NCLEX Y 10,14, 37,40-43

1. Nontherapeutic communication may interfere with professional nursing care by hindering the patient-nurse relationship. Which of the following are examples of nontherapeutic communication? Select all that apply: a. A nurse provides education on smoking cessation: "The same thing happened to me and I was able to quit." b. A nurse attempts to distract a patient at the end of their life: "Let's focus on your walking for the day, not your worries about death." c. A nurse states during report that "the patient should not get an abortion because it is wrong." d. A nurse is sending a pediatric patient for cardiac surgery. As he leaves, she states "Don't worry, everything will be fine!" e. A nurse is discussing care options with the family of a patient: "What have your experiences been like with home healthcare in the past?"

1. a, b, c, d. Giving advice, changing the subject, being moralistic, and giving false reassurance are all components of nontherapeutic communication. Open-ended questions are a therapeutic technique.

1. Which of the following factors may influence sexual function among individuals? Select all that apply: a. Cognition b. Values and beliefs c. Illness d. Medications

1. a, b, c, d. Sexual function can be influenced by numerous factors, including relationships, cognition and perception, culture, values, beliefs, self-concept, previous experience, pregnancy, gender identification, environment, illness, surgery, and/or medications.

1. The capacity of physiologic systems to maintain stability yet alter the set point required for optimum system functioning is known as which of the following? a. Homeostasis b. Allostasis c. Coping d. Adaptation

1. b. Allostasis is described in the definition above. Homeostasis refers to the automatic, coordinated, self-regulating process to maintain a steady state rather than appropriate adaptation to change. Coping is a process to manage stress, including but not limited to physiologic management. Adaptation is a person's capacity to flourish and survive; an outcome of coping.

1. A teen has recently survived a car accident in which his friend was killed. The nurse assigns the nursing diagnosis of spiritual distress. Which of the following statements would best support this diagnosis? a. "I need some time alone; can't we do this later?" b. "Why did I have to survive?" c. "I just want to sleep!" d. "I don't want those pills!"

1. b. Evidence of survivor guilt is related to spiritual distress. Requesting time alone may indicate effective coping or spiritual well-being. Using sleep as a coping mechanism may be ineffective but does not indicate spiritual distress. Refusing medications or refusing to participate in the therapeutic regimen is evidence of noncompliance, not spiritual distress.

1. In admitting a patient with confusion and labile affect, the nurse discovers that the patient recently lost his son in a motor vehicle accident. Which nursing diagnosis best describes this patient? a. Anticipatory Grieving b. Ineffective Health Maintenance c. Dysfunctional Grieving d. Impaired Family Processes

1. c. Dysfunctional Grieving describes unsuccessful use of intellectual and emotional responses by which individuals attempt to work through the process of modifying self-concept based on the perception of loss. Characteristics include difficulty expressing loss, interference with life functioning, and labile affect. Anticipatory Grieving does not reflect the time period following the son's death. There is not enough information to conclude that there is either Ineffective Health Maintenance or Impaired Family Processes.

1. Self-perception or personal identity is how a person explains behavior based on self-observation. Which of the following are dimensions of self-perception? a. Self-knowledge, self-expectation, self-esteem, and role performance b. Self-knowledge, self-esteem, social self, and self-evaluation c. Self-esteem, self-expectation, social self, and self-evaluation d. Self-knowledge, self-expectation, social self, and self-evaluation

1. d. Self-perception is based on several dimensions: self-knowledge, self-expectation, social self, and self-evaluation. Self-esteem and role performance are elements of normal self-concept patterns.

2. Which of the following are elements that improve documentation when using an electronic health record? (Select all that apply.) a. Nurses are "tasked" to perform scheduled assessments. b. Reassessment of pain medications is scheduled depending on administration route. c. Computerized order entry to directly communicate orders legibly and timely. d. Access codes to track patient care and compare to established standards of care. e. Prevention of use of all abbreviations to improve clarity.

2. a, b, c, d. All characteristics mentioned in statements A through D improve nursing documentation, patient safety, and tracking of patient care. Only certain abbreviations are prohibited.

2. An unemployed, single woman is seen at a prenatal visit. Which of the following assessment findings would indicate the effects of chronic stress? a. Elevated blood glucose b. Decreased immune response c. Dilated pupils d. Rapid breathing pattern

2. b. Immunosuppression is associated with chronic stress. Blood glucose would not be elevated related to chronic stress. Dilated pupils and rapid respiratory rate are signs of acute stressors.

