regard to cardiovascular health risk. In addition, the FDA has recently removed trans fatty acids from the list of generally recognized as safe (GRAS) food additives 24 Food manufacturers have until 2018 to discontinue the use of partially hydrogenated oils (the primary source of trans-fatty acids in the food supply) in any food product, thereby drastically reducing the overall consumption of trans fats in the United States.

Which atypical antipsychotic agent would be prescribed for a patient undergoing initial pharmacologic treatment for bipolar disorder as monotherapy? Valproate Olanzapine Lamotrigine Carbamazepine

Olanzapine Rationale olanzapine is an atypical antipsychotic agent used for the initial treatment of a patient with acute mania as monotherapy. Valproate is also used for the initial treatment of acute mania as a monotherapy, but valproate is not an atypical antipsychotic agent. Lamotrigine and carbamazepine are used for patients who do not adequately respond to lithium.

What is responsible for rapid deinstitutionalization as a result of severe fiscal cuts? O Electroconvulsive therapy O Committee for Mental Hygiene O President's Commission on Mental Health O Omnibus Budget Reconciliation Act (OBRA))

Omnibus Budget Reconciliation Act (OBRA)) Rationale The OBRA, passed during President Reagan's administration, is responsible for drastically reducing funding for the mental health system. The President's Commission on Mental Health assessed mental health care needs of the nation and made recommendations of action for the government to take. The Committee for Mental Hygiene was developed in response to a book that a mental patient wrote while hospitalized for 3 years, detailing beatings, isolation, and confinement. Electroconvulsive therapy is a treatment option that was developed during the 1930s; it is not credited with deinstitutionalization.

nasogastric tube

•Gastric Decompression •Salem-sump: air vent •Low intermittent suction @100-125mmHg •Assess for dehydration •Hypokalemia: muscle weakness/dysrhythmia •Measure & monitor contents

The nurse is caring for a patient who is experiencing a mental health crisis after losing his spouse. Which patient outcome indicates that the nursing interventions are effective? O Organizes resources O Rationalizes his behavior O Returns to a precrisis state O Finds ways to engage himself O Emotional stress is decreased

Organizes resources Returns to a precrisis state Finds ways to engage himself Emotional stress is decreased Rationale Short-term active support provided by the nurse focuses on problem-solving and helps facilitate a positive resolution to the crisis. The nurse should assist the patient to organize and mobilize the resources for support. The patient returning to precrisis state is an outcome expected after performing interventions and indicates that the patient has overcome the crisis. The nurse should help the patient find out ways to engage himself to avoid loneliness. Rationalizing one's behavior is a defense mechanism.

A patient with chronic alcohol ingestion presents for detoxification. Which medications would be beneficial for this condition? Select all that apply. O Oxazepam (Serax). O Disulfiram (Antabuse) O Clorazepate O Acamprosate (Campral) O Carbamazepine (Tegretol)

Oxazepam (Serax) Clorazepate Rationale Oxazepam (Serax) and clorazepate (Tranxene) are administered for detoxification from chronic alcohol ingestion. They enhance gamma-aminobutyric acid activity that has been suppressed by chronic alcohol ingestion. Disulfiram (Antabuse) is used to reduce the desire for alcohol in patients with chronic alcohol ingestion. Acamprosate (Campral) is used to treat chronic alcoholic patients who want to maintain sobriety. Carbamazepine (Tegretol) is used to decrease seizure frequency and some psychiatric symptoms associated with alcohol withdrawal.

Cellulitis Manifestation

•infection involving underlying tissues of the skin. •Streptococcus pyogenes •May spread and become life-threatening as the infection invades the deeper tissues, lymph nodes & bloodstreams.

What are woman at the highest risk for because of the gradual physical changes that occur during middle adulthood (ages 40 to 65)? O Osteoporosis O Diabetes O Heart Disease O Respiratory problems

Osteoporosis

Physical care of the dying client

Pain Administer pain medication. Do not delay or deny pain medication. Dyspnea Elevate the head of the bed or position the client on her side. Administer supplemental oxygen for comfort. Suction fluids from the airway as needed. Administer medications as prescribed. Skin Check color and temperature. Check for breakdown. Implement measures to prevent breakdown. Dehydration Maintain regular oral care. Encourage taking ice chips and sips of fluid. Do not force the client to eat or drink. Use moist cloths to provide moisture to the mouth. Apply lubricant to the lips and oral mucous membranes. Anorexia, Nausea, and Vomiting Provide antiemetics before meals. Have family members provide the client's favorite foods. Provide frequent small portions of favorite foods. Elimination Monitor urinary and bowel elimination. Place absorbent pads under the client and check frequently. Weakness and Fatigue Provide rest periods. Assess tolerance for activities.

When assessing the patient's integumentary system, which dermatologic manifestation may indicate anemia? O Pallor O Cyanosis O Skin tags O Cherry angiomas

Pallor Rationale Pallor indicates anemia, whereas cyanosis, also known as blue discoloration, may result from a respiratory disorder. Skin tags and cherry angiomas are benign neoplasms related to aging.

An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply.

Palpation Induration

An elderly patient on an orthopedic unit is experiencing joint stiffness. Which intervention should the nurse implement to assist the patient to feel more comfortable? O Perform passive range-of-motion exercises O Decrease mobility O Maintain strict bed rest O Limit any physical activity

Perform passive range-of-motion exercises

Physical Care After Death

Performed according to the culture of the patient and the protocols of the institution •Communicate with the family concerning policies and routines related to care and transport of the body •Family may want private time with the deceased •Provide referrals for funeral home and support groups

SMALL INTESTINE

Peristalsis continues to help with digestion in the small intestine by mixing and moving chyme along the length of the organ. The chemical digestion of carbo hydrate is completed in the small intestine by specific enzymes from both the pancreas and the intestine.

A nurse is developing a care plan for a patient with an obsessive-compulsive behavior disorder. Which nursing intervention will most likely increase the patient's anxiety? O Permitting the patient's ritualistic acts three times a day O Involving the patient in establishing the therapeutic plan O Helping the patient understand the nature of the anxiety O Providing the patient with a nonjudgmental environment

Permitting the patient's ritualistic acts three times a day Rationale By permitting the patient's ritualistic acts three times a day, the nurse sets an unrealistic limit thatwill increase anxiety by removing a defense mechanism that the patient needs. Involving the patient in the plan will increase self-control, not anxiety. Helping the patient develop insight will decrease anxiety. Providing a nonjudgmental environment will reduce anxiety.

Which symptoms will be experienced by a patient with major depressive disorder? Select all that apply. Symptoms of mania Physical symptoms Cognitive symptoms Emotional symptoms Psychomotor symptoms

Physical symptoms Cognitive symptoms Emotional symptoms Psychomotor symptoms Rationale A patient with major depressive disorder exhibits varying degrees of depression. Patients with depression display physical, cognitive, emotional, and psychomotor symptoms Patients with major depressive disorder do not experience symptoms of mania.

A nurse has prepared the body of a deceased patient. Which intervention, if implemented by the nurse, would reduce or eliminate discoloration to the patient's face? O Use Trendelenburg's position. O Place a pillow under the patient's head. O Place the patient in the high Fowler's position. O Apply gentle pressure on the carotid arteries.

Place a pillow under the patient's head. Rationale Discoloration of the face can result if blood is allowed to pool. To prevent this, a small pillow or towel should be placed under the head. Placing the patient in the high Fowler's position or applying gentle pressure on the carotid arteries does not prevent the pooling of blood to the face. The Trendelenburg's position will cause pooling to the face

A nurse is assisting a patient with dementia. In addition to reality orientation, which intervention would be important to implement in caring for patients with dementia? O Increase sensory stimuli. O Give complex instructions. O Place bed in lowest position. O Document intake and output.

Place bed in lowest position. Rationale Patients with dementia need to have a safe environment to prevent injury, such as having the bed in the lowest position, having the side rails up, having adequate lighting, and having personal belongings within reach. The nurse should decrease sensory stimuli, not increase it. The nurse should speak clearly and directly to the patient and provide short instructions for patients with dementia. Documenting intake and output is part of data collection, nota nursing intervention.

Adolescence: 12 -19 years

•transition from childhood to adulthood (Begins at puberty, Menarche) •Sebaceous & sweat glands become active (Are risk-takers) •Becomes capable of reasoning & formal logic •Are risk-takers

Which characteristics does the nurse expect in a mentally ill patient as evidence of improved mental health? Select all that apply.

Positive self-concept Adaptability to change Acceptance of emotions

Ostomy

Postoperative Colostomy: •Pink to bright red/pink & shiny •Pale pink stoma indicates low H/H •Empty pouch 1/3 full •Avoid food that causes gas Postoperative Ileostomy: •Health stoma is red•normal stool is liquid •Increased risk for dehydration and electrolyte imbalance

A patient with mania is prescribed lithium carbonate. The nurse advises the patient to take the medication with food. Which outcome does the nurse expect from this intervention? O Reduced indigestion O Prevention of drowsiness O Prevention of kidney damage O Decrease in toxic levels of lithium

Prevention of drowsiness Rationale The outcome the nurse expects from this intervention is that the patient will have reduced indigestion. Lithium carbonate is used to treat patients with mania and its side effects include indigestion, drowsiness, nausea, vomiting, anemia,abdominal cramps, polydipsia, and polyuria. Taking lithium carbonate with food can prevent indigestion by reducing its interaction with the gastric mucosa. Kidney damage is prevented by routinely monitoring serum lithium levels for toxicity. Taking the medication with food is unrelated to the therapeutic or toxic levels of lithium in the body.

An elderly male patient arrives at the clinic complaining of urinary incontinence. The nurse would ensure which examination is performed? O Penile O Rectal O Prostate O Testicular

Prostate Rationale Urinary incontinence in men is often caused by benign prostatic hyperplasia. Therefore, the nurse should ensure that a prostate examination is performed. Although important, penile, rectal, and testicular examinations are not as important to address incontinence issues compared with prostate examination.

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? O Rapid and continual rewarming of the toes when flushing occurs O Rapid and continual rewarming of the toes in cold water for 45 minutes O Rapid and continual rewarming of the toes in hot water for 15 to 20 minutes O Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

Which condition is associated with delirium tremens (DTS)? O Fetal alcohol syndrome O Overdose of opioid analgesics O Excessive alcohol consumption O Amotivational cannabis syndrome

Rationale Delirium tremens is a psychotic reaction seen in a patient who consumes excessive alcohol and abruptly quits. The patient experiences tremors, panic reactions, and hallucinations; there is a risk of death. Fetal alcohol syndrome is a congenital condition seen in infants due to the maternal consumption of alcohol. during pregnancy. An overdose of opioids will cause respiratory depression, pinpoint pupils, and stupor or coma. Amotivational cannabis syndrome is seen in patients addicted to cannabis, or marijuana.

Which information noted in the health history of a patient with atypical depression prevents the nurse from giving the prescribed monoamine oxidase inhibitors (MAOls) and requires consultation with the prescriber? Recurrent congestive heart failure Chronic seizures Intolerance of dairy products Allergy to eggs

Recurrent congestive heart failure Rationale MAOIs are contraindicated in patients with a history of severe congestive heart failure or renal, hepatic, or cerebrovascular disease. The medication should not be given until the prescriber is consulted. Use of MAOls is not contraindicated by seizures, intolerance to dairy products, or an allergy to eggs.

A hospice patient in the last stage of death is experiencing dyspnea. Which interventions should the nurse perform? Select all that apply. Provide ice chips. Reduce anxiety and fear. Maintain a patent airway. Position the patient supine. Provide oxygen as prescribed.

Reduce anxiety and fear. Maintain a patent airway. Provide oxygen as prescribed. Rationale For the near-death patient with dyspnea, the nurse should maximize the patient's oxygenation. Examples are positioning the patient upright, providing supplemental oxygen, maintaining a patent airway, and reducing anxiety and fear. Ice chips should not be given because aspiration can occur; positioning the patient supine would make breathing more difficult.

Which outcome is expected by the nurse after administering loperamide to a patient with substance abuse? O Decrease in seizure frequency O Decrease in tremors and sweating O Reduction of skeletal muscle spasms O Reduction of gastrointestinal cramping

Reduction of gastrointestinal cramping Rationale Loperamide reduces gastrointestinal cramping and diarrhea in patients with opioid abuse. Carbamazepine, decreases seizure frequency and relieves some of the psychiatric symptoms associated with alcohol withdrawal. Clonidine is used to decrease tremors, sweating, and agitation in patients with opioid abuse Cyclobenzaprine reduces skeletal muscle spasms.

After assessing a patient with substance abuse, the healthcare provider prescribes cyclobenzaprine (Flexeril). Which outcome is expected? O Decrease in seizure frequency O Decrease in tremors and sweating O Reduction of skeletal muscle spasms O Reduction of gastrointestinal cramping

Reduction of skeletal muscle spasms Rationale Cyclobenzaprine (Flexeril) reduces skeletal muscle spasms without interfering with muscle function. Carbamazepine (Carbatrol) is effective in decreasing seizure frequency and some psychiatric symptoms associated with alcohol withdrawal. Clonidine (Catapres) is used to decrease tremors, sweating, and agitation with opioid abuse. Dicyclomine (Dicyclocot) reduces gastrointestinal cramping and diarrhea in patients with opioid abuse.

The nurse observes a loss of appetite in a patient being treated for addiction. Which prescription would most likely be prescribed by the health care provider?

Thiamine

An oncology nurse is caring for a terminally ill patient. Which expected outcome for the patient, if found on the nursing care plan of this patient, is inappropriate? O Maintain dignity until death. O Express concerns and hopes through the illness. O Regain function at or above the pre-illness phase. O Verbalize an understanding of the disease process.

Regain function at or above the pre-illness phase. Rationale A return to full functioning is not an expected outcome for a patient who is terminally ill or even a person who experiences a disability or other loss of function. Maintaining dignity, expressing concerns and hope, and verbalizing an understanding of the disease process are goals that the dying patient can achieve.

The nurse is caring for a patient who has bipolar disorder and experiences mood swings, psychomotor overactivity, and insomnia. Which interventions should the nurse use to communicate with this patient? Select all that apply. O Reinforce assertive behavior. O Ask directly about hallucinations. O Avoid expression of negative thoughts. O Encourage the patient to make decisions. O Encourage alternative ways to cope with stress.

Reinforce assertive behavior. Encourage the patient to make decisions. Encourage alternative ways to cope with stress. Rationale Irregular mood swings, psychomotor overactivity, and insomnia are signs and symptoms of bipolar disorder. Reinforcing the assertive behavior in the patient helps boost the patient's self-esteem. Encouraging the patient to make decisions helps the patient participate in self-care and increases the feeling of self-worth. A patient with bipolar disorder undergoes stress due to regular mood swings; therefore the patient should be encouraged to use alternate ways to cope with stress. Hallucinations are not observed in bipolar disorder, so questioning the patient about hallucinations is unnecessary. The patient is encouraged to express negative feelings because this helps in exploring the patient's destructive way of thinking.

Which nursing interventions should the nurse follow for a patient reporting hallucinations and delusions for more than l month? Select all that apply. O Report the positive behaviors. O Report the negative behaviors. O Give instructions one at a time. O Orient the patient back to reality. O Set limits for the patient's behavior.

