nurs 406 test 3

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EAQs

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An individual with a history of verbal and physical abuse of others is beginning to demonstrate aggressive behavior toward a visitor. Place the following nursing interventions in the appropriate order to best ensure milieu safety. 1.Calmly addressing the individual by name to redirect the client's attention 2.Suggesting to the client, "Walk with me to your room." 3.Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt" 4.Explaining that the client will be placed in seclusion if the aggressive behavior continues 5.Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so

1.Calmly addressing the individual by name to redirect the client's attention 2.Suggesting to the client, "Walk with me to your room." 3.Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt" 4.Explaining that the client will be placed in seclusion if the aggressive behavior continues 5.Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so The initial action is to redirect the client's attention. The second action is to remove the client to a safe low-stimulus environment. The third action is to set limits by explaining why the behavior cannot be tolerated. The fourth action is to describe the outcome of not complying. Finally the client must be assured that if the client is unable to control the behavior, staff will help do so.

A client reports having a severe throbbing unilateral headache, nausea, and intolerance to light and sound. What is the chronologic order for the pathophysiologic events that are causing this headache? Arrange events in order from 1 to 5 with 1 being the first event. 1.Hyper-excitable neuronal pathway stimulation 2.Trigeminal nerve and nociceptor activation 3.Vasodilation, inflammation, and swelling 4.Prostaglandin release 5.Throbbing pain

1.Hyper-excitable neuronal pathway stimulation 2.Trigeminal nerve and nociceptor activation 3.Prostaglandin release 4.Vasodilation, inflammation, and swelling 5.Throbbing pain The classic signs of a migraine headache are throbbing and unilateral head pain with nausea and sensitivity to light, sound, and/or head movement. Hyper-excitable neuronal pathway stimulation initiates the migraine headache by starting many vascular changes. The trigeminal nerve pathway then activates and promotes nociceptor (pain receptor) activation. Cerebral artery dilation then facilitates prostaglandin release, and vasodilation promotes prostaglandins and other intravascular molecules to leak into surrounding tissue which contributes to widespread tissue inflammation and swelling and the sensation of throbbing pain. Prostaglandins are a well-known and significant contributor to the inflammatory process.

A client with posttraumatic stress disorder is admitted for depression and medication management. On the second night of hospitalization, the client awakens from a nightmare and begins threatening to strangle the roommate for "coming at me with that knife you've got hidden." Place the following nursing interventions in the appropriate order to best ensure client and milieu safety. 1.Remove roommate from the room 2.Remain with the client until the agitation is under control 3.Arrange for antianxiety medication to be administered as prescribed 4.Arrange for a private room the near nurses' station 5.Institute homicide precautions at night

1.Remove roommate from the room 2.Remain with the client until the agitation is under control 3.Arrange for antianxiety medication to be administered as prescribed 4.Arrange for a private room the near nurses' station 5.Institute homicide precautions at nigh Addressing the roommate's safety is the priority. For the client's safety, the client should not be left alone until the crisis has been managed. The extreme agitation will generally require both pharmaceutical and nonpharmaceutical measures. Once the crisis has been managed, the long-term safety of the client and milieu should be addressed. Instituting homicide precautions at night is appropriate in preparation for future nights.

The student nurse is collecting a clean-catch midstream urine specimen from a client suspected of urinary tract infection. After reviewing the results, the head nurse instructs the student nurse to repeat the procedure. Which finding in the urinalysis report supports the head nurse's instruction? 10^2 organisms/mL 10^6 organisms/mL 10^4 organisms/mL 10^8 organisms/mL

10^4 organisms/mL The reference interval 103 to 105 organisms/mL is usually not diagnostic and usually requires the test to be repeated. Therefore, the finding 104 organisms/mL supports the head nurse's instruction. The finding of 102 organisms/mL usually indicates no infection. A value greater than 105 organisms/mL indicates infection. The findings of 106 organisms/mL and 108 organisms/mL indicate infection and do not require repetition of the test.

A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis? Client A Client B Client C Client D

A client suffering from atelectasis may have decreased fremitus, dull percussion over the affected area, and crackle sounds upon auscultation like Client C. Decreased chest wall movements, hyperresonance, and wheezing indicate asthma in Client A. Client B with increased vibrations over the chest wall above effusion, dull percussion, and diminished or absent breath sounds over the affected area may have a pleural effusion. Client D with increased fremitus over the affected area, dull percussion over the affected area, and bronchial sounds upon auscultation may have pneumonia.