5. A nurse is conducting a patient assessment of coping and adaptation. Which of the following questions would be appropriate? Select all that apply: a. "How have you coped with difficult situations in the past?" b. "What type of stressors do you find most difficult?" c. "Are you able to discuss your feelings when you are stressed?" d. "Whom do you rely on for social support?"

5. a, b, c, d. All questions are appropriate in eliciting coping and adaptation behaviors.

2. The nurse is caring for an East African family that has just experienced a fetal demise at full term. The family initially refuses to see the stillborn infant. What should the nurse do first? a. Assist family members to see the infant in order to gain closure. b. Ask the family about their expectations for mourning. c. Evaluate the need for emotional and practical help. d. Provide educational materials about loss of an infant.

2. b. Religious and ethnic beliefs and customs should be observed as much as possible in the grief process and caring for the deceased. Assessment of these aspects is a priority according to the nursing process and should also be done prior to interventions or evaluation. Gaining closure through viewing the body is a Western construct of mourning and may not be appropriate for this family. Other interventions and evaluation should follow assessment.

2. Physical factors that may affect sexuality include which of the following? Select all that apply: a. Inhibited sexual desire b. History of sexual abuse c. Dyspareunia d. Ejaculatory dysfunction

2. c, d. Dyspareunia is painful intercourse, which occurs regularly in 1% to 2% of women and occasionally in up to 15%. Ejaculatory dysfunction, either premature ejaculation or the inability to ejaculate, physically alters a man's ability to feel confident during sexual acts. Inhibited sexual desire and sexual abuse both may influence altered sexuality but are not physically motivated.

2. You are caring for a patient following bilateral mastectomy surgery. The patient refuses to look at her chest and states "I'm hardly even a woman now." What nursing diagnosis would be most applicable to this situation? a. Impaired coping b. Anticipatory grieving c. Disturbed body image d. Powerlessness

2. c. Disturbed body image is defined by verbalization of feelings or perceptions that reflect an altered view of one's body in appearance, structure, or function. Behaviors of avoidance, monitoring, or acknowledgment of one's body are also common clinical cues related to disturbed body image. Impaired coping and powerlessness are not the most directly indicated nursing diagnoses. Anticipatory grieving is not appropriate because the patient has already experienced the surgical change and is not making these statements prior to the surgery.

2. An elderly woman has recently become a resident in a skilled nursing facility as a result of her worsening health conditions. Which of the following may lead to impaired spiritual health? Select all that apply: a. Anger at treatment regimen b. Lack of concentration and short-term memory c. Lack of transportation to usual meditation group d. Fear about living in a new environment

2. c. Lack of transportation to attend a spiritual group could cause impaired spiritual health. Anger, lack of concentration or memory, and fear describe manifestations of altered spiritual function.

2. A previously healthy and active 31-year-old patient with a radical mastectomy snaps at the nurse and asks her to leave her alone. In analyzing this, the nurse is able to attribute the behavior to: a. Empathy b. Comfortable sense of self c. Developmental stage of intimacy versus isolation d. Vulnerability of illness

2. d. Active, achieving adults may find it difficult to suddenly need assistance from nurses and may struggle with role transition during hospitalization. Empathy relates to the ability to perceive, reason, and communicate understanding of the other person's feelings. A comfortable sense of self refers to the nurse's ability to be self-aware of biases, communication styles, and values: not relevant in the patient's behavior. Intimacy versus isolation is part of Erikson theory of self-concept; though appropriate for the age, it does not address this specific behavior.

3. A nurse is talking with a wife whose husband just expired. What would appropriate nursing interventions be for someone in the shock phase of the grief cycle model? Select all that apply: a. Help mobilize a support system. b. Encourage expression of diverse feelings. c. Help to establish coping behaviors used in past. d. Provide role models who have coped with similar loss.

3. a, c. Helping to mobilize a support system and establish coping behaviors used in the past are appropriate interventions for the shock phase. Encouraging the expression of diverse feelings and providing role models are appropriate for the protest phase of the grief cycle model.

3. A teenage girl seen for her annual physical remarks that she is "so ugly." What should the nurse do first? a. Recommend counseling to the parent and physician. b. Ask the patient to explain why she feels this way. c. Recognize this as a developmentally appropriate statement for teenagers. d. Evaluate physiologic changes since the last appointment.