Report the positive behaviors. Report the negative behaviors. Orient the patient back to reality. Rationale Patients with schizophrenia show both positive and negative behaviors. Reporting these behaviors helps in further assessment to predict the treatment response and prognosis of the patient. large clock and a calendar should be placed in view to reinforce a daily routine and help the patient to orient to the reality of time, place, and person. Instructions are given one step at a time and in simple terms for a patient with dementia. Limits for a patient's behavior are set for a patient with a personality disorder.

Health Problems related to Fat

Research continues to indicate that health problems from excess dietary fat are specific to certain types of fat. And the whole diet must be considered before making any conclusions about the overall health of a diet. In addition, not all individuals metabolize and process fat the same (see the Cultural Considerations box, "Ethnic Differences in Lipid Metabolism"). Amount of fat. Too many kilocalories in the diet, regardless of the source-fat, carbohydrates, or protein—will exceed the requirement of immediate energy needs. The surplus is stored as body fat. Excess body fat is associated with higher rates of all-cause mortality and risk factors for chronic diseases such as diabetes, hypertension, and heart disease. 18,19 How much fat is in your own daily diet? See the Clinical Applications box entitled "How Much Fat Are You Eating?" to assess your fat intake.

The nurse finds that a patient has typical signs of schizophrenia without evidence of gross disorganization, concreteness, and hallucinations. Which type of schizophrenia is the patient suffering from? O Residual O Paranoid O Catatonic O Disorganized

Residual Rationale Typical signs of schizophrenia include gross distortion of reality, disturbance of language and communication, and withdrawal from social interaction. The patient may also have disorganization and fragmentation of thought, perception, and emotional reaction. These typical signs without evidence o gross disorganization, concreteness, and hallucinations are signs of the residual type of schizophrenia. The paranoid type of schizophrenia is characterized by delusions and auditory hallucinations. The catatonic type shows stupor, negativism, and excitement. The disorganized form of schizophrenia shows fat effect and incoherence.

A school nurse is asked to provide an in-service on inhalants to high school students. During the in-service, the nurse discusses the variety of volatile chemical substances that can alter thinking and emotions when inhaled. Which risks associated with ingesting high doses of inhalants should be included in the in-service?

Respiratory arrest, brain damage, and kidney damage

Postoperative Problems and complications

Respiratory: Airway obstruction, hypoxemia, hypoxia, hypoventilation, atelectasis, pulmonary embolism, PNA What are S/S of PNA? • Cardiovascular: Tachycardia and other arrhythmias, low-high BP decreased cardiac output, DVT, hemorrhage, shock, thrombophlebitis • Gastrointestinal: N/V, paralytic ileus, constipation • Urinary: retention, UTI • Hypothermia or fever •Pain and discomfort Medicate as needed, Tolerance • Wound infection Antibiotics before and after, Nosocomial • Dehiscence, Evisceration

Which goal in planning care for a patient in crisis is the nurse's primary concern? O Reinforce positive behaviors. O Schedule counseling for the patient. O Restore the patient's psychological equilibrium. O Have the patient develop insight regarding the crisis.

Restore the patient's psychological equilibrium. Rationale Restoring the patient's psychological equilibrium is the correct answer because the primary goal of crisis intervention is that the patient will return to precrisis status. Having the patient develop insight is important, but not a priority. Once the patient's condition is stable, the nurse could work with the patient on developing insight. Scheduling counseling is an action, not a goal in planning care for a patient in crisis.

A patient is taking lithium carbonate to stabilize his mood and behaviors. The nurse knows that the patient is at risk for toxicity, which is commonly encountered with lithium. Which action would increase the risk of toxicity? O Continually monitoring lithium levels O Restricting fluid intake and sodium in the diet O Reporting of nausea and vomiting by the patient O Educating regarding the taking of the medication

Restricting fluid intake and sodium in the diet Rationale Poor fluid intake and salt restrictions increase the risk of toxicity. Continually monitoring lithium levels decreases the risk of lithium toxicity. Reporting any nausea or vomiting by the patient decreases the risk of lithium toxicity. Educating the patient about taking the medication decreases the risk of lithium toxicity.

Which would the nurse observe for in a patient with fecal incontinence? O Diarrhea O Rectocele O Sensory deficits O Skin breakdown

Skin breakdown Rationale The nurse should routinely examine an incontinent patient's skin, as fecal matter is very irritating and can lead to skin breakdown Diarrhea, a rectocele, and sensory deficits can lead to fecal incontinence but are not potential complications the nurse should observe for

Which class of antidepressants is chemically unrelated to other antidepressants? Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Serotonin-norepinephrine reuptake inhibitors

Selective serotonin reuptake inhibitors Rationale Selective serotonin reuptake inhibitors are a newer class of antidepressants that are chemically unrelated to other antidepressants.

Which therapy does the nurse anticipate for a patient in whom tricyclic antidepressants were ineffective? Selegiline Fluoxetine Amoxapine Venlafaxine

Selegiline Rationale Selegiline is an approved monoamine oxidase inhibitor used to treat the major depressive disorder. If tricyclic antidepressant therapy is unsatisfactory or electroconvulsive therapy is inappropriate or refused, a transdermal patch of selegiline is advised. Fluoxetine is a selective serotonin reuptake inhibitor that is recommended for treating depression in children and adolescents. Amoxapine is a tricyclic antidepressant; the patient did not have satisfactory results with this group of drugs. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is not used to treat major depressive disorder.

Which therapy does the nurse anticipate for a patient in whom tricyclic antidepressants were ineffective? Selegiline Fluoxetine Amoxapine Venlafaxine

Selegiline Rationale Selegiline is an approved monoamine oxidase inhibitor used to treat the major depressive disorder. If tricyclic antidepressant therapy is unsatisfactory or electroconvulsive therapy is inappropriate or refused, a transdermal patch of selegiline is advised. Fluoxetine is a selective serotonin reuptake inhibitor that is recommended for treating depression in children and adolescents. Amoxapine is a tricyclic antidepressant; the patient did not have satisfactory results with this group of drugs. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is not used to treat the major depressive disorder.

A patient prescribed mirtazapine has developed hypertension. The nurse finds the patient was administered phenelzine sulfate l week ago. Which syndrome is suspected to cause the patient to develop hypertension? O Serotonin O Sundowning O Relocation stress O Neuroleptic malignant

Serotonin Rationale Mirtazapine is an antidepressant drug, and phenelzine sulphate is a monoamine oxidase inhibitor(MAOl). These two drugs should not be taken together or within l4 days of each other. This combination causes serotonin syndrome, characterized by serious reactions such as hypertension, high body temperature, muscle rigidity, twitching, and agitation, leading to delirium and coma. Sundowning syndrome or nocturnal delirium involves increased disorientation and agitation during the evening and nighttime only. Relocation stress syndrome is seen in patients with personality disorder and is characterized by physiologic or psychological disturbances due to transfer from one environment to another. The neuroleptic malignant syndrome may occur with antipsychotic agents and is characterized by confusion, labile blood pressure, and hyperthermia.

A graduate nurse is caring for a patient with difficulty hearing. Which action would best facilitate patient-nurse interaction? O Speaking loudly O conversing in a quick firm manner O Talking slowly in a low tone O Standing at the patient's side during interaction

Talking slowly in a low tone

Dehiscence

Separation of a surgical incision or rupture of a wound closure

Which neurotransmitters are known to change in the brains of patients with depression? Select all that apply. O Glutamate O Epinephrine O Serotonin O Dopamine O Norepinephrine

Serotonin Dopamine Norepinephrine Rationale Brain neurotransmitters such as serotonin, dopamine, and norepinephrine are changed in patients with depression. Glutamate is a neurotransmitter that plays a role in learning and memory. Epinephrine is a neurotransmitter involved in the stimulation of the sympathetic nervous system.

A patient diagnosed with depression is prescribed fluoxetine. On assessment, the nurse finds that the patient has a history of Parkinson's disease as well Which risks are increased in the patient due to drug interactions? O Serotonin syndrome O Sundowning syndrome O Irritable bowel syndrome O Relocation stress syndrome

Serotonin syndrome Rationale Fluoxetine is a selective serotonin reuptake inhibitor, which acts by increasing the levels of serotonin at the synaptic cleft. Patients with Parkinson's disease would take antiparkinsonian drugs, which also retain serotonin. As a result, the serotonin levels in the patient may increase, leading to a life-threatening condition called serotonin syndrome. Serotonin syndrome is characterized by hypertension, high body temperature, muscle rigidity, twitching, and agitation, leading to delirium and coma. Sundowning syndrome is a psychological disorder that is seen mostly during the evening and nighttime. irritable bowel syndrome is a physical disorder that is believed to have psychological underpinnings. Relocation stress syndrome is associated with personality disorders.

A mother tells the nurse that her 3-year-old son has been acting out against others and throwing temper tantrums. What is the most important instruction to provide this mother? O Punish the child every time he says "No" to change his behavior O Acknowledge the child's actions to discipline appropriately O Set limits on your son's behavior. O Allow the behavior because it is normal at this age

Set limits on your son's behavior.

A fatigued patient tells the nurse, "I have a feeling that something will go wrong." The nurse is having difficulty communicating with the patient because the patient's communication is distorted. The nurse also notices a marked increase in the patient's blood pressure. Which level of anxiety would the nurse document in the patient's medical record? O Mild O Panic O Severe O Moderate

Severe Rationale Feelings of impending danger, distorted communication, fatigue, and changes in vital signs are characteristic features of a severe level of anxiety. Mild anxiety is characterized by a slight increase in vital signs, heightened awareness, and increased motivation. Panic is characterized by extreme terror, possible immobilization, and distortion of reality. A patient with moderate anxiety feels tense, has decreased perception, and may be prone to arguing, teasing, or complaining

A patient is prescribed phenelzine sulfate for the treatment of depression. The nurse finds that the patient is using St. John's wort without the advice of the health care provider. Which complication may be expected in the patient due to concomitant use of these drugs? O Renal failure O Disorientation O Phototoxicity O Severe hypertension

Severe hypertension Rationale St. John's wort is one of the most commonly used therapeutic herbs in the world. It is used for the treatment of mild depression. Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI used for the treatment of depression. The use o monoamine oxidase inhibitors and St. John's wort together is contraindicated because it may cause severe hypertension and may lead to stroke. Renal failure is caused by other medications, but it is unrelated to the combination of phenelzine sulfate and St. Joh's wort. Disorientation is generally observed in elderly patients or in patients with neuron degenerative disorders and phototoxicity is an adverse effect of diuretics.

During shift change, the evening nurse reports that a patient displays pseudo parkinsonism. Which assessment findings would the nurse document in the patient record to support this nursing report? O Constipation and dry mouth O Shuffling gait, tremor, rigidity O Bizarre movements of the face and neck O Involuntary movements of the tongue and lips

Shuffling gait, tremor, rigidity Rationale Signs of pseudo parkinsonism include rigidity, resting tremor, and shuffling gait and develop as a side effect of antipsychotic medications. Tardive dyskinesia is the involuntary movement of the tongue and lips. Dystonia is a disorder involving bizarre movements of the face and neck. Constipation and dry mouth are anticholinergic effects.

Which treatment is used to reduce pain from hemorrhoids? Select all that apply. O Enemas O Laxatives O Sitz baths O Witch hazel pads O Narcotic analgesics

Sitz baths Witch hazel pads Rationale Sitz baths and witch hazel pads can provide localized relief for patients with hemorrhoids. Enemas can cause the hemorrhoids to bleed. Laxatives can lead to dependence. Narcotic analgesics are stronger than is necessary to alleviate hemorrhoidal pain.

A patient reports, "I've had a kidney stone for the past 3 months." On diagnosis, the health care provider finds the patient's renal function is normal. Which mental disorder is the patient suffering from? O Concreteness O Somatic delusions O Thought withdrawal O Thought broadcasting

Somatic delusions Rationale Patients with somatic delusions believe that they have impaired body functioning although they are normal. Concreteness is a sign of disordered thinking in which the patient lacks abstract thinking. The symptom of thought withdrawalis when patients feel that someone is stealing their thoughts. Patient with thought broadcasting assume that other people are aware of their thoughts even before they convey them.

A patient reports, "I've had a kidney stone for the past 3 months." On diagnosis the health care provider finds the patient's renal function is normal. Which mental disorder is the patient suffering from?

Somatic delusions- defined as fixed false beliefs that one's bodily function or appearance is grossly abnormal. They are a poorly understood psychiatric symptom and pose a significant clinical challenge to clinicians.

Nursing interventions during detoxification are geared toward ensuring the safety of the patient and assisting the patient to progress through the detoxification process. Which nursing interventions would be appropriate for all patients undergoing detoxification? Select all that apply.

Speaking in a calm voice Keeping instructions and explanations simple Monitoring cardiovascular, respiratory, and neurologic function Facilitating a peaceful environment with reduced environmental stimul

Nursing interventions during detoxification are geared toward ensuring the safety of the patient and assisting the patient to progress through the detoxification process. Which nursing interventions would be appropriate for all patients undergoing detoxification? Select all that apply. O Speaking in a calm voice O Keeping instructions and explanations simple O Administering sedative-hypnotics for insomnia O Monitoring cardiovascular, respiratory, and neurologic function O Facilitating a peaceful environment with reduced environmental stimuli O Maintaining nothing by mouth (NPO) status and intravenous (IV) hydration

Speaking in a calm voice Keeping instructions and explanations simple Monitoring cardiovascular, respiratory, and neurologic function Facilitating a peaceful environment with reduced environmental stimuli Rationale Speaking in a calm voice and facilitating an environment with reduced stimuli helps to reduce stress experienced by the patient, as does keeping instructions and explanations simple. Detoxification can result in life-threatening cardiovascular, respiratory, and neurologic complications, so monitoring for changes in vital functions is essential. Many addicted patients are malnourished and have a lack of appetite. Incorporating nutritious foods and inquiring about food preferences will help address nutritional deficits. NPO orders with IV hydration only would not be a standard approach. Offering the patient a snack or a back rub for insomnia would be preferred to providing medications such as sedative hypnotics, which could further impair neurologic function and mask adverse neurologic responses to detoxification.

STARCHES

Starch is the most important carbohydrate in a bal anced diet. Whole-grain starches such as rice, wheat, corn, and potatoes provide important sources of fiber and other essential nutrients

Starch

Starches are by far the most significant poly saccharides in the diet. They are found in grains, legumes, and other vegetables and in some fruits in small amounts. Starches are more complex in structure than simple sugars, so they break down more slowly and supply energy over a longer period of time. Cooking starch improves its flavor and also softens and ruptures the starch cells, thereby making digestion easier and faster. Starch mixtures thicken when cooked, because the portion that encases the starch granules has a gel-like quality that thickens the starch mixture in the same way that pectin causes jelly to set.

Which response is the nurse's priority when a patient begins to cough and gag during a nasogastric tube insertion? O Assess the oropharynx. O Withdraw the tube. O Pull the tube slightly back. O Stop advancing the tube.