3. b. According to the nursing process, assessment should be done first; thus, asking for more information is most appropriate. Recommending counseling is an intervention. This is not a developmentally appropriate method of coping with body and role changes of adolescence. Physiologic changes do not identify the issues of self-concept; evaluation should be done last according to the nursing process.

3. A nurse is seeing a teenage girl at an annual visit. In her assessment about the girl's sexual activity, which question would be most appropriate to ask first? a. "Do you ever masturbate?" b. "Have you begun menstruating?" c. "How frequently do you have sexual activity?" d. "Are you secure with your sexual orientation?"

3. b. The most appropriate question to ask first would be "Have you begun menstruating?" This question begins with objective information and allows the patient to establish a rapport with the nurse prior to moving into more sensitive topics. Statement A implies judgment. Statement C is objective but too sensitive to begin with. Statement D may be appropriate once further information is gathered.

3. A new mother seen in a postpartum visit reports high levels of stress associated with her new role as a mother. Which of the following nursing interventions would be most appropriate? a. Recognizing stressor b. Using assertiveness to express feelings c. Encouraging adequate exercise and diet d. Offering crisis intervention resources

3. c. Adequate exercise and diet are lifestyle changes that help to release tension and promote healthy management of stress. This mother has already verbalized active stressors and expressed her feelings. Crisis intervention resources are not appropriate at this time.

3. A group of nurses are discussing a patient case in the elevator when a group of people enter the elevator. Which aspect of HIPAA is most directly in violation? a. Patient education on privacy protection b. Patient recourse if privacy protections are violated c. Minimal disclosure of protected health information d. Limit use of information to accomplish intended purpose

3. c. Disclosure of protected health information is at issue when patient cases are discussed in public. Patient education on privacy protection, patient recourse if privacy protections are violated, and limiting use of information to accomplish the intended purpose are also aspects of HIPAA but are not discussed in this scenario.

3. In communicating with a developmentally delayed adult patient, which of the following would be the best techniques for the nurse to use? a. Silence b. Providing reassurance at all times c. Setting clear limits while allowing participation d. Establishing a contract including values and rights

3. c. Limit setting is a key factor in working effectively with children and adolescents. Although considered a therapeutic technique, silence may not be appropriate with this patient. False reassurance should be avoided with all patients, particularly pediatric patients and those who are developing trust. An informal contract would not be appropriate based only on the patient experiencing a developmental delay.

3. A Catholic patient is anxious related to her hospitalization. The nurse attending to her is Buddhist. Which statement is most appropriate for the nurse to make? a. "I have to give pain medications to another patient, so I'll leave you alone to pray." b. "I can't pray with you; we believe in different Gods." c. "Do you have a Bible or book of Psalms that I can read to you?" d. "Don't worry; many patients are anxious about being in the hospital."

3. c. Statement C best displays understanding of the patient's spiritual needs by the nurse, despite differing beliefs. Statement A shows avoidance and a lack of attention to the importance of spiritual care. Statement B shows fear and a lack of comfort with spiritual care. Statement D fails to address the patient's need for spirituality for coping.

4. A nurse is performing patient education related to a new therapeutic regimen. Incorporating which of the following factors would be most applicable in promoting adherence? Select all that apply: a. Social support and coping b. Self-efficacy c. Education about evaluation d. Role ambiguity

4. a, b. Social support/coping influence self-concept and may impact a patient's ability to manage a new health regimen. Self-efficacy is the degree of confidence a person has about his or her ability to perform specific activities. Education about evaluation is not indicated, and role ambiguity is not noted as an issue.

4. A nurse is providing patient education to a 22-year-old male. Which of the following topics would be most appropriate to include? Select all that apply: a. Testicular examinations b. Kegel exercises c. Contraceptive methods d. Self-awareness e. Information about STIs

4. c, d, e. Contraception is important to discuss with male and female patients alike. Self-awareness is important for all patients in order to understand their anatomy and stimulants that may help them develop healthy sexual relationships. Information about STIs is important for sexually active persons. Testicular examinations are no longer recommended for the general population. Kegel exercises are pelvic floor exercises used for women to increase tone, resulting in improved bladder control, relief from constipation, postpartum recovery, and sexual performance.

4. A patient's sister expresses her dissatisfaction to the nurse regarding the discharge care coordination between the physician and cardiology team. In order to practice patient advocacy, what should the nurse do first? a. Call the social worker to coordinate the discharge care. b. Call the physician immediately to request a visit with the patient's sister. c. Assist the patient's sister in compiling a list of questions related to discharge. d. Admit to the patient's sister that there are problems with the discharge system and resolve to correct these oversights.

4. c. Assisting the patient's sister in compiling a list of questions should be done first to clarify patient and family needs and does not interfere with the physician-patient relationship. While discussing the case and advocating for the family with the physician and social work are important steps, these would not be the first action. Admitting problems with the healthcare system can undermine confidence in the system and is not the best option in patient advocacy.

4. A nurse calls a provider regarding a patient's increased output from a surgical Jackson-Pratt (JP) drain. She relays the following information: "The patient has had 600 mL of serosanguineous drainage from his JP drain over the last 2 hours; the previous 8-hour shift had a total of 160 mL. He is post-op day #1 for a prostatectomy. He has had no increase in pain but is now hypotensive with a BP of 100/64 and a HR of 98. I think he has a urine leak." What is missing from this SBAR communication? a. Situation b. Background c. Assessment d. Recommendation

4. d. A recommendation is missing from this SBAR, answering the question of "What should we do to correct the problem?" Situation, Background, and Assessment are all included in the scenario.

4. A patient is admitted with malnutrition and bilateral pneumonia. During the admission process, it is discovered that the patient's significant other recently died. Which nursing diagnosis is most appropriate? a. Defensive Coping b. Caregiver Role Strain c. Chronic Sorrow d. Ineffective Coping

4. d. Ineffective Coping is characterized by inability to meet basic needs and a high illness rate. Defensive Coping does not involve physical illness. Caregiver Role Strain is not appropriate because the situation does not describe a caregiver relationship at this time. Chronic Sorrow is not appropriate based on the amount of time elapsed since the significant other's death.

4. A nurse is developing outcome criteria for a patient's plan of care regarding the patient with spiritual distress. Which of the following is an appropriate criterion? a. Patient verbalizes feelings. b. Patient identifies support provided by family. c. Patient expresses increased understanding and acceptance of current situation. d. Patient expresses satisfaction with tie to faith community within 1 month.

4. d. Outcome criteria phrasing should be specific, should be measurable, and should include a time frame. Other statements lack time frames or reflect broad patient goals.

4. The nurse is caring for a patient newly diagnosed with metastatic lung cancer. What would be the most appropriate statement for the nurse to make regarding palliative care resources? a. "Palliative care is for when you have a prognosis of less than 6 months." b. "Once you decide that you don't want to receive further treatment, palliative care will help keep you comfortable." c. "Palliative care can only be done once you discharge from the hospital." d. "Palliative care focuses on quality of life and may be used from the time of diagnosis."

4. d. Palliative care is the "active total care for those patients whose diseases are no longer curable and the focus of the treatment is to achieve the best possible quality of care for patients and their families." It may be used from as early as diagnosis, may be used together with curative treatments, and may occur in the hospital.

5. The nurse is caring for an actively dying, unresponsive patient while the family sits at the bedside. The husband asks "Isn't she hungry? She hasn't had anything to eat in 24 hours." Which response by the nurse would be most appropriate? a. "The body doesn't need food at this stage." b. "We should talk to the physician about placing a feeding tube to help with intake." c. "Here is a menu—we can order some foods that she enjoys eating." d. "Motility of the stomach and intestines are decreased, so eating could make her nauseous."

5. a. Nutrient and metabolic needs are decreased in active stages of dying. Placing a feeding tube would not be appropriate in an actively dying patient since this is a surgical procedure. Ordering desirable foods may be appropriate for dying patients; however, this patient is unresponsive. Gastromotility is decreased in the dying process, but this is not the best answer since the patient is unable to eat due to her lack of responsiveness; nausea is not the primary concern.

5. A nurse is caring for a patient with terminal lung cancer. Which of the following would indicate potential risk for spiritual distress? Select all that apply: a. Patient has had many visitors while hospitalized. b. Patient formerly sang in the local choir, quitting due to shortness of breath. c. Patient is a member of a church group and attends regular mass. d. Disease prognosis is terminal with projected mortality within 3 months.