Stop advancing the tube. Rationale If a patient begins to cough or gag during a nasogastric insertion, the first thing the nurse should do is to stop advancing the tube. If the symptoms continue when tube insertion resumes, the nurse should pull the tube back slightly. The oropharynx should then be assessed with a flashlight. If the patient is exhibiting respiratory distress, the tube should be removed,

A patient is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. Which intervention by the nurse is important to maintain the safety of the patient during the 6-week treatment program? O Provide tyramine-free meals during the 6 weeks of therapy. O Maintain patient's sodium intake prior to each procedure. O Avoid patient's exposure to the sun during the 6 weeks of therapy. O Stop the patient from taking any food by mouth for 8 hours before the procedure.

Stop patient from taking any food by mouth for 8 hours before the procedure. Rationale Patients should receive nothing by mouth (NPO) 8 hours before ECT to ensure safety when under general anesthesia Patients taking a monoamine oxidase inhibitor (MAOl) should avoid tyramine in the diet, such as aged foods, beer, and wine. Photosensitivity is not a side effect of ECT Maintaining sodium intake is necessary for patients taking lithium, not for patients getting ECT.

Which nursing intervention is best when a patient with major depressive disorder and congestive heart failure is prescribed a monoamine oxidase inhibitor? Anticipate oral hyperglycemic therapy. Encourage the patient to eat meals with a high tyramine content. Stop the medication and consult the prescriber. Measure the blood pressure at regular intervals after initiating therapy.

Stop the medication and consult the prescriber.

A 17-year-old patient who plays competitive sports has trouble dealing with aggression. Which defense mechanism is this patient displaying? O Regression O Sublimation O Displacement O Rationalization

Sublimation Rationale Sublimation is the discharge of sexual or aggressive energy and impulses in a socially acceptable manner, such as sports or exercise. Rationalization is justification of one's behavior by giving untrue but seemingly more acceptable reasons for behavior. Regression is the display of behavior used at an earlier stage of development. Displacement is the expression of emotions toward someone other than the actual source of the emotion.

The nurse is teaching a 60-year-old female patient about the changes that occur in the urinary system as a result of aging. Which condition would the nurse stress during the teaching session? O Renal failure O Stress incontinence O Incomplete emptying O Urinary tract infection (UTI)

Stress incontinence Rationale Stress incontinence is the involuntary passing of urine in association with coughing, laughing, and any activity that increases the intraabdominal pressure. Older women are at higher risk for stress incontinence. In the aging process, the bladder loses tone and the perineal muscles relax, resulting in stress incontinence. By age 70 years, the kidneys lose nearly half their normal function. However, renal failure is not a normal part of aging. Incomplete emptying is the retention or incomplete expulsion of urine in the bladder. In older men, the prostate enlarges and constricts the urethra, a condition called prostatic hypertrophy, which results in incomplete emptying of bladder. Thus, older men are at a higher risk for incomplete emptying. In older women with stress incontinence, urinary tract infections (UTI) may develop.

A 45-year-old woman is admitted to the psychiatric floor with a diagnosis of catatonic schizophrenia. Which assessment findings would be documented in the patient record to support this diagnosis? O Stupor, negativism, rigidity, posturing O Flat or inappropriate affect, incoherence O Rapid speech, decreased sleep, delusions that she is God O Delusional thoughts that nurses are trying to poison her with medication

Stupor, negativism, rigidity, posturing Rationale Classic findings of catatonic schizophrenia include stupor, negativism, rigidity, and posturing. Delusional thoughts that nurses are trying to poison the patient with medication would be categorized as paranoid schizophrenia. Flat or inappropriate affect and incoherence are typical of disorganized schizophrenia. Rapid speech decreased sleep, and delusions of grandeur common in bipolar patients during the manic phase.

Which defense mechanism has a positive influence on the person's behavior? O Denial O Regression O Sublimation O Displacement

Sublimation Rationale Sublimation is a defense mechanism characterized by the discharge of sexual or aggressive energy and impulses in a socially acceptable way. This would include investing the energy in sports or any other activities with a positive influence on mental health. Denial is disregard for reality. Regression is a defense mechanism characterized by the exhibition of behavior, thoughts, or feelings used at an earlier stage of development, like a 10-year-old child regressing to thumb sucking, Displacement is the process of expressing emotions toward someone or something other than the actual source of the emotion, such as yelling at family members because of issues at the office.

A nurse is caring for an older adult who lives in a long-term care facility on the Alzheimer's unit. Every evening at around 5:00 p.m., the resident becomes increasingly agitated and more confused, lasting throughout the evening. Which behaviour would the nurse document in the patient's record?

Sundowning syndrome

Essential fatty acids

Support blood clotting, blood pressure and inflammatory response. •Ex: fish, olive oil, nuts

which extrapyramidal side effect of antipsychotic medications may be irreversible? O Tardive Dyskinesia O Parkinson's syndrome O Acute dystonic reaction O Akathisia

Tardive Dyskinesia

A nurse monitors a patient with schizophrenia for the side effects of an antipsychotic drug. For which potentially irreversible extrapyramidal side effect should the nurse monitor? O Dystonia O Akathisia O Tardive dyskinesia O Pseudoparkinsonism

Tardive dyskinesia Rationale The potential irreversible extrapyramidal side effect is tardive dyskinesia-involuntary movements of the lips, tongue, and jaw. Pseudoparkinsonism is a possible side effect, but benztropine can decrease effects. Akathisia is severe restlessness that can be decreased with benztropine. Dystonias such as bizarre movements of the face and neck can be decreased with benztropine.

Glucose.

The basic single sugar in human metabolism is glucose, which is the form of sugar circulating in the blood. It is the primary fuel for cells. Glucose, a mod erately sweet sugar, usually is not found as such in the diet, except in corn syrup or processed food items. The body's supply of glucose mainly comes from the diges tion of starch. Glucose is also called dextrose to denote the structure of the molecule (i.e., six carbons).

While interviewing a female patient, the senior nurse finds that the patient is taking isotretinoin (Accutane) to treat acne. On further assessment, the patient states that she plans to conceive. Which is the most important nursing action? O Tell the patient to stop the medication, to avoid adverse effects on the fetus O Inform the patient that she can continue the medication because the acne has reduced O Teach the patient the process of taking the drug with food to minimize the side effects. O Inform the patient that an overdose of Accutane can have serious consequences during pregnancy

Tell the patient to stop the medication, to avoid adverse effects on the fetus Rationale The drug isotretinoin is used for treating acne. Isotretinoin (Accutane) can cause abnormal fetal development and so, it should not be used by women who are pregnant or are planning to become pregnant. While a nurse would normally discuss the drug's side effects and effectiveness on continuing the medication, these issues are not relevant if the patient is instructed to discontinue the medication while trying to conceive.

Assisted Suicide and Euthanasia

The action of a person other than the patient to facilitate suicide •An intentional act that causes death •Involve legal, moral, and ethical issues that have been tested in the courts through the years and remain controversial

Dispensable amino acids

The amino acids the body can make for itself, also called nonessential amino acids

Animal Fats

The chief dietary supply of saturated fat and choles terol comes from animal sources, the most concen trated of which include meat fats (e.g., bacon, sausage) dairy fats (e.g., cream, ice cream, butter, cheese), and egg yolks. The exception to this rule is coconut and palm oils, which are plant fats and also contain satu rated fatty acids. The American diet has traditionally featured meats and other foods of animal origin. The U.S. Department of Agriculture reports that animal products in particular (e.g., meat, poultry, fish, eggs, dairy products) contribute 38.1% of the total fat to U.S. diets as well as 53.8% of the saturated fat and 95.3% of the cholesterol. Some animal fats also contain small amounts of unsaturated fats. For example, 6 oz of sockeye salmon provides 4.2 g of monounsaturated fat and 3 g of polyunsaturated fat, in addition to 2.5 g of saturated fat.

The nurse is assessing the cognitive development of a 4-year-old child using Piaget's method. Which observation by the nurse indicates that the child has good cognitive development? O Interacts actively with family members O The child identifies the pictures in the chart. O Shows interest in saving water and planting trees O Separate cards by identifying both colors and pictures

The child identifies the pictures in the chart.

The nurse is observing the behavior of schoolchildren from an extended democratic family. The nurse finds that one child clings to the parents every morning before school. What could the nurse understand from the child's behavior? O The child is experiencing stress. O The child is afraid of the parents O One of the parents has died O Child has been adopted recently

The child is experiencing stress.

During a home visit, the nurse observes a child and concludes that the family pattern is autocratic. What made the nurse conclude so? O Child is attached to the grandparents O Child's mother makes financial decisions O Child is very mischievous and ill-mannered O The child needs to follow the parents' strict rules.

The child needs to follow the parents' strict rules.

Which condition would be a factor in placing a child in foster care rather than with his or her nuclear family? O The child's parents are economically unstable. O The child has poor grades at school O The child has frequent mood swings O The child's parents both work long hours

The child's parents are economically unstable.

DIETARY REFERENCE INTAKES

The current DRIs recommend that the fat content of the diet not exceed 35% of the total kilocalories, that less than 10% of the kilocalories come from saturated fats, and that dietary cholesterol be limited to a maximum of 300 mg/day (see Chapter 1). No DRI or Tolerable Upper Intake Level is set for trans-fatty acids. The National Academy of Sciences recommends limiting trans-fat intake to as low as possible while maintain ing a nutritionally adequate diet. As mentioned previ ously, fat is an essential part of the diet; therefore, diets that are completely devoid of fat are equally unhealthy and can result in a deficiency of essential fatty acids.

Early child hood

The early childhood period is between 1 and 6 years of age and is separated into the toddler phase and the preschool phase. Tasks to be mastered during early childhood include understanding and speaking words, social interaction, mastery of self-control in feeding and toileting, and beginning to develop a self-concept and a sense of autonomy. • Toilet training occurs as sphincter control develops and the child masters basic communication skills to indicate the need to use the toilet. Complete bowel and bladder control is typically complete by age 2 ½ to 3 years. Adequate nutrition is essential for optimum physical and mental development. A 2-year-old child exhibits negativistic behavior and tantrums because of frustrations and struggles for independence. • Preschool thinking involves Piaget's preoperational or prelogical characteristics. A 2-year-old cannot distinguish between intentional acts and mistakes. Impulse control is typically achieved by age 4. A 3-year-old is ritualistic and feels all rules must be obeyed. According to Kohlberg, the preconventional stage of moral development begins during the preschool age. Discipline should have as its purpose the guiding, teaching, or correcting of behavior rather than punishment. • Toddlers and preschoolers do not completely understand the rights of others.

Hospice Care

The goal is to promote "death with dignity" •To keep patient comfortable as death approaches •Initiated when curative goals are no longer effective •Supports the patient and family through the dying process •Confer with the family to plan changes in the scope of care 6 months or less to live

The nurse asks an infant's mother to reduce the frequency of feeding. What symptoms would the nurse have observed in the infant? O The infant passes watery stools. O Fussy O Wrinkled skin O Poor weight gain

The infant passes watery stools.

The nurse is teaching a group of student nurses about the sexual differentiation of a zygote. The instructor asks the student nurse to explain the pattern of chromosomal fusion for a male zygote. What would be a relevant answer given by the student nurse? O The male sperm's X chromosome fuses with the female ova's X chromosome O The male sperm's Y chromosome fuses with the female ova's X chromosome. O The male sperm's Y chromosome fuses with the female ova's Y chromosome O The male sperm's X chromosome fuses with the female ova's Y chromosome

The male sperm's Y chromosome fuses with the female ova's X chromosome.

A student nurse is administering medications to a patient who has recently undergone detoxification with a diagnosis of alcohol abuse. The medications that have been prescribed include B1 (thiamine), B, (folic acid), and B 12 (cobalamin). The patient questions whether the student nurse is giving him something to "knock him out" or "shut him up. Which response by the student nurse would be appropriate? O The medications are relaxing, but not to the point of knocking you out." O The medications are part of the facility therapy. Every patient gets them." O The medications are supplements only. You can always refuse them if you want. O The medications are supplements to address vitamin deficiencies common to alcohol abuse.

The medications are supplements to address vitamin deficiencies common to alcohol abuse. Rationale B8 and B are all 8 complex vitamins Prolonged use of alcohol has a toxic effect on the intestinal mucosa that results in decreased absorption of vitamins B (thiamine), B, (folic acid), and B(cobalamin) Providing factual information about medications is an important nursing action: B vitamins do not cause relaxation and are prescribed based on individual patient needs, not as a facility protocol. Offering the patient the opportunity to refuse needed medications does not provide the appropriate encouragement

Experts have identified the disease of dependence as a chronic, incurable, progressive one. In the course of interviewing the patient, the nurse discovers that the patient has been consuming alcohol on a daily basis for a couple of years." He says he just doesn't feel "right" until he gets a drink or two. He recently was fired from his job after he got into a physical confrontation with a coworker. The patient appears slender, somewhat malnourished, and anxious. The nurse identifies that the patient is most likely in which stage of dependence? O The late-stage O The early stage: O The middle stage O The stage cannot be identified.

The middle stage Rationale The middle stage of dependence is characterized by using the drug to feel normal, an established pattern of use, noticeable weight loss, financial and legal problems, and job loss or frequent job changes. The early-stage has fewer, less severe health and life consequences; in the late stage, health and life consequences are more severe. Enough information is provided to identify the patient's stage of dependence.

A nurse working on a psychiatric unit knows that there are different therapeutic techniques used. Which component is essential for psychiatric-mental health treatment? O The nurse and patient develop a helping-trust relationship. O Therapeutic communication is not a necessary part of treatment. O The nurse works to resolve mental issues through developing a social relationship with the patient. O The information that the patient shares is known by only one individual on the health care team.

The nurse and patient develop a helping-trust relationship. Rationale A helping-trusting relationship is a therapeutic professional relationship used by the nurse to assist the patient in learning new ways of responding to people or situations. Therapeutic communication is key in building the helping-trust relationship. Patient information is shared with other members of the team. The relationship between nurse and patient should not be social in nature, only therapeutic.

The nurse caring for a terminally ill patient sets a nursing goal that the patient will actively participate in grief work. Which action by the patient signifies the achievement of the goal? O The nurse observes that the patient makes a plan for the future. O The nurse finds that the patient progresses in the resolution of grief. O The patient informs the nurse that he or she finds "peace" in meditation. O The nurse observes that the patient is discussing loss with his or her significant other.

The nurse observes that the patient is discussing loss with his or her significant other. Rationale During the evaluation, if the nurse finds that the patient discussing loss with his or her family members, then the nursing goal is achieved. When the patient informs the nurse that he or she finds "peace" in meditation, or the patient verbalizes progress in the resolution of grief, these actions of the patient indicate the achievement of the nursing goal"Patientwil verbalizes finding meaning in life."If the nurse finds that the patient is planning for the future, that indicates the achievement of the nursing goal-"Patient will verbalize finding meaning in life.'

The nursing instructor is teaching the student nurses about caring for a patient who is undergoing a crisis and showing symptoms of anger and hostility. Which statement by the practicing nurse indicates a need for further teaching? O The nurse should provide empathic gestures, such as giving a hug to the patient." O The nurse should instruct the patient to develop assertive communication skills." O "The nurse should encourage the patient to describe the current state of anxiety. O "The nurse should advise the patient to use progressive muscle relaxation techniques

The nurse should provide empathic gestures, such as giving a hug to the patient." Rationale A crisis can be defined as an unstable period in a person's life characterized by the inability to adapt to change from a precipitating event. Providing empathic gestures, such as holding a hand or giving a hug, should not be done for a person who is angry and hostile. Assertive communication skills help the patient regain mental wellness. If a patient clearly describes the state of anxiety, it helps the nurse plan the interventions to reduce anxiety, Progressive muscle relaxation techniques enable the patient in crisis to reduce the mental, physical, and emotional stress that accompanies crisis.