5. b, d. Illness that forces a patient to change his or her way of living may lead to spiritual distress. A terminal diagnosis also may lead the patient to question meaning in life and end of life beliefs. Many visitors indicate social support and reinforce spirituality. Membership in a group, particularly a religious or spiritual group, indicates both social support and a strong faith-based belief system that may assist in coping.

5. The circle of confidentiality is essential in maintaining sensitive information among appropriate professionals. A nurse overhears a conversation about an unknown patient's care in the elevator. The best immediate response would be: a. "Clinically relevant information should be shared with the healthcare team, thanks for your report" b. "I'm concerned to hear discussions like this in nonprivate areas; let's be mindful of patient privacy" c. An incident report describing the event with the names of those employees involved d. Interjections with suggestions for the patient's care plan considering his or her current situation

5. b. Voicing concerns about discussions of patient information in nonprivate areas states the nurse's ethical concerns and violation of the Patient's Bill of Rights. Alternative options do not address violation of the Patient's Bill of Rights directly to the providers.

5. The nurse is discussing home care of a patient with a below-the-knee amputation 1 month ago. She suspects a self-care deficit because the patient reported that he "sits in his chair and watches television all day" and does not shower or eat regularly. What intervention would be most appropriate to address this altered self-concept? a. Risk identification b. Classification of developmental level c. Self-evaluation d. Assess stressors

5. c. To break a cycle of poor self-concept and negative self-evaluation, realistic self-evaluation and identification of positive attributes are needed. Risk identification is part of assessment. Classification of developmental level is not indicated. Assessing stressors is not an intervention.

5. Two nurses are performing a change-of-shift handoff at the bedside of a patient with a recent abdominal surgery who is receiving a constant infusion of opioids via a patient-controlled analgesia (PCA) IV pump. The off-going nurse provides a thorough report including the plan of care and the biggest safety risks. What else should these nurses do as part of their handoff? a. In-depth neurologic assessment b. List of all medications ordered c. In-depth medical history d. Double-check of high-alert infusion rates

5. d. Double-check of all high-alert infusions should be performed by both the off-going and oncoming nurses. Acute changes or interventions (e.g., neurologic status) may be indicated by patient status but are not relevant for this patient scenario. A complete list of medications is not needed since this is available as part of the patient's medical record. Similarly, a complete past medical history is not needed and is available in the patient's chart.

5. A patient with a pregnancy of 9 weeks is discussing her desire for an elective abortion with the nurse. According to the PLISSIT model of counseling, which would be the nurse's best response after giving the patient permission to discuss abortion? a. "It is an individual choice." b. "You should consider a clinic that is cost-effective for you and that is known to provide safe, supportive care." c. "You may want to discuss this decision, both prior to and following the procedure, with a counselor to help you through any difficult emotions." d. "People choose contraceptive methods that are appropriate for their situation."

5. d. Statement D provides limited information and supports the patient's decision, appropriate for the second step of PLISSIT. Statement A reaffirms permission giving (step 1). Statement B provides specific suggestions (step 3). Statement C recommends intensive therapy (step 4).

6. Which physiologic process involves ongoing assessments between internal resources and external demands? a. Allostasis b. Autonomic c. Circadian d. Homeostasis

6. a. Allostasis is described as ongoing assessments between internal resources and external demands, physiologic adjustments in anticipation of oncoming events, and adaptation occurring over time. Homeostasis is described as the physiologic parameters that must be maintained for the human body to survive under emergency circumstances. Autonomic and circadian are body processes that do not necessarily coordinate various systems.

6. A 35-year-old patient who is married is apprehensive about her scheduled mastectomy procedure. After assessing the patient's knowledge about the procedure, the nurse manages the patient's fears by explaining the procedure and plans for the patient to see the oncology nurse educator. Which fundamental criterion of self-appraisal did the nurse helped the patient reflect? a. Competence b. Meaning c. Power d. Virtue

6. b. Meaning is the sense of being valued and worthwhile—that is, feeling as if one's existence matters to others. The patient is anxious about her body image, which includes the total conscious and unconscious disposition toward one's body. It is the unifying concept behind feelings about one's size, sex, and sexuality; the way one looks; the way one's body functions; and whether one's body can help one accomplish goals.