During the examination, the nurse suspects that an elderly patient has presbycusis. What behavioral changes would the nurse have observed in the patient? O Irritation while the nurse takes the medical history O Needing support while standing O The patient constantly asked the nurse to speak louder. O Rubbing the eyes

The patient constantly asked the nurse to speak louder.

A registered nurse is completing a psychosocial component of the nursing care plan. What behavior, if observed, indicates the patient has successfully completed the developmental task of late adulthood? O Refusing to socialize outside of the home O Verbalizing unhappiness with family relationships O Admitting to being unhappy with life choices O The patient has accepted illness and has prepared a will.

The patient has accepted illness and has prepared a will.

The nurse is observing an elderly patient with benign prostatic hypertrophy. What finding would the nurse obtain during the observation? O Pigmented skin O The patient has impaired urinary flow. O blood in stools O yellow, discolored nails

The patient has impaired urinary flow.

Which condition in the postoperative patient will indicate that the fluid status is normal? The patient's urinary output is 30 mL/hr. The patient does not have foul-smelling urine. There is normal bowel movement in the patient The patient is able to consume large amounts of fluids.

The patient's urinary output is 30 mL/hr. Rationale A urinary output of 30 mL/hr indicates that the patient's fluid balance is normal. The absence of foul-smelling urine may indicate that the patient does not have infection. The fluid status may or may not be normal in such a patient. A normal bowel movement may indicate that there is normal kidney function in the patient but may not help indicate the fluid status. Inability to consume large amount of fluids indicates a problem in a gastrointestinal function.

A school nurse asks a group of high school-age students to write down the last time they used alcohol or other illicit substance and to describe O The student who had two glasses of wine with family members at dinner. O The student who drank three cans of beer and vomited at an after-prom party. O The student who had a "puff" of marijuana with an older brother who was home from college. O The student who removed several ounces of vodka from the parents' supply and replaced it with water.

The student who removed several ounces of vodka from the parents' supply and replaced it with water. Rationale The indicator that substance abuse has become a problem or disease appears to be loss of control-in other words, when the desire for the substance exceeds one's ability to resist, even in the face of negative consequences. The teenager who removed several ounces of vodka and replaced the liquid with water is engaging in subterfuge to acquire a substance, which is very likely to be discovered.

A patient with depression asks the nurse about possible causes of depression. Which response by the nurse would be best? O There is no hereditary factor for depression. O Most people suffer from depression from time to time. O There is an excess of the neurotransmitter norepinephrine. O There is a deficiency of the neurotransmitters norepinephrine and serotonin.

There is a deficiency of the neurotransmitters norepinephrine and serotonin. Rationale Patients with depression have lower amounts of the neurotransmitters norepinephrine and serotonin, which is why patients have usuallyprescribed serotonin or norepinephrine reuptake inhibitors such as fluoxetine (Prozac) or duloxetine (Cymbalta) Although it is true that most people experience some type of depression, it does not directly answer the patient's question. Sixty percent to 80% of cases of mood disorders have a hereditary factor. There is an excess of the neurotransmitter norepinephrine in manic individuals.

The U.S. The Department of Agriculture regularly surveys food intake.

These reports indicate that Americans consume 6.5 oz of grain products per day, on average. The Dietary Guidelines for Americans encourage people to make at least half of all grains consumed whole grains. However, the average American consumes 88% of their grain products in the form of refined grains and only 12% as whole grains. Additionally, the average American continues to consume an excess of added sugar daily.

Which statement is true regarding amphetamine-type stimulants? O They cause respiratory depression and pupillary dilation. O "They reduce the desire for alcohol by inducing nausea and vomiting. O They block the transmission of nerve impulses when applied to tissues. O They can be used to treat schizophrenia, depression, and nicotine addiction.

They can be used to treat schizophrenia, depression, and nicotine addiction. Rationale Amphetamine-type stimulants can be used to treat schizophrenia, depression, and nicotine addiction. Opioids cause respiratory depression and pupillary dilation and block the transmission of nerve impulses when applied to tissues. Disulfiram (Antabuse) reduces the desire for alcohol by inducing nausea and vomiting

Which group of psychotic disorders is characterized by severe and inappropriate emotional responses and prolonged and persistent disturbances of mood and related thought distortions? O Mood disorders O Anxiety disorders O Personality disorders O Thought process disorders

Thought process disorders Rationale Severe and inappropriate emotional responses and prolonged and persistent disturbances of mood and related thought distortions define a group of mood disorders and other symptoms associated with either depressed or manic states. Anxiety is a normal response to stress. Mood disorders are known as affective disorders. Personality disorders are inflexible maladaptive patterns of behavior or thinking that are associated with significant impairment of functioning.

Which occurrence may precipitate feelings of anxiety? O Emotional growth O Threats to self-esteem O Threats to those around us O Encouragement in physical strengths

Threats to self-esteem Rationale Loss of significant relationships, loss of a spouse, difficulty at work, or loss of job are all threats to self-esteem and influence the amount of anxiety a person has. Encouragement and emotional growth are positive to self esteem. Threats to others do not affect self-esteem..

Which type of catheter would be used to maintain continuous bladder irrigation for a patient after urinary surgery? O Coudé O Three-way O Mushroom O Winged tip

Three-way Rationale A three-way indwelling catheter is used for continuous bladder irrigation. One lumen is attached to the irrigating fluid, one to the drainage bag, and the third is for the retention balloon. The Coudé catheter is angled at the tip and used in patients with obstructions, such as enlarged prostates, A mushroom catheter is used for suprapubic catheterization. A winged-tip catheter is rarely used in practice today.

An elderly patient is feeling hopeless and depressed due to social isolation. Encouraging the patient to do which action would best help the patient overcome these feelings? O To improve decision-making skills O To do a life review, and reminisce O To perform progressive muscle relaxation O To develop assertive communication skills

To do a life review, and reminisce Rationale Reminiscence and life review are effective techniques to help older adults cope with life changing circumstances. Reminiscence is the act of recollecting past experiences or events; this helps the older adults relieve their stress and depression. Interventions such as encouraging decision-making skills, progressive muscle relaxation, and helping the patient develop assertive communication skills are common for any patient with mental illness.

When planning care for a patient taking antipsychotic drug therapy, which goal is the nurse's priority? To prevent side effects of the medication To promote adherence to the medication regimen To monitor for hallucinations To establish a consistent sleep-wake cycle

To promote adherence to the medication regimen Rationale Promoting adherence to the medication regimen is a priority goal The medication can be effective only if taken as prescribed. Nonadherence to the medication regimen is thought to be a major cause of repeat hospitalization. Preventing or controlling side effects, monitoring for hallucinations and establishing a consistent sleep-wake cycle are important for specific patients but do not treat the basic problem.

During a home visit, the nurse is assessing a toddler's toys. Which type of toys does the nurse suspect could cause harm and hurt the toddler? Select all that apply. O Toys with long strings O Toys containing balloons O Toys with detachable parts O Smooth contours O one-piece construction

Toys with long strings Toys containing balloons Toys with detachable parts

Which drugs would result in the development of serotonin syndrome when given concurrently with vilazodone? Select all that apply. Trazodone Haloperidol Linezolid St. John's wort Monoamine oxidase inhibitors

Trazodone Linezolid St. John's wort Monoamine oxidase inhibitors Rationale When trazodone is used in conjunction with vilazodone, serotonin syndrome may develop. Concurrent use of vilazodone with linezolid St. John's wort, and monoamine oxidase inhibitors may stimulate excess serotonin levels, which may also cause serotonin syndrome. Because vilazodone inhibits the metabolism of haloperidol, its dose may have to be reduced to prevent potential toxicity, but there is no risk of serotonin syndrome.

Which antidepressant medications require the nurse to monitor a patient's blood pressure in the supine, sitting, and standing positions before initiating therapy Sele all that apply. Trazodone therapy Mirtazapine therapy Monoamine oxidase inhibitor therapy Selective serotonin reuptake inhibitor therapy Serotonin-norepinephrine reuptake inhibitor therapy

Trazodone therapy Mirtazapine therapy Selective serotonin reuptake inhibitor therapy Rationale Trazodone, mirtazapine, nefazodone, and selective serotonin reuptake inhibitor therapies require the nurse to record the patient's baseline blood pressures in the supine,itting, and standing positions. For monoamine oxidase inhibitor therapy, the nurse obtains the patient's blood pressure and pulse rate before and at regular intervals after initiating the therapy. Serotonin-norepinephrine reuptake inhibitor therapy requires the nurse to obtain the patient's baseline weight and blood pressure.

Treatment for Pain

Treatment •Assessment •Medication •Distraction •Relaxation •Massage •Biofeedback •Evaluate

Which drugs are first-generation antidepressants? Select all that apply. Vortioxetine Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Serotonin-norepinephrine reuptake inhibitors

Tricyclic antidepressants Monoamine oxidase inhibitors Rationale Tricyclic antidepressants and monoamine oxidase inhibitors are first-generation antidepressants. Vortioxetine is a miscellaneous agent used to treat depression. Selective serotonin reuptake inhibitors and serotonin- norepinephrine reuptake inhibitors are second-generation antidepressants.

Which drugs increase serotonin levels in patients undergoing selective serotonin reuptake inhibitor therapy? Select all that apply. Cimetidine Tryptophan Carbamazepine Amphetamines Pseudoephedrine

Tryptophan Amphetamines Pseudoephedrine Rationale Tryptophan, amphetamines, and pseudoephedrine increase serotonin levels when used concurrently with selective serotonin reuptake inhibitors. The supervision ofa healthcare provider is required if these drugs are used together. Cimetidine inhibits the metabolism of paroxetine and sertraline. Patients undergoing cimetidine and paroxetine therapies simultaneously should be closely monitored. Concurrent use of carbamazepine and fluoxetine increases the concentration of carbamazepine, ausing toxicity.

How would the nurse describe a person who constantly seeks pleasure and keeps discomfort to a minimum? O In the state of preconsciousness O Under the leadership of the id O Under the leadership of the ego O Under the leadership of the superego

Under the leadership of the id

Which outcomes does the nurse expect while caring for a patient with a personality disorder? Select all that apply. O Reversal of tremors O Reduced risk of fall O Ventilation of feelings O Improved sleeping time O Good social interactions

Ventilation of feelings Good social interactions Rationale Personality disorders involve impaired social interactions, poor impulse control, and inability to express feelings Good social interactions indicate that the treatment has been effective. Patients with personality disorders may not be able to ventilate their feelings. Therefore the nursing outcome would include the patient's improved ability to ventilate feelings. Reversal of tremors and reduction in risk of fall is expected in the case of Parkinson's disease. patient with a personality disorder does not have a sleep disorder; this is observed in depressive patients.

Which statements regarding the antidepressant drug vortioxetine are correct? Select all that apply. Vortioxetine is an agonist of the serotonin 5-HT la receptors. Vortioxetine may result in renal failure. A patient taking vortioxetine may experience episodes of dizziness. Use of monoamine oxidase inhibitors MAOls) with vortioxetine may cause excitement, diaphoresis, rigidity, convulsions, and possible death. Vortioxetine inhibits serotonin and norepinephrine reuptake from the neuronal cleft.

Vortioxetine is an agonist ofthe serotonin 5-HT la receptors. A patient taking vortioxetine may experience episodes of dizziness. Use of monoamine oxidase inhibitors MAOls) with vortioxetine may cause excitement, diaphoresis, rigidity, convulsions, and possible death. Rationale Vortioxetine is a new medication that acts as a selective serotonin reuptake inhibitor, an agonist of the serotonin 5-HTlA receptors that enhances serotonin activity, and antagonizes the serotonin 5-HT 3 receptors. The patient can experience episodes of dizziness The nurse should provide for patient safety during these episodes. Severe reactions-including excitement, diaphoresis, rigidity, convulsions, hyperpyrexia, and death-may result from the concurrent use of MAOIs and vortioxetine. Vortioxetine does not cause renal failure. Vortioxetine does not inhibit serotonin and norepinephrine reuptake from the neuronal clef.

After assessing an infant, the nurse suggests the infant's parents to avoid giving excess water to the infant. Why did the nurse give this instruction to the infant's parents? O Decreased calcium levels O Decreased blood pressure O Edema present O Water intoxication causes poor weight gain in an infant.

Water intoxication causes poor weight gain in an infant.

A community health nurse is planning a health fair. An information booth will be included to educate the adolescent population. Which essential topics should the nurse include as part of the discussion? Select all that apply. O Financial independence O Water safety O Drug education O Accident prevention O Water safety

Water safety Drug education Accident prevention

STOMACH

Wavelike contractions of the stomach muscles continue the mechanical digestive process. This action, called peristalsis, further mixes food particles with gastric secretions to facilitate chemical digestion. The gastric secretions contain no specific enzymes for the breakdown of carbohydrates. Gastric secretions include hydrochloric acid, which inhibits the action of salivary amylase. However, before the food completely mixes with the acidic stomach secretions, up to 20% to 30% of the starch may have been changed to maltose. Muscle action continues to mix the food mass and then moves the food to the lower part of the stomach. Here, the food mass is a thick and creamy chyme, ready for its controlled emptying through the pyloric valve and into the duodenum, which is the first portion of the small intestine.

A patient is being discharged from the psychiatric unit with a prescription for an antipsychotic. Which information should the nurse educate the patient before discharge? O Take medication in the morning. O Restrict the intake of salty foods. O Undergo monthly laboratory tests. O Wear sunscreen and sunglasses when outside.

Wear sunscreen and sunglasses when outside. Rationale Antipsychotics can cause photosensitivity; patients should be instructed to wear special clothing, sunscreen, and sunglasses. Taking medication in the morning is suggested with selective serotonin reuptake inhibitors (SSRls) because of the side effects of insomnia. Restricting the intake of salty foods and undergoing monthly laboratory tests are specific to patients taking lithium.

The U.S. RDA standards

Were first published during World War II as a guide for planning and obtaining food supplies for national defense and for providing population standards as a goal for good nutrition. revised and expanded every 5 to 10 years.

A nurse is caring for a patient who is suspected of drug dependence. Which questions are the most appropriate for the nurse to ask? O Why and when did you start doing illegal drugs?" O "How long were you going to try to hide this from your friends?" O What type, how much, and what effects do the drugs have on you?" O The nurse does not ask questions about drugs for fear the patient might deny any problems.

What type, how much, and what effects do the drugs have on you?" Rationale During the assessment process, the nurse obtains subjective data that include the patient's normali patterns of use and what effects are seen. The remaining options involve casting blame or being judgmental and are insensitive toward the patient, or they avoid garnering subjective data pertinent to the concern.

Which statement by a patient indicates a need for teaching about ostomy self-care? O I must monitor my skin every time change my colostomy pouches. O The skin around the colostomy must be washed and dried carefully!" O I must change the colostomy bag immediately if I notice or feel a leak." O When applied correctly, should feel pressure from the ostomy appliance.

When applied correctly, should feel pressure from the ostomy appliance." Rationale When the skin barriers are cut to fit the stoma, the nurse ensures that the ostomy appliance opening is small enough to form a proper seal, 1/16 inch larger than the stoma, and does not cause pressure on the stoma because there is blood and nerve supply in the stoma but no sensation. An ill-fitting appliance can cause a pressure sore and lead to gangrene. If the patient is feeling pressure from the appliance, this is an indication that the appliance has been incorrectly applied

mental illness

a disorder that affects a person's thoughts, emotions, and behaviors

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? O A pink edematous hand O Red skin with edema in the nail beds O White skin that is insensitive to touch O Black fingertips surrounded by an erythematous rash

White skin that is insensitive to touch

glycogen

a polysaccharide; the main storage form of carbohydrate in the body, which is stored primarily in the liver and to a lesser extent in muscle tissue. •Storage form of carbohydrates •In the liver (12-48hrs) & muscles (1-2hrs) •Ensure brains need for constant supply of glucose •Sustain normal blood glucose even during fasting/sleeping

A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient, knowing that tremors from alcohol cessation are usually seen how long after cessation? O Within 6 hours O Within 2 to 3 weeks O Within 6 days O Within 1 week

Within 6 hours

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

Wound from repair of a perforated appendix Gunshot wound that punctured the small intestine Traumatic wound to the abdomen and intentionally left open for several days Wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect

kilocalorie

a unit of heat measure, and it is used alone to designate the small calorie the calorie that is used in nutrition science and the study of metabolism is the large Calorie or kilocalorie, which avoids the use of large numbers in calculations; a kilocalorie, which is composed of 1000 calories, is the measure of heat that is necessary to raise the temperature of 1000 g (1 L) of water by 1° C.

28. The nurse is caring for a 72-year-old patient who is being treated for a chronic ulcer on the right lower leg. The patient lives alone. He is diabetic and reports poor vision. The nurse notes that the patient has trouble with fine motor control. He reports that he does his own meal preparation, although he admits that he doesn't make the effort to prepare fresh produce. He is 15 pounds underweight and he has "cut down on his smoking." a. Identify factors that may impair wound healing for this patient.

a. Factors that impair wound healing include age, malnutrition, smoking, drugs, and diabetes mellitus. Patient's ability to care for himself is also not optimal.

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. a. How does the Good Samaritan law affect the nurse in the situation?

a. Good Samaritan laws stipulate legal protection for those who give first aid in emergency situations if they follow a reasonable and prudent course of action. Once the nurse initiates any action, there is a moral and legal obligation to continue until qualified help arrives.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. a. What factors in the scenario helped the nurse to identify that hypothermia might be occurring?

a. The weather is cool and windy. The man's clothes are wet. He is shivering, confused, and his speech is slurred. The absence of shoes suggests that he has discarded them in his confusion, and that loss of the shoes is contributing to heat loss.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. (625, 627, 628) a. What is the purpose of wound irrigation?

a. Wound irrigation is used to clean the wound and remove debris and eschar.

The nursing strategy that may be most helpful in preventing falls in elderly patients on a skilled nursing unit would be to: a.answer call bells promptly. b.use vest restraints as needed. c.keep lights dim for eye protection. d.always keep bed rails up.

a.answer call bells promptly.

alpha-linolenic

acid is an essential fatty acid with 18 carbon atoms and 3 double bonds. The first double bond is located at the third carbon from the omega end, making it an omega-3 fatty acid. Found in soybean, canola, and flaxseed oil. cholesterol a fat-related compound called a sterol that is synthesized only in animal tissues; a normal constituent of bile and a principal constituent of gallstones; in the body, cholesterol is primarily synthesized in the liver, in the diet, cholesterol is found in animal food sources.

linoleic acid

an essential fatty acid that consists of 18 carbon atoms and 2 double bonds. The first double bond is located at the sixth carbon from the omega end, making it an omega-6 fatty acid. Found in vegetable oils.

Regarding Cataracs, the most important point is that they: O Albert and or symptoms of other medical conditions O block some of the light I did not cause blindness O are a normal part of aging most older people have cataracts in both eyes O occurs in both eyes and the patient deteriorate at the same rate

are a normal part of aging most older people have cataracts in both eyes

An appropriate strategy when teaching geriatric adults is to: O Ego integrity Use many videos and charts to keep their interests O Ego integrity Present all the material in one long session rather than two short ones O Ego integrity speed up the presentation because of short attention span O Ego integrity ask them to repeat what they heard because of possible hearing deficits

ask them to repeat what they heard because of possible hearing deficits

tinea pedis

athlete's foot keep the feet dry

1. The period of infancy occurs between: a. birth and 1 month. b. 4 weeks and 1 year. c. 1 and 3 years. d. 1 and 12 years.

b. 4 weeks and 1 year.

1. Middle childhood includes children between the ages of: a. 3 and 5 years. b. 6 and 12 years. C. 13 and 15 years. d. 16 and 19 years.

b. 6 and 12 years.

3. Separation anxiety typically begins at what age? a. 3 months b. 6 months c. 1 year d. 2 years

b. 6 months

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. b. What equipment is needed for irrigation at the patient's bedside?

b. Equipment needed: 35-mL syringe, 19-gauge catheter, sterile solution, basin and/or linen protectors and a clean towel.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. b. What are the signs and symptoms of hypothermia?

b. Hypothermia is demonstrated by uncontrollable shivering; low body temperature; slow, slurred speech; disorientation; and uncoordinated or decreased muscle movement. The skin may appear mottled and edematous, with general numbness. Pulse is weak and irregular, with depressed respiratory rate. The victim becomes more lethargic, with decreasing level of consciousness, until reflexes are also lost.

28. The nurse is caring for a 72-year-old patient who is being treated for a chronic ulcer on the right lower leg. The patient lives alone. He is diabetic and reports poor vision. The nurse notes that the patient has trouble with fine motor control. He reports that he does his own meal preparation, although he admits that he doesn't make the effort to prepare fresh produce. He is 15 pounds underweight and he has "cut down on his smoking." b. Discuss how the nurse applies knowledge about older adults to help this patient achieve wound healing.

b. The nurse would assess his ability to perform self-care, to reach the wound, and to manipulate the wound dressings. He has trouble with his vision, so the nurse would adapt the teaching (e.g., using color-coding of dressing materials). The nurse will increase time allowed for the skills and repetition of teaching and give small amounts of information at a time. This patient will have a decrease in sensory receptors and a decrease in pain sensation; therefore, he will need to have someone to help him visually inspect the wound on a routine basis. The nurse should ask the patient about his resources and arrange for home health if necessary. This patient needs assistance to increase fluid intake and nutrition. Social services could be contacted about having meals delivered to his house.

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. b. What actions should the nurse take first to help this victim?

b. Use simple language and remain calm. Direct a bystander to call 911. Ask the woman for permission to help her and tell her to remain in a supine position. Identify the source of bleeding and apply direct pressure (use the cleanest material available). Once bleeding is controlled continue observations of skin color, temperature, pupil reaction, and neuromuscular status.

3. The type of play activities typical in the middle-childhood age group include: a. parallel play. b. competitive games. c. solitary play. d. reading and fantasy.

b. competitive games.

4. By 9 months of age, a pincer action is well developed, enabling the infant to: a. increase locomotion. b. grasp small objects with the thumb and forefinger. c. scoop up toys within reach. d. achieve increased depth perception.

b. grasp small objects with the thumb and forefinger.

2. The definition of puberty is: a. exhibiting secondary sex characteristics. b. having the ability to reproduce. c. the decrease of gonadotropic hormones. d. becoming fertile.

b. having the ability to reproduce.

3. The preschool-age child, between 4 and 6 years of age, is in Erikson's stage of: a. trust versus mistrust. b. initiative versus guilt. c. autonomy versus shame and doubt. d. identity versus role confusion.

b. initiative versus guilt.

4. The Wechsler intelligence test is used to determine: a. the overall intelligence of the child. b. verbal and nonverbal intelligence. c. presence of mental retardation. d. whether the child has college potential.

b. verbal and nonverbal intelligence.

for the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today the patient tearfully refused to dress or get out of bed. The nurse recognizes these behaviors as evidence of which psychiatric disorder? O Ego integrity unibipolar depression O Ego integrity dysthymic disorder O Ego integrity hypomanic episode O Ego integrity bipolar disorder

bipolar disorder

Vitamin K:

blood clotting & bone development required intestinal antidote for warfarin Food Source: green leafy vegetables, cauliflower, cabbage Anything leafy green Deficiency: 2nd deficiency w/ severe malabsorption or abx that kills intestinal bacteria. Given to babies don't have intestinal bacteria

Phosphorus:

bone formation, acid-base balance, inverse relation to calcium (one is high the other is low), Ph balance 7.35-7.45, phosphorus will be elevated with patients with kidney failure Food Source: dairy, fish, organ meats, nuts, pork, beef, chicken, whole grains, cereals Deficiency: < deep tendon reflex, bone pain Toxicity: muscle weakness, +Chovostek's or Trousseaus sig

There are five general types of open wounds

brasions punctures incisions lacerations avulsions

nonthermal burns

burns resulting from electricity, chemicals, and radiation.

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a wom-an who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. c. What assessments would lead the nurse to believe the victim is in shock?

c. A victim in shock may have a change in the level of consciousness, skin temperature and color changes, decreased blood pressure, increased pulse rate and respirations, diminished urinary output, muscle weakness or tremors, pupil dilation, nausea, and vomiting.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. c. For the conscious victim with hypothermia, what interventions can be provided at the scene?

c. Victim should be moved to a warm environment if possible and wet clothes should be removed and the victim should be covered with warm blankets. For a conscious victim, warm nonalcoholic fluids should be provided. The victim needs medical help as soon as possible.

5. Middle childhood includes Erikson's stage of: a. trust. b. autonomy. c. industry. d. identity.

c. industry.

5. By 1 year of age, the normal infant should weigh approximately: a. twice the birth weight. b. quadruple the birth weight. c. triple the birth weight. d. 30 pounds.

c. triple the birth weight.

Bleeding from a wound may occur through one or more of the following three sources

capillaries, veins, and arteries most common sites of arterial bleeding • Brachial (in the medial aspect of the upper arm) • Carotid (on either side of the neck) • Femoral (in the upper thigh and groin) • Radial (in the medial aspect of the lower arm)

Middle childhood

children between the ages of 6 and 12. In the school-age child, the body develops a lower center of gravity than it had in preschool years. The loss of primary teeth begins at about age 6, and approximately four permanent teeth erupt each year. Regular dental checkups are an important part of routine health care. • Visual maturity is complete between preschool age and 6 years, and therefore large-print books are no longer necessary at this time. • Excessive time spent with computers and video games can contribute to a sedentary lifestyle, which may result in obesity, poor health, and poor social development. • By ages 9 and 10, an understanding of rules and teamwork enables the child to participate in competitive team games. • School-age children, according to Piaget, are concrete thinkers, and hands-on learning is retained best. School-age children often tell jokes to entertain peers and to tease elders. School-age children are less egocentric than they were at earlier ages, and they can understand how their actions affect others. • Moral behavior is based on logical understanding and feeling pride or guilt as a result of the behavior. Knowing a rule is right does not guarantee behavior according to that rule.

An older adult is having difficulty swallowing what position should the nurse recommend aiding in swallowing? O chin parallel O chin upward O chin downward O chin to the side

chin downward

Serous

clear, watery plasma

paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

Vitamin C (Ascorbic Acid):

connective tissue, antioxidant protects from free radicals Food Source: strawberries, citrus, tomatoes, broccoli, cabbage, helps with the formation of collagen Deficiency: Scurvy (easy bruising, pinpoint skin hemorrhages, poor wound healing, bleeding gums), depleted by smoking ( vasoconstrictors the blood vessels which slows down healing) Toxicity: GI disturbances

Vitamin B3 (Niacin):

convert glucose to energy Food Source: meat, poultry fish, whole grains, cereals, peanuts Deficiency: Pellagra, weakness, poor appetite, found in alcoholics, four D's Patient teaching: your urine will turn bright yellow Toxicity: skin flushing, burning/tingling

Which nursing intervention is a priority for a client with delirium? O providing a body massage O arranging for music therapy O creating a calm and safe environment

creating a calm and safe environment

The RD and RDN (registered dietitian nutritionist)

credentials are legally protected titles that may only be used by authorized practitioners and by the CDR. The term nutritionist alone is not a legally protected title in most states and may be used by virtually anyone. See www.eatright.org for more details.

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. d. What interventions are appropriate for a victim in shock at the scene of an accident?

d. Appropriate interventions for this victim in shock include: control bleeding, maintain airway, maintain supine body position, and avoid hyperextension of the neck to protect against potential neck or spine injuries. Cover the patient. Do not allow anyone to administer food or fluids. Give emotional support.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. d. What is the direction of cleansing?

d. Direction of cleansing is from least to most contaminated.

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

The older patient informs the nurse that food has no taste and therefore the patient has no appetite. What is this most likely caused by? a.Tasteless food b.Overuse of salt c.Lack of variety d.decrease saliva production

decrease saliva production

A young man with malaria spikes a temperature of 105°F and begins to hallucinate how should the nurse assess this? O delirium O psychotic break O possible stroke O anxiety disorder

delirium

A patient's spouse died one year earlier complains of feeling overwhelming loneliness and has withdrawn from interpersonal interactions the patient is demonstrating what stage of dying according to Kubler Ross stages of dying. O Anger O denial O depression O bargaining

denial

Dietary fiber

divided into two groups on the basis of solubility. Cellulose, lignin, and most hemicelluloses are not soluble in water. The rest of the dietary fibers (ie, most pectins, B-glucans, gums, mucilages) are water soluble. These two classes of dietary fiber are listed in Table 2-2. The looser physical structure and greater water-holding capacity of gums, mucilages, pectins, and algal polysaccharides partly account for their greater water solubility. Recommendations for specific types of fiber to consume often are based on the water-solubility distinction.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. e. What findings should be immediately reported to the provider?

e. Report evidence of fresh bleeding, sharp increase in pain, retention of irrigant, or signs of shock.

Vitamin B1 (Thiamin):

enable the body to use CHO as energy (GI, Nervous & Cardiac) Important to transform from food to energy (glucose to energy), given to alcoholics Food Source: pork, nuts, wholegrain, cereals, legumes Deficiency: beriberi , poor appetite, found in alcoholics, constipation, symptoms of confusion

pincer action

enables the infant to grasp with the thumb and finger 9 months

Fat

fats should provide about 20% to 35% of the total kilocalories. two thirds of this amount should be from plant sources monounsaturated and polyunsaturated fats no more than 10% of kilocalories should come from saturated fat Provides a feeling of fullness & satisfaction •Enhance absorption of fat-soluble vitamins •Vitamin A D E K

Teeth in the infant

first 20 decidious teeth (baby teeth) begin at 5 to 7 months

Deep Partial-Thickness Burns

first layer of skin (epidermis), as well as some of the underlying tissue (dermis); scarring from vesicles and infection is possible. Common causes of second-degree burns are severe sunburn, scalding liquids, direct flame, and chemical substances. Healing may take 5 to 21 days.