6. The nurse observes that a 42-year-old patient admitted for femur fracture from falling at home refuses meals or any social interaction with family. The patient was hired as a driver a week prior to the injury for a busy delivery company. What type of loss will the nurse suspect the patient is experiencing? a. Expected b. Material c. Physiological d. Unexpected

6. b. The nurse suspects the patient is experiencing a material loss. The client will be unable to work and thus loses income, which is important for survival. Expected and unexpected losses involve preparedness or having time to reflect about the loss. Psychological, not physiologic, can also be an answer to this question.

6. What is the initial action a nurse should take when preparing a public presentation to discuss variations in gender identification at a community youth center? a. Assure the audience that the environment will be one of mutual respect and confidentiality. b. Determine if anyone in the group is actually experiencing a variation in gender identification. c. Self-reflect to identify any personal biases that exist on the subject of gender variations. d. Be prepared to discuss the comorbid conditions of depression and suicidal ideations.

6. c. It is important that healthcare providers evaluate any bias they may have before interacting with a patient or discussing the topic of gender identification with a public group. The discussion can be effectively presented without determining if anyone in the audience is experiencing an issue with gender identification. While nurses should be aware that individuals who identify as transgender have a significantly higher rate of suicidality, sexual abuse, physical victimization, human trafficking, and homicide than does the general population, the presentation of such information should not be the nurse's initial concern. It is appropriate to assure the audience that the information will be presented in a respect manner and any discussion will be held in a confidential manner, but self-reflection must be the initial action taken by the nurse in preparation for this presentation.

6. A nurse is charting the application of medication and dressing change on the patient's pressure ulcer. Which purpose of health record-keeping requires the nurse to provide a meticulous recording using the guidelines of the Centers for Medicare and Medicaid? a. Legal document b. Quality assurance c. Reimbursement d. Research

6. c. Medicare and Medicaid regulations require specific criteria to be met to receive reimbursement for specific health-related expenses. The patient chart is used for litigation, auditing patient care practices, and research, but those purposes do not require the need to follow the specific Medicare or Medicare guidelines.

6. Which nurse-patient interaction is an example of a nonverbal communication? a. The nurse is using the computer to chart in the patient's room. b. The patient is watching the television while talking to the nurse. c. The nurse is assessing a patient in pain who is grimacing. d. The patient wants the nurse to call the physical therapist.

6. c. When a patient is grimacing during pain assessment, it is an indication of a nonverbal response to pain. While using the computer, the nurse is not communicating with the patient in any form. The other answers indicate that the patient and the nurse are talking.

6. The family of a patient who recently died is requesting to position the patient facing the east according to that individual's religious belief. What will the nurse do? a. Call the charge nurse to talk to the patient's family. b. Explain to the family the hospital's biohazard protocol. c. Place the patient in the bag and leave the family to grieve. d. Turn the patient according to the family's request.

6. d. One of the Quality and Safety Education for Nurses (QSEN) competencies is patient-centered care. The patient should be treated and recognized as people throughout his or her life and even until death. Also, the expression of spirituality, often through a specific religious group, usually follows an established order of practices. Patients should be allowed to practice their spiritual and religious beliefs. Answers a, b, and c negate the patient's needs.

7. During assessment, a 27-year-old patient tells the nurse, "Dying is better than constantly seeing the scar on my face." Which statement made by the nurse conveys empathy? a. "How long have you been feeling this way?" b. "How would your mother feel if you died?" c. "It is a relief that you would like to discuss how you feel." d. "You may feel that way now, but you'll feel better in a few months."

7. a. Engaging the patient to talk gives the patient a feeling of being heard and shows the nurse identifying with the patient's perspective and encourages reflection. Answer b is judgmental, and answers c and d negate the patient's feelings.

7. A young adult diagnosed with syphilis tells the nurse, "I don't want my new boyfriend to know about this." What response by the nurse best presents the information she needs to convey in a caring, professional manner? a. "All of your sexual partners, past and present, need to be notified so that antibiotic therapy can be prescribed to treat the infection and prevent reinfection." b. "I can understand why you don't want to share that information, but if you two have had sex, notification has to occur." c. "You will be prescribed antibiotic therapy, and it is best if all your sexual partners are treated as well." d. "Antibiotic treatment is necessary, and he will be grateful you told him, so he can be treated as well."

7. a. Syphilis can be successfully treated with antibiotic therapy, and partners must be treated for their health and to prevent reinfection of the patient. This information should be presented clearly and respectfully to the patient. None of the other options clearly presents the action needed and rationale.