Severe blunt trauma can result in________________?

flail chest (two or more ribs fractured in two or more places, resulting in instability in part of the chest wall) with associated hemothorax, pneumothorax, and pulmonary contusion

Iron:

functional part of hemoglobin Food Source: liver, meats, egg yolk, whole grains, dark green leafy, enriched grain, legumes Deficiency: anemia (check lab values hemoglobin) Toxicity: most common side effect of constipation, turns tool black or green

overflow incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder

The preventive health care approach:

involves identifying risk factors in advance that increase a person's chances of developing a particular health problem.

A nurse is assessing a patient and trying to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. O Labile mood O irelevant speech O Hallucinations and illusions O Slow deterioration in cognition O Fluctuating levels of consciousness

irrelevant speech Hallucinations and illusions Fluctuating levels of consciousness Rationale Delirium is a transient cognitive disorder that can cause sparse or rapid speech that may be slurred or incoherent. Hallucinations and illusions may occur with delirium because of altered mental status. Patients with delirium go from hyperalertness to being difficult to arouse. Labile mood is associated with dementia. Dementia causes slow deterioration in cognitive function over years; the onset of delirium is abrupt.

Superficial spreading melanoma

lower extremities, back

A nurse is assessing a patient and trying to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. O Labile mood O irrelevant speech O Hallucinations and illusions O Slow deterioration in cognition O Fluctuating levels of consciousness

irrelevant speech Hallucinations and illusions Fluctuating levels of consciousness Rationale Delirium is a transient cognitive disorder that can cause sparse or rapid speech that may be slurred or incoherent. Hallucinations and illusions may occur with delirium because of altered mental status. Patients with delirium go from hyperalertness to being difficult to arouse. Labile mood is associated with dementia. Dementia causes slow deterioration in cognitive function over years; the onset of delirium is abrupt.

How is a durable power of attorney helpful to an incapacitated patient O It directs treatment in accordance with the patient's wishes O it directs an agent to make health care decisions O it gives power to an agent to make decisions regarding health, property and other assets O it can only be executed by an attorney

it directs an angent to make health care decisions

The parents ask the nurse why their alcohol-addicted adolescent has prescribed disulfiram (Antabuse) during the rehabilitation phase. Which is the best response by the nurse? O "It will have a calming effect. O It will help increase appetite." O "It will prevent the risk for seizure activity" O it will encourage abstinence from alcohol consumption."

it will encourage abstinence from alcohol consumption." Rationale If the patient consumes alcohol during treatment with disulfiram (Antabuse), there is facial flushing, nausea, tachycardia, dyspnea, dizziness, and confusion. The patient is encouraged to abstain from alcohol consumption. Disulfiram (Antabuse) does not have a calming effect on the patient but causes distress if alcohol is consumed. Multivitamins and thiamine (Vitamin B) are used to increase the patient's appetite. Phenytoin (Dilantin) is an anticonvulsant medication used to treat seizures in an addicted patient.

The nurse recognizes that an older adult patient with COPD has a higher incidence of developing which age-related skills to change that will alter the ability to exchange our effectively O Osteoporosis O arthritis O kyphosis O osteomyelitis

kyphosis- excessive outward curvature of the spine, causing hunching of the back.

incomplete proteins

lack one or more essential amino acids Found in grains, legumes, nuts, and seeds, edamame, spinach, broccoli, legumes, nuts

lacto-vegetarian diet

lacto-vegetarians eat milk, cheese, and dairy foods, but avoid meat, fish, poultry, and eggs

complex carbohydrates

large complex molecules of carbohydrates composed of many sugar units (polysaccharides); the complex forms of dietary carbohydrates are starch and dietary fiber.

A client has been in an acute care psychiatric unit for three days and is receiving help or down tablets or lead to reduce agitation and preoccupation with auditory hallucinations there has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started What nursing action should be the priority intervention? O Asking the healthcare provider to change the medication O making certain that the client is following the medication O concluding that a therapeutic level of the drug has not been achieved O Prescription for asking me that sedation until the client calms down

making certain that the client is following the medication

basal cell carcinoma

malignant tumor of the basal cell layer of the epidermis

Potassium:

muscle action (affects the heart), insulin D50 if they have levels of potassium (do not have to be diabetic) release Food Source: avocados, bananas, cantaloupe, orange, strawberries, tomatoes, carrots, spinach, fish, port, beef, potatoes Deficiency: anorexia, leg cramps, and distention 3.5-5 Normal level Toxicity: muscle vomiting, irregular HR, palpitation, cardiac dysrhythmia

Post-Op Assessment Priorities

•Vital signs •Assess for bleeding •Assess for pain, nausea, and discomforts •Bowel sounds •Gag reflex •Safety interventions •IV fluids •Drainage & Dressing •Foley or assess for bladder distention •Documentation •Physician's orders

a nurse is performing patient teaching for a patient who has urolithiasis. this patient has been determined to be a "calcium stone former." on which current research recommendation will the nurse base the answer to the patient's dietary questions? o restriction of fluid o restriction of calcium o restricted animal protein O sodium chloride supplementation

o restricted animal protein rationale the newer research on the impact of diet on the development of calcium oxalate kidney stones suggests that restricted consumption of animal protein and salt in combination with normal calcium intake better reduces the risk of kidney stones compared with the traditional low-calcium diet. fluids are encouraged for the patient with kidney stones. restriction of fluid can lead to increased alkalinity of urine and the development of more kidney stones. sodium chloride, or salt, supplementation would not be advisable for this patient

A client had just awakened from their first electroconvulsive therapy treatment which initial intervention by the nurse is most appropriate O Immediately get the client out of bed and back into the unit routine O Set the client up and arrange for the dietary staff to deliver a lunch tray O orient the client to the time and place and explain that the treatment is over O take the clients pulse and blood pressure every 15 minutes until the client is falling awake

orient the client to the time and place and explain that the treatment is over

The MyPlate food guidance system released in June 2011 by the U.S. Department of Agriculture

provides the public with a valuable nutrition education tool. promote variety, proportionality, moderation, gradual improvements, and physical activity. worksheets, resources, and individualized tools such as the Food Tracker, Physical Activity Tracker, and Weight Manager.

The Dietary Reference Intakes

recommend that 45% to 65% of total kilocalories consumed come from carbohydrates, with a greater portion of that intake coming from complex carbohy drates. For countries in which starch is the staple food, carbohydrates make up an even higher proportion of the diet. The major food sources of starch (Figure 2-2) include grains in the form of cereal, pasta, crackers, bread, and other baked goods; legumes in the form of beans and peas; potatoes, rice, corn, and bulgur; and other vegetables, especially of the root variety. The term whole grain is used for food products such as flours, breads, or cereals that are produced from unrefined grain.

Acids and bases:

refers to hydrogen ion concentration, pH of 7 is neutral • Acid: compound has more hydrogen ions, can release extra hydrogen ions when in solution • Base: compound with fewer hydrogen ions, can accept hydrogen ions when in solution

Palliative

relieving or soothing the symptoms of a disease or disorder without effecting a cure

An 83-year-old senior in a nursing home spends a great deal of time telling stories about past accomplishments and life experiences. The health-care worker recognizes that: O Ego integrity reminiscing about positive life experiences is therapeutic and helps bring a feeling of achievement and satisfaction to the elder adult. O Ego integrity This may be early senility as the elder cannot remember from one to next what stones have been told O Ego integrity this storytelling needs to be curtailed to allow others to participate O Ego integrity the reminiscences should not be encouraged to prevent feelings of bitterness or anxiety

reminiscing about positive life experiences is therapeutic and helps bring a feeling of achievement and satisfaction to the elder adult.

debridement

removal of foreign material and dead or damaged tissue from a wound

The following are possible indications of poisonings

respiratory distress; pulmonary edema; bronchospasm; severe nausea, vomiting, or diarrhea; seizures, twitching, or paralysis; decreased level of consciousness or unconsciousness; restlessness, delirium, agitation, or panic; color changes; pale, flushed, or cyanotic skin; signs of burns or edema around the mouth or other areas of the body; pain, tenderness, or cramps on swallowing; characteristic odor on the breath; unusual urine color (red, green, bright yellow, black, bronze); slow, labored breathing or wheezing; abnormal constriction or dilation of pupils; abnormal eye movements, such as nystagmus (constant, involuntary, cyclic movement of the eyeball); skin irritation, erythema, or edema; and shock or cardiac arrest.

nasogastric tube gastric gavage

single lumen

anastomosis

surgical joining of two ducts, vessels, or bowel segments to allow flow from one to another

brush border

the cells that are located on the microvilli within the lining of the intestinal tract; the microvilli are tiny hair-like projections that protrude from the mucosal cells that help to increase surface area for the digestion and absorption of nutrients.

glycerides

the chemical group name for fats: fats are formed from a glycerol base with one, two, or three fatty acids attached to make monoglycerides diglycerides, and triglycerides, respectively: glycerides are the principal constituents of adipose tissue, and they are found in animal and vegetable fats and oils.

saccharide

the chemical name for sugar molecules; may occur as single molecules in monosaccharides (glucose, fructose, galactose), two molecules in disaccharides (sucrose, lactose, maltose), or multiple molecules in polysaccharides (starch, dietary fiber, glycogen).

mixed incontinence

the combination of stress incontinence and urge incontinence

Iodine:

the healthy thyroid gland, component of thyroid hormone (Thyroxine T4) Food Source: iodized salt, seafood Deficiency: goiter (enlarger thyroid gland) can lead to hypothyroidism

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

Osteoporosis is O the loss of bone mass O the occurrence of bone fracture O the development of mental confusion O an inevitable part of the aging process

the loss of bone mass

portal an entrance or gateway

the portal blood circulation designates the entry of blood vessels from the intestines into the liver; it carries nutrients for liver metabolism, and it then drains into the body's main systemic circulation to deliver metabolic products to body cells,

fecal impaction

the prolonged retention and buildup of feces in the rectum

ablation

the removal of a body part or the destruction of its function

metabolism

the sum of all chemical changes that take place in the body by which it maintains itself and produces energy for its functioning; products of the various reactions are called metabolites.

Autograft

transplantation of healthy tissue from one site to another site in the same individual

Medical Management Burns

• Stop, drop & roll • Do not apply ice to the burns - cause vasoconstriction - increasing depth of burn • Rinse the chemical burn • Electrical burn has an entry point & exit point • Most electrical burns result in cardiac arrest - begin cardiopulmonary resuscitation & cardiac monitoring

Risk Factors for Pressure Ulcer Development

•Being elderly (thinner and less elastic) •Being emaciated or malnourished •Being incontinent of bowel or bladder (moisture leading to maceration (softened)) •Being immobile •Having impaired circulation or chronic metabolic conditions

Signs of Good Nutrition

well developed body the ideal weight for height and body composition (i.e., the ratio of muscle mass to fat mass) good muscle development. smooth and clear the hair is glossy, eyes are clear and bright.

Bulimia Nervosa

•Binging & purging syndrome •Diet, vomiting, enemas, cathartics, amphetamines or diuretics •Normal weight range •Asses for dehydration •Low self-esteem & mood swings •Poor interpersonal relationships

T-Tube Drain

• Drain by gravity until edema subsides • Empty when full • Protect skin from bile drainage • Stool is brown when patent

Musculoskeletal System

• Early ambulation Physical therapy, Premedicate- CNS depressant • Restrictions • Low-Fowler for chest expansion • Turning Q2 hours • Neurovascular assessment Numbness and tingling, strength, cap refill, skin color, temperature

Nursing Responsibilities for Drain Care

• Empty drain q8hrs or when they become ½ or 2/3 full • Compress for suction • Monitor for bleeding • Report significant increase in the amount and presence of purulent drainage to the MD immediately • Prevent dislodging the tube

Early childhood pt 2

• According to Freud, a conscience begins to develop in the preschool phase, and children begin then to understand how their behavior affects others. • Age-appropriate, daily, moderate and vigorous physical activities are important to maintain the health of children. Children should be kept well hydrated by offering water before, during, and after exercise. Sports-appropriate protective equipment should be worn by children to prevent injuries. • Play is an important part of a child's life. Appropriate toys can promote growth and development. Twenty primary teeth erupt by age 2. Half the adult height is reached by age 2, and the birth weight quadruples as well. The preschool child can more easily learn more than one language when the different languages are used in the home. Language milestones can be used to assess the child's development. • In a preschool child, the number or words in a typical sentence is equal to the child's age in years. A preschool child learns socially acceptable behavior by positive reinforcement. Time-outs should last 1 minute per year of age. A 2-year-old exhibits parallel play, whereas a 3-year-old engages in cooperative play with groups using a high level of imagination. • Parents who hold, hug, and rock their children can influence the ability of the child to establish intimate relationships later in life. • Accident prevention techniques should be discussed with parents. An active immunization program schedule starts at 2 months and continues through the preschool years. Many communicable diseases in childhood can be prevented through immunization.

Signs and Symptoms of Hypoxia

• Apprehension, anxiety, restlessness • Behavioral changes • Cardiac dysrhythmias • Cyanosis • Decreased ability to concentrate • Decreased level of consciousness • Digital clubbing (with chronic hypoxia) • Dyspnea • Elevated blood pressure • Increased fatigue • Increased pulse rate: As hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation • Increased rate and depth of respiration: As hypoxia progresses, respirations become shallow and slower, and apnea develops • Pallor • Vertigo

Nursing Process for the Patient with an Integumentary Disorder

• Assessment • Diagnosis • Ineffective airwal clearance • Deficient fluid volume • Impaired skin integrity • Decreased cardiac output • Risk for aspiration • Impaired swallowing • Impaired verbal communication • Disturbed sleep pattern • Anxiety • Pain • Deficient knowledge • Risk for infection

Healthy People 2020 Overarching Goals:

• Attain high quality, longer lives free of preventable disease, disability, injury, and premature death • Achieve health equity, eliminate disparities, and improve the health of all groups • Create social and physical environments that promote good health for all • Promote quality of life, healthy development and healthy behaviors across all life stages

Rehabilitation phase

• Begins at admission • Goal is to promote independence • Addresses both social and physical skills & may take years • Physical therapy for positioning, skincare, exercise, ambulation & ADLs • Set realistic short term goal • Encourage patient to talk about fears and concerns • Assess family interactions • Helping family cope

Compulsive Eating

• Binge-like overeating w/o purging • Eating relieves tension but does not produce pleasure • Feels helpless & hopeless about weight • Guilts, anger, depression, boredom, loneliness, inadequacy & ambivalence by eating

Medical conditions that increase the risk of surgery

• Bleeding disorders (ex: thrombocytopenia) • DM • Coverage? • Chronic pain • Heart disease (Ex: MI, dysrhythmia, CHF PVD) • Obstructive sleep apnea • URI • Liver disease • Fever • Chronic respiratory disease (Ex: emphysema, bronchitis, asthma) • Immunologic D/O (Ex: leukemia, AIDS, bone marrow depression, chemotherapy) • Abuse of street drugs • Tolerance

Complication of Wound Healing Stat Nursing Response

• Call for help • Stay w/ patient • Low-fowler w/ knee bent • Notify physician immediately • Request sterile normal saline dressing & keep the dressing moist • Monitor VS • Prepare for surgery

Discharge from surgery

• Care for the incision • Cover w/ plastic if showering • Follow-up visits • Sutures removed 7-10 days • Medications • Nutrition & drink 6-8 glasses of liquid a day • Activity level • Avoid lifting 6 weeks on major surgeries • Return to work 6-8weeks • Signs/symptoms of complications • When to call the 911

Wet to Moist Dressings

• Change frequently, to prevent from drying out • Favored for wound healing • Preserve fragile granulating tissue

Cardiovascular System

• Check pulse & rhythm • Monitor circulatory: skin color, peripheral pulses, capillary refill & absence of edema, numbness or tingling • Monitor for bleeding • Monitor dysrhythmias • Monitor for signs of thrombophlebitis • Encourage the use of anti embolism stockings or SCD.

several types of common fractures

• Closed fracture: The skin overlying the injury is intact. • Open or compound fractures: An open wound exists over the fracture site. Often the affected bone is visible as it protrudes through the skin. • Comminuted fracture: The bone is shattered into two or more fragments or pieces. • Spiral fracture: Results from a twisting force. • Impacted fracture: Results from trauma that causes the bone ends to jam together. • Greenstick fracture: An incomplete break, occurring most commonly in children because their bones are more pliable. • Compressed fracture: To the vertebrae as the result of pressure. • Depression fracture: Results from blunt trauma to a flat bone, causing an indentation in the bone. • Displaced fracture: Fracture in which the ends of the bones are not in alignment with each other. • Oblique fracture: Break runs diagonally across the bone, at approximately a 45-degree angle to the shaft of the bone.

Jackson-Pratt & Hemovac

• Compress to maintain suction • Empty when 1/2 full

burns 3

• Fluid shift back to the vascular compartment in approximately 48-72 hours (beginning of the diuretic stage) • Risk for fluid overload • Monitor VS, urinary output & LOC • May experience smoke inhalation (damage the cilia & mucosa) • Atelectasis may occur • Signs of respiratory distress (inhalation injury): hoarse voice, productive cough, agitation, tachypnea, flaring nostrils, intercostal retractions, brassy cough, grunting, guttural respiratory sounds, sooty sputum

Abductor/Splint/Pillow

• Foam pillow placed between the legs of patients • Hip replacement • Keeps hips abducted • Remove during skin care & physical therapy

Types of Drains

• Hemovac: Active drain uses suction • Jackson-Pratt: Active drain uses suction • T-tube: drain uses gravity • Protect skin from drainage • Empty q8-12hrs • Monitor stool • Penrose: Open drain; not commonly used because can provide pathway for pathogens

Role of the Nurse in Perioperative Nursing

• Identification bracelet • Allergies • NPO status @ least 8 hours: Due to risk of aspiration, no cough reflex • Review checklist • Informed consents • Operative procedure Anesthesia • Blood transfusions? • Laboratory test/radiological tests • EKG • Pregnancy screening • Cardiology clearance. H & P • Remove the client's jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses as appropriate. - Document • Vitals signs • Preoperative medications given • Antibiotics • Last voided

middle childhood pt 2

• In later childhood, the 10-year-old may enjoy creating new rules or changing the rules of a game. • Kohlberg believed that moral reasoning develops as cognitive skills mature. A school-age child may have a maximum attention span of 45 minutes. School-age children use language as an effective communication tool in relationships with others. • Intelligence tests were designed for use in predicting scholastic ability and future performance. • The primary developmental task of the school-age child is to attain a sense of industry by mastering skills and achieving goals. • Belonging to a peer group is very important to a school-age child. • The home, school, and neighborhood each affect the growth and development of school-age children. • Creativity should be encouraged because it helps develop problem-solving skills. • Information concerning sexuality should be age-appropriate, culturally relevant, and treated as a healthy aspect of life. • Discipline should be used for teaching and reinforcing good behavior, which plays an important role in social and emotional development. • Strength, endurance, and coordination can be nurtured by daily physical activity. Physical activity can also decrease risk factors for illness in later life. The major health-teaching needs of the school-age child include prevention of injury; maintenance of adequate nutrition; providing regular dental care; screening for scoliosis, vision, and hearing problems; and developing an active lifestyle.

Anesthesia

• Local Anesthesia (Ex: tooth removal) • Regional Anesthesia (Ex: cesarian delivery) • Conscious (Moderate) • Sedation (Ex: colonoscopy) • General Anesthesia (Ex: appendectomy, amputation)

Plasma proteins

• Mainly albumin and globulin • Organic compounds of large molecular size • Retained in blood vessels • Control water movement • Colloids guard blood volume (colloidal osmotic pressure) Copyright ©

Wet to Dry Dressing

• May help to debride the wound, Ex: necrotic tissue in the wound sticks to the dry gauze • However it is easy to damage granulation tissue w/ this method Change less frequently because you want some of the debris, slough will stick to the dressing

Conscious Sedation

• Medication has reduced the patient's sensation • Allows the patient to be relaxed and in twilight sleep • Able to maintain his or her own airway • Able to respond purposefully • Advantages: patient comfort, less risk & ability to wake the patient Used for colonoscopy

Chemical buffer system

• Mixture of acid and base that protects a solution from wide variations in pH • Main buffer system: carbonic acid(H2CO3)/base bicarbonate(NaHCO3)

Respiratory System

• Monitor VS • Rate 10-30, depth & quality of respirations • Auscultate lungs: atelectasis? • Monitor airway patency • Monitor secretions: the ability to cough? TCDB • Observe chest for symmetry & the use of accessory muscles • Monitor oxygen administration • Encourage TCDB & IS • No shallow breathing can increase the risk for pneumonia

Nursing Process for the Patient with an Integumentary Disorder 2

• Outcome and goals • Implementation • Prevent skin problems • Provide education • Provide safety tips • Evaluation • Determine if outcomes were met

Body Water Functions

• Particles and electrolytes in water determine all internal shifts & balances between compartments • Extracellular vs intracellular • Sodium, Chloride, Potassium, Bicarbonate & protein

Electrolyte

• Play a major role in osmolality, Water regulation, acid-base balance, enzyme reactions & neuromuscular activity • All must be consumed from diet

Burns Nursing Interventions

• Prioritizing nursing care using ABCs • Respiratory pattern • High protein & high calorie • Vital signs • Circulation • Intake & output • Ambulation • Bowel sounds • Inspection of wound • Mental status

Emergent phase Burns

• Priority is airway. • Suspect inhalation injury • Establish airway • Begin fluid resuscitation • Insert a Foley catheter • Insert an NG tube • Treat pain • Monitor vital signs • Provide immunization (Tetanus) prophylaxis as needed

Signs of Wound Infection

• Redness • Warmth • Swelling • Purulent drainage • Unpleasant smell • Pain around wound • Fever above 100°F

Foley catheter

• Remove when it's not medically necessary • S/S: urgency, frequency, hesitancy, burning sensation, bladder spasms, back pain & nocturia Intervention • >fluid intake 1.5-2L unless contraindicated • Cleanse 1st 6 inches with soap & water shift • Assess for urinary retention once the catheter is removed/unable to urinate • After should void w/in 6-8 hours, contact if pt has not voided • Bladder scan (PVR)

Burns 2

• The greatest fluid loss occurs w/in the first 12 hours. • Capillary hyperpermeability that lasts 24 hours - resulting in edema & vesiculation (blistering) • Proteins, plasma & electrolytes shift from the vascular to the interstitial compartment (third spacing) • Greatest threat to life because cell become dehydrated (hypovolemic shock & ARF may occur) • RBC remain in the vascular system causing falsely elevated hematocrit levels. • Acute dehydration is present & renal perfusion is seriously compromised. • May lead to burn shock • The rapid loss of fluid places a strain on the heart - low perfusion to the vital organs (refer to a burn center) At-risk the first 48 hours

CPR, it should not be discontinued except for the following reasons

• The victim recovers. • An automated external defibrillator (AED) is available and CPR is discontinued before the equipment is applied. • The scene becomes unsafe and evacuation of the victim is necessary. • The rescuer is exhausted and is not able to continue CPR. • Trained medical personnel arrive on the scene and take over CPR. • A licensed health care provider arrives on the scene, has the authority to pronounce the victim dead, and orders CPR to be discontinued.

Incentive Spirometer (helps prevent atelectisis and pnuemonia)

• Upright position • Mouth around the mouthpiece • Inhale slowly • Hold breath for 5 seconds then exhale through pursed lips • Repeat 10x/Q hour • Cough deeply after Turn Cough & Deep Breath • Upright position • Breath deep 3x by inhaling through the nostrils and exhaling slowly through pursed lips • 3rd breath hold 3 seconds, then cough deeply 3xx Splint abdomen • Perform Q1-2 hours -check meter to ensure the patients are performing exercise correctly.

Special Senses

•< Visual acuity •< accommodation in the yes, w/ requires > time for adjustment to changes in light •< peripheral vision & > sensitivity to glares •Presbyopia- farsightedness caused by loss of elasticity of the lens of the eye & cataract formation •Presbycusis- Age-related hearing loss •< sense of smell

Renal

•< kidney size, function, & ability to concentrate urine •< glomerular filtration rate •< capacity of the bladder •> residual urine, > incidence of infection & possibly incontinence •Impaired medication excretion

Gastrointestinal

•< need for calories •< appetite, thirst & oral intake •< lean body mass•<stomach-emptying time •> tendency toward constipation •> susceptibility to dehydration •Tooth loss•< saliva production •Slowing of peristalsis •Difficulty w/ chewing & swallowing food

Endocrine

•< secretion of hormones, with specific changes related to each hormone function •< metabolic rate •< glucose tolerance, with resistance to insulin in the peripheral tissues.

Respiratory

•< stretch &compliance of the chest wall •< respiratory muscle strength •<size & # of alveoli •Respiratory rate usually unchanged •< depth of respirations & O2 intake •< ability to cough & expectorate sputum

Ageism

•A form of discrimination & prejudice against the older adult •Society must relinquish old stereotypes & learn to affirm the positive aspects of aging

Substance Abuse

•A pattern of repeated use of the substance •Result in tolerance, withdrawal symptoms, compulsive behavior •Michigan Alcohol Screening Test (MAST) •Drug Abuse Screening Test (DAST) •CAGE Screening questionnaire

Impetigo Contagiosa Interventions

•Abx (erythromycin & cephalosporin) •Topical abx(Bactroban) •Antiseptic soaps to remove crusted exudate •Primary goal is to prevent glomerulonephritis •Preventing the spread of disease

Developmental Tasks of Late Adulthood

•Accepts own life •Recognize accomplishments •Finds satisfaction with new roles, relationships, and leisure time. •Maximizes independence and maintains a high level of involvement •Accepts own mortality and prepares for death

Cellulitis Interventions

•Administer antibiotic •Monitor & treat pain •Monitor change •Change dressings •Monitor nutrition & hydration status •Immobilized & elevate

Posttraumatic Stress Disorder (PTSD)

•After experiencing a psychologically traumatic event •Prone to re-experience the event, •Recurrent dreams & flashbacks •Data Collection •Emotional numbness •Detachment •Depression •Anxiety •Sleep disturbances & nightmares Interventions: •Be nonjudgmental & supportive •Encourage to express his/her feelings

Alcohol Withdrawal Delirium

•Agitation •Anxiety •Delirium •Diaphoresis •Disorientation •Hallucination & Delusions •Insomnia •Tachycardia & hypertension •Seizures

Fungal Infections of the Skin

•Antifungal drugs (Fulvicin, Grifulvin) •Antifungal soaps & shampoo (Tinactin, Lotrimin AF, Monistat-Derm, Desenex, Mentax) •Protect the involved area from trauma & irritation •Keep it clean and dry •Warm compresses •Tinea pedistreated w/ warm soaks using Burow'ssolution, wearing sandals or going barefoot to help decrease foot moisture

Saturated Fatty acids

•Are generally of animal origin and solid at room temperature. •Tend to increase blood cholesterol levels and the risk of atherosclerosis •Ex: animal origin (meat, dairy and eggs)

Opioid interventions

•Assess for Respiratory Depression •Antagonist (naloxone (Narcan)) •Methadone (Dolophine) •Tapering dosage •Clonidine (Catapres) •Withdrawal symptoms •Narcotics Anonymous

Eating Disorders Interventions

•Assess nutritional status & complications •Restore fluid & electrolytes •Identifying precipitants to eating disorder •Establish Trust •Encourage to express feelings •Weight daily •Assess & limit physical activity •Assess suicidal ideation •Administer medication •Psychotherapy •Support group

Kidney Ureter Bladder (KUB) Radiography

•Assess structure & position of the urinary tract structures •Tumors, calculi, glomerulonephritis & cysts •No specific preparation

Psoriasis

•Autoimmune disease•Skill cells divide more rapidly than normal •Severe scaling results from the rapid cell division

Alcohol Abuse

•CNS depressants Signs/Symptoms •Slurred speech, unsteady gait, confusion, decrease inhibitions, denial, isolation, irritability, belligerent, hostile Complications •Peripheral neuropathies •Vitamin B deficiency •Thiamine deficiency •Korsakoff's syndrome (a form of amnesia) •Wernicke's encephalopathy •Cirrhosis, pancreatitis•Anemia

Bipolar Depression

•Characterized by episodes of mania & depression Interventions: •Remove hazardous objects •Monitor for fatigue •Ignore or distract grandiose thinking •Provide high-calorie food, finger food & liquids •Set limits •Avoid competitive games

Interventions 1-3 years

•Choking hazard •Visit dentist (Oral hygiene, Never sleep w/ a bottle) •Intake of 2-3 glasses of milk •Iron intake •Assess for readiness for toilet training •WIC Women infant children •Keep dangling cords away •Safety gates on stairways •Safety from drowning •Remove chemicals, medication & poisons out of reach •Use highchairs

Acne Vulgaris

•Chronic skin disorder •Begins in puberty •Face, neck chest, shoulders & back •Comedones, pustules, papules & nodules interventions •Gentle cleansing •Avoid oil-based products •Mild: Topical antimicrobials & retinoids •Moderate: oral antibiotics •Severe: isotretinion

Acne Vulgaris Assessment, Treatment, and Nursing Interventions

•Comedones(blackheads) and pustules are found on the skin of the face, back, or chest •Medical management can involve topical, systemic, or intralesionalmedications •Nursing interventions should focus on promoting self-esteem and teaching preventive care

Herpes Zoster (Shingles)

•Commonly referred human herpesvirus type 3 •Caused by the same virus as chickenpox (varicella) •Manifest as skin lesions of small vesicles along a peripheral nerve route (spinal ganglia) •Can result in eye complications (blindness), deafness, brain inflammation & death. Do not treat if you have never had chickenpox or pregnant

Scabies Interventions

•Contact precaution •Treat family or anyone in contact •Permethin 5% apply all over the body, leave for 12 hours and wash off •Highly contagious •Prevent reinfection

Pediculosis Interventions

•Contact precaution•Nit comb •Lindane (kwell), Permethrin 1% (RID) •Assess family •Highly contagious •Prevent reinfection •Secondary infection •Impetigo

Serum Creatinine

•Creatinine is a catabolic product of creatinine, w/c is used in skeletal muscle contraction •Depends on muscle mass •Normal 0.5 -1.2 mg/dL •> acute tubular necrosis, glomerulonephritis, pyelonephritis, reduced kidney function & renal failure •<myasthenia gravis & late-stage muscular dystrophy