7. A caretaker of a 70-year-old patient who is actively dying is mentally preparing for the patient's death. What term related to loss and grieving is the caretaker presenting? a. Anticipatory grieving b. Bereavement c. Expected grieving d. Mourning

7. a. The caretaker knows that the client is eventually going to die and is presenting the pattern of anticipatory grieving to the impending loss. Bereavement is a state of anguish as a result of a loss. Mourning is how people present their grief outwardly that is socially acceptable after a loss. Expected loss, not expected grieving, is a type of loss.

7. Which patient statement describes the most self-destructive behavior? a. "Walking around the mall to shop is my exercise." b. "I cannot eat meat because of its texture." c. "I only smoke cigarettes when I'm with my friends." d. "Every week, I eat a large piece of steak."

7. c. Nicotine is addictive, and sometimes addiction originates in a social event. Another example of addiction being initiated in a social event is an intoxicated person's progression from becoming less self-aware, to failing to use good judgment, to subsequently behaving atypically. The other statements may not describe ideal behavior, but these types of behavior are less likely to become self-destructive.

7. The family of a patient who recently died starts chanting to honor the body of the family member. A patient in an adjacent room reports inability to rest because of the "strange" humming in the other room. What will the nurse do? a. Explain to the patient that empathy is a great virtue. b. Give the patient a pair of ear plugs and close the door. c. Move the family of the patient who just died to a room at the end of the hallway. d. Turn the patient's television's volume higher to drown out the humming.

7. c. Patients should be allowed to practice their spiritual and religious beliefs while ensuring that other patients' needs are met. Answer a gives advice and is disrespectful, and answers b and d dismiss the needs of the patient who is being disturbed by the chanting.

7. Which is a result of activation of the parasympathetic nervous system (PNS) ? a. High blood pressure b. Increased heart rate c. Pupil constriction d. Pupil dilation

7. c. The stimulation of the parasympathetic system, known for "rest and digest" functions, causes pupil constriction. The activation of the sympathetic nervous system causes pupil dilation, increased heart rate and force of contraction, and bronchial dilation.

7. The nurse, who has an assignment of five patients for the shift, follows a routine of getting bedside report from the outgoing nurse, assessing the patients, and providing immediate care as needed. What is the best practice for documenting? a. After finishing the shift b. At the nurse's station after passing scheduled medications c. When there is an unexpected occurrence with a patient d. While in the patient's room performing each procedure

7. d. The nurse should be documenting after each procedure because timely reporting is necessary. Documenting after busy hours of work or at the end of the shift could result in errors or forgetting to document important information. Unexpected occurrence reporting is not part of the patient's medical record; it is used by the hospital for risk management to prevent a repeat of the incident.

8. A nurse's brother is admitted to the hospital. The nurse opens and reads the brother's laboratory report in the electronic health record, per the mother's request, without the patient's permission. What will most likely happen to the nurse? a. The nurse will be criminally prosecuted. b. The nurse will be fined a minimum of $50,000. c. The nurse will be jailed for 10 years. d. The nurse will be retrained or terminated.

8. d. The nurse has committed a HIPAA violation and will most likely be terminated or retrained. Civil prosecution is more likely than criminal prosecution for HIPAA violations. Financial penalties are reserved for the most serious violations, such as those resulting in patient suffering.

1. As a patient is admitted to the ICU, the nurse documents that the skin is intact. The patient is in the unit for nearly a month, and a chart audit discovers that no wound care was charted and the wound care nurse consult was not done until the patient was transferred to a medical-surgical unit. At this time, the patient's skin is documented as having a stage II pressure ulcer on her coccyx. What does this lack of documentation indicate? a. Appropriate admission assessment b. Wound care was not done daily c. Medicare reimbursement will be possible d. The nursing role of care planning is not apparent

d. Documentation of the nursing process within this record provides essential data related to assessment, interventions, and goals. Clear, accurate, and up-to-date patient documentation is a cornerstone for safe care delivery providing flow of information between providers of care. If a patient record or portions of it are unavailable or inaccurate, a vital line of communication is blocked. Medicare and Medicaid stopped reimbursement in 2008 for some hospital-acquired complications, including pressure ulcers. The admission assessment is not an issue of lack of documentation.