Frostbite

•Damage to tissue & blood vessels •Prolonged exposure to cold •Fingers, toes, face, nose & ears Interventions •Rewarm rapidly 105-108 •Immobilize •Analgesia, tetanus, antibiotics •Avoid compression of tissues •Loose & nonadherent sterile dressing •Monitor for compartment syndrome •Debridement

hemmorrhoids

•Dilated varicose veins of the anal canal, which may be internal, external, or prolapsed Interventions •Sitz baths. •Apply witch hazel soaks and topical anesthetics. •High-fiber diet and fluids •Stool softeners. •To prevent dehydration increase fluid intake

Cardiovascular

•Diminished energy and endurance, with lowered tolerance to exercise •< compliance of the heart muscle, heart valves become thicker and more rigid. •< cardiac output; < efficiency of blood return to the heart •<resting heart rate •Weak peripheral pulses •>blood pressure, but susceptible to postural hypotension

Morphine

•Drug of choice •Relaxes the patient's respiratory effort •Optimal dose is the one that provides pain relief •Common side effect (Nausea & constipation) •Medicate w/ antiemetic 30 minutes before meals

Advance Directives

•Durable Power of Attorney for Health Care •Transfer the health care decision-making power to a person designated by the patient •Advance Directive •Do Not Resuscitate Order •Level of life-saving measures •Life support measures •Organ donation

Adulthood

•Energy needs plateau as full growth achieved •BEE then declines 1% to 2% per decade, reducing energy needs •Rapid decline occurs at age 40 (men) and 50 (women)

A 72-year-old patient is in the terminal stage of prostate cancer. The patient is weak, anxious, experiences loss of appetite, and is in severe pain. Which nursing goals are ideal for this patient? Select all that apply. Control pain Ensure safety Relieve anxiety Independent activities of daily life Adequate nutrition, hydration, and elimination

•Ensure safety •Relieve anxiety •Adequate nutrition, hydration, and elimination Rationale Because the patient is experiencing pain, controlling pain is an important nursing goal It is important for the nurse to provide adequate nutrition to the patient, either orally or by other means. The patient should be given enough safety measures to prevent falls, as the patient is weak. The patient's anxiety should also be relieved. Such a patient cannot undertake activities of daily life independently; the patient needs assistance for this.

Ethical And Legal Issues

•Ethical issues concerning death are influenced by values, culture, and religion •Legal issues are rooted in the law •Informed consent

Intravenous Pyelography (IVP)

•Evaluates structure of the kidneys, ureters & bladder •IV radiopaque dye Nursing Intervention: •Assess allergy to iodine, saltwater fish, seaweed products •Corticosteroid/antihistamine •NPO 8 hours •Laxative before going to bed •Warm flushing sensation & a metallic taste •Monitor vital signs •Increase fluid intake

Growth periods

•Extra energy needed to build new tissues •Greatest growth is infancy and adolescence •Pregnancy and lactation also require increased energy intake

Poison Ivy

•From poison ivy, oak, or sumac plant •Papulovesicular lesions •Severe pruritisInterventions: •Cleanse the oil off the skin •Calamine lotion, hydrocortisone, Glucocorticoids •Burning, dryness, thinning of skin

Infancy: 1 -12 Months

•Growth is rapid the first 6 months of life (Double birth weight 4-6M, 3x birth weight 1Y) •Teething begins at 5-6M •Bottle-mouth syndrome tooth decay because the bottle is propped up •Anterior fontanel closes 12-18M •7M sit up w/o support (Safety, Car seat) •Human breast milk preferred •Introduction of solid food (4-6M, Cereal, Choking) •9-10 hours of sleep •SIDS sudden infant death syndrome. Should be sleeping on the back, no pillows no bed rails

Preschool: 3-5 years

•Growth is slow & steady (Taller & thinner) •Gross motor skills improve dramatically •Piaget (Use symptoms to represent objects) •Trial & error •If not talking by 3 years (Evaluation by PCP, Hearing test, Pathologic speech disturbances?) •High protein & Calcium •Pretend play •Imaginary playmate •Safety (Teach full names, addresses & telephone # 911)

Impetigo Contagiosa

•Highly contagious •Common in children •Characterized by macules that turn to vesicles then rupture & form a dried exudate, honey-colored crust that can be easily removed. •Face, hands, arms & legs •Itching, pain, low-grade fever •Malaise•>WBC

Chemical Digestion: GI secretions

•Hydrochloric acid & buffer ions are needed to produce the correct pH that is necessary for enzymatic activity. •Digestive enzymes to break down other nutrients •Mucus lubricate and protect the mucosal tissues that line the GI tract and help to mix the food mass •Water & Electrolytes carry & circulate products of digestions •Bile emulsifies fat into smaller pieces to expose more surface area

Alcohol Abuse Interventions

•Initiate seizure precaution •Small frequent high-CHO foods •Vitamin B complex •Thiamine •Vitamin C •fluid & electrolyte •Benzodiazepine •Chlordiazepoxide (Librium) q6 •Lorazepam (Ativan) •Administer medication •Psychotherapy •Individual, group, family •Support groups •Alcohol Anonymous •Al-Anon•For friends & family •Adult Children of Alcoholics •Treatment centers

Late Adulthood

•Late Adulthood: 65 years and older •Biological, psychological, physiological, and sociological aspects of aging •Goal is to maximize the ability to function and to live independently and to shorten the period of illness and disability •Aging is a complex process that affects cells, tissues & organs •Older adults are living longer, healthier lives•Aging occurs at a highly individualized rate

Factors That Influence Basal Energy Expenditure

•Lean body mass •Growth periods •Body temperature•Hormonal status •Disease state

Pediculosis

•Lice & nits •Contact precaution •S/S: itching, erythema Use permathin 1% and nit comb to remove

Integumentary

•Loss of pigment in hair & skin •Wrinkling of the skin •Thinning of the epidermis, easy bruising, and tearing of the skin •< skin turgor, elasticity, & subcutaneous fat •> nail thickness & <nail growth •Dry, itchy & scaly skin

Mechanical digestion: GI motility

•Mastication •Muscle at the base of the tongue facilitate the swallowing process •Esophagus: automatic peristaltic waves •Gravity helps with the movement of food •Gastroesophageal sphincter muscle relaxes: one-way valve •Villi •Surface villi motions stir and mix chyme, which also exposes nutrients for absorption

Musculoskeletal

•Muscle mass & strength <, muscle atrophy •<mobility, range of motion flexibility, coordination & stability •Change in gait w/ a shortened step and a wider base •Posture & stature changes that cause a decrease in height •>brittleness of the bones •Kyphosis of the dorsal spine

Total parental nutrition (TPN)

•Must be administered through a central intravenous catheter •AT risk for hyperglycemia •3P's Polyphagia, polyuria, polydisia , Nausea, HA •Monitor blood glucose levels •What is normal BS? •infuse slowly •What are signs of fluid overload? Intervention? •Prevents hyperglycemia & cellular dehydration

Death As Part Of The Life Cycle

•Normal part of the life cycle •Not unique to the elderly •Few are really prepared for the actual event •Acute care hospital versus home or hospice environment

Anxiety

•Normal response to stress Levels of Anxiety 1.Mild: alert, the perceptual field is increased, motivating, produce growth, enhance creativity, increase learning 2.Moderate: narrows the perceptual field, selective inattentiveness 3.Severe: feelings that something bad is about to happen, need direction to focus 4.Panic: unable to communicate or function effectively, inability to concentration

Renal Biopsy

•Open procedure or Percutaneous biopsy Interventions: Check coagulation studies, Consent, Adm pain medications, Encourage fluid, Hold breath, Bed rest 24 hours (BRP), Position prone w/ pillow under abdomen & shoulder, Bedrest in supine for 2-6 hours, Pressure to biopsy site 30 minutes, Test for urine occult blood, Monitor for HR & BP, Avoid heavy lifting for 2 weeks Complications: Infection, damage to the kidney, bleeding •Bleeding pain at the biopsy site that radiate to the flank & around the abdomen

Opioids

•Opium, heroin, meperidine, morphine, codeine, methadone, Dilaudid, fentanyl, etc •CNS depressants

Herpes Zoster (Shingles) Interventions

•Pain control & preventing complications•Infection, blindness •Acyclovir w/in 72 hours reduces pain & duration of the virus •Airborne Precaution •Steroids •Lotions (kenalog, Lidex), Atarax •to relieve pruritus & inflammation •Zostavax vaccine to prevent •Inhibiting spread of disease •Chickenpox •Vitamin C to promote healing •Dressing •Avoid pregnant women

eczema manifestations

•Papularlesions •Vesicular lesions •Erythema

Acne Vulgaris

•Papulopustularskin eruption that involves the sebaceous glands •Occurs primarily in adolescents

Acute Care of the Dying Patient

•Patient •Continuation of full life support •Full cardiopulmonary resuscitation •Removing all life support or life-sustaining equipment •Stopping all drugs except sedation and relief of pain

Absorption in the Large Intestine

•Water: main absorptive task of large intestine is to absorb water; small amount remains for feces •Dietary fiber: contributes bulk to help form feces •Macronutrients and micronutrients: absorbed through lymph or blood •Minerals, vitaminsand waterare already small enough to be absorbed by the body without being broken down, so they are not digested.

laboratory values for NG tube

•Weight patient, Daily•3x a week •Serum Albumin: 3.3-5.5g/dL •Serum Transferrin: 250-430mg/dL •Serum Prealbumin: BUN

Bowel assessment

•Position supine w/ head raised slightly & knees slightly flexed •Inspection, Auscultation, Percussion & Palpation •Abdominal pain, indigestion, N/V, appetite, bowel elimination, weight loss, family history, ETOH •Listen for at least 5 minutes before determining that no bowel sounds are present •Normally 1 bowel sounds to 1 breath

Family Behaviors Related to the Dying Process

•Preparation and education are key •Helplessness and guilt should be quickly recognized •Pain-relieving techniques (swallowing may be difficult, assessing for pain) •Therapeutic communication (Have a frank, open discussion with him/her about his feelings)

Signs And Symptoms Of Death

•Prepare family for the symptoms that accompany death •Loss of appetite •Increased physical weakness •Cheyne-Stokes breathing •Morphine •Changes in urination •Swelling to feet, ankles, and hands The hearing will be the last sense to go

Depression

•Prolonged intense unhappinessInterventions: •Establish a therapeutic relationship •Communications •Planned activity •Nutritional risk •Drug therapy •Electroconvulsive therapy (Ect) •ADLs •Assess for suicidal ideation

enternal nutrition

•Provides liquified foods to the GI tract via a tube •Use w/ swallowing problems, burns, major trauma, oral surgery, comatose, malabsorption •Intermittent or Continuous •Monitor blood glucose @4-6hrs •Check for placement •Check for residual •Provide mouth care q2hrs •Assess ostomy•HOB elevated

Eczema Assessment

•Pruritus •Scratching

Fat Sparing Action of Carbohydrates

•Rapid breakdown of fat results in the production of ketones. •Lead to acidosis •Results in cellular damage in severe cases •Ex: Diabetic Acidosis

Herpes Zoster (Shingles) Manifestations

•Rash occurs in the thoracic region, lumbar, cervical & cranial region •Vesicles erupt in a line along the involved nerve •Vesicle rupture & form a crust & the serous fluid in the vesicles may become purulent •lasts 7-28 days •Pain is severe (burning & knif elike, extreme tenderness & pruritusoccur •Can be fatal with a compromised immune system.

Vegetarian Diets Interventions

•Refer to a dietician •Vitamin B12 •Intrinsic factor

School Age: 6 -12 years interventions

•Refinement of fine motor skills •Wear protective gear •Traffic safety rules •Stranger danger •Gun safety •Bullying

Opioid Intoxication

•Respiratory Depression •Pinpoint pupils •Drowsiness •Euphoria Hypotension •Slurred speech, impaired memory, attention & judgment •Coma •Shock •Seizure •Death

Psoriasis Nursing Intervensions

•Rest & measures to promote psychological well-being •Education of the disease process •Moisturize•Avoid triggers •Stress, overuse of ETOH, streptococcal infections, beta-blockers, Ace inhibitors

3-5 years Interventions

•Safety •Teach full names, addresses & telephone # 911 •Can be taught fire drills •Gun secured under lock & key •Safety from drowning •Socialization

Isotretinoin (Accutane)

•Severe cystic acne •Discontinue Vit A supplement •Nosebleed, inflammation of eyes & lips, drying or itching of the skin, stiffness in joints, bones or muscles & back pain •Photosensitivity •Teratogenic

Neurological

•Slowed reflexes •Decrease in tactile sensitivity •Decrease in pain perception •Slight tremors & difficulty w/ fine motor movement •Loss of balance •> susceptibility to hypothermia & hyperthermia •Short-term memory may decline

12 -19 years Interventions

•Teach about •Danger of drugs & alcohol •Danger associated w/ guns, violence & drugs •Complication w/ body piercing, tattooing & sun tanning •Driver's education •Water safety training •Drugs, Alcohol, cigarettes •Use a seat belt •Discuss STI •Safe sex practices •Signs of Depression

Prevention of Pressure Ulcers

•Thorough assessment •Braden scale-Scoring system. Evaluates patient's risk of developing a pressure ulcer. •Assess skin turgor •Turn @2hrs •Keep skin clean & dry •Prevent shearing •Adequate nutrition & hydration •Specialty devices (air mattress, waffle boots, pillows, foams)

Energy Output

•Total energy demands determined by: •Basal energy expenditure: Factors affecting basal metabolism (lean body mass (male > female muscle mass), growth period, body surface area, extreme temperature, thyroid hormone, stress, drugs, caffeine, genetic makeup) •Physical activity •Thermic effect of food: 5 -10% total energy needs for metabolism

Alcohol Abuse Early Withdrawals Symptoms

•Tremors •Anorexia •Irritability •Easily startled

Weight Management

•Underlying causes of obesity •genetic, environmental & psychologic •Body mass index (BMI) •Total body weight relative to height •Body composition •Ex: Body fat calipers •Realistic Goals•½ to 1 lb loss/week •Negative energy balance 500-1000cal/day

urinary elimination function

•Urine formation: 1000-2000mL/day •Fluid & electrolyte balance •Acid-base balance•Excretion of waste products •Blood pressure regulation •Red blood cell production •Erythropoietin •Regulation of Vitamin D Activation

Opioids Naloxone (Narcan)

•Used to treat respiratory depression from opioid overdose •Monitor BP, P & RR •Q5 min, tapering q15min & then q30min •Place on cardiac monitoring •Monitor for withdrawal symptoms

Lithium

•Value 0.8 to 1.2 mEq/LS/E: polyuria, polydipsia, dry mouth Lithium Toxicity: Mild: apathy, lethargy, ataxia Moderate: N/V, diarrhea, slurred speech Severe: nystagmus, visual or tactile hallucination, oliguria, anuria Interventions: •Monitor serum lithium level monthly •8-14 hours after the last dose •Drink 6-8 glasses of water •Salt •Monitor Suicidal Ideation •Effective 1-3 wks •Avoid caffeine (diuretic effect) •Take missed dose w/in 2 hours of the scheduled time