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. Provide a low-fat diet Administer analgesics Teach relaxation exercises Encourage walking in the hall Monitor cardiac rate and rhythm Observe for signs of hypercalcemia

Administer analgesics Teach relaxation exercises Monitor cardiac rate and rhythm Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be administered to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Relaxation will decrease the metabolic rate, which will decrease gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume changes. The client would be kept nothing by mouth to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Walking increases the metabolic rate, which will increase gastrointestinal activity, including the secretion of pancreatic enzymes. Hypocalcemia, not hypercalcemia, occurs because of calcium and fatty acids combining during fat necrosis.

A client is scheduled for an abdominal surgery. What is the priority preoperative nursing objective when caring for this client? Recording accurate vital signs Alleviating the client's anxiety Teaching about early ambulation Maintaining the client's nutritional status

Alleviating the client's anxiety Anxiety experienced by a preoperative client can be a disruptive force that may affect the client's ability to cope psychologically and physiologically. Anxiety must be alleviated for other nursing measures to be effective. Although vital signs are recorded because they will serve as a baseline in postoperative assessment, they are not the priority. Learning is hampered by high anxiety levels. The diet is limited before surgery so that residue in the intestines is decreased.

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply. Fatigue Anxiety Runny nose Diaphoresis Psychomotor agitation

Anxiety Diaphoresis Psychomotor agitation Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity. Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

A primary healthcare provider prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement? Complimenting the client's appearance Starting preparations for the client's discharge Arranging for constant supervision of the client Adding privileges to the client's plan of care as a reward

Arranging for constant supervision of the client A change in behavior that seems positive may actually indicate that the client has worked out a plan for suicide; the potential for suicide increases when physical energy returns. Increased supervision is needed. Complimenting the client's appearance may increase the client's feelings of inadequacy, because it implies that the client did not look good before. It is inappropriate to consider discharge simply because of a change in behavior. Many factors should be considered in the decision to discharge a client. The addition of privileges is not indicated at this time.

A depressed client is admitted to the hospital after being found bleeding from a superficial self-inflicted gunshot wound. The client does not respond to any of the nurse's questions. What should the nurse do to assess the client's current potential for suicide? Investigate the family's history of suicide. Ask the client the reason for the attempted suicide. Ask the family about any recent suicide attempts or threats by the client. Examine the client for scars on the wrists or other signs of past suicide attempts.

Ask the family about any recent suicide attempts or threats by the client. Because the client refuses to talk, pertinent data must be obtained from the family. Although information on a family history of suicide may eventually be obtained, it does not have immediate relevance to the client's recent behavior. The client is not responding to questions; the client may not know the reason for the attempt. Conclusions about the presence of scars are assumptions and may not be accurate.

A client reports neck stiffness, severe headache, and a decreased level of consciousness. What condition does the nurse suspect? Encephalitis Brain abscess Viral meningitis Bacterial meningitis

Bacterial meningitis Bacterial meningitis is caused by a bacterium such as Streptococcus pneumonia. Fever, severe headache, neck stiffness, photophobia, and decreased levels of consciousness are symptoms that indicate bacterial meningitis. Encephalitis is the acute inflammation of brain. Nausea and vomiting are symptoms of encephalitis. Headache, fever, nausea, and vomiting are the symptoms of brain abscess. Headache, fever, and photophobia are the symptoms of viral meningitis.

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min

Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply. Jaundice Boardlike abdomen Abdominal tenderness Decreased bowel sounds Rapid decrease in coagulation ability

Boardlike abdomen Abdominal tenderness Decreased bowel sounds A boardlike abdomen is associated with the inflammatory process in the peritoneum. Abdominal tenderness is caused by the local inflammatory process and resulting bowel distention and irritation of the peritoneum. A decrease or absence of bowel sounds occurs in response to bowel distention caused by gas and shifting of fluid into the bowel. Jaundice is not a sign of peritonitis; it is caused by a disturbance in bilirubin metabolism. A rapid decrease in coagulation ability is associated with acute liver failure, not peritonitis.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record? Botulism Bell palsy Trigeminal neuralgia Guillain-Barré syndrome

Botulism Bell palsy Trigeminal neuralgia Guillain-Barré syndrome Bell palsy is a cranial nerve disorder characterized by inflammation of the facial nerve on one side of the face. Botulism is a type of polyneuropathy caused by food poisoning due to Clostridium botulinum that can be fatal. Trigeminal neuralgia is a cranial nerve disorder characterized by pain in the distribution of the trigeminal nerve. Guillain-Barré syndrome is an acute, rapidly progressing, potentially fatal polyneuritis.

A client remains depressed even after an 8-week trial on several antidepressant medications. A decision to initiate electroconvulsive therapy (ECT) is being considered by the treatment team. Which condition is a contraindication to ECT? Brain tumor Type 1 diabetes Hypothyroid disorder Urinary tract infection

Brain tumor ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroid, or urinary tract infection.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected? CN III CN V CN VII CN VIII

CN III CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; thus the pupils will remain dilated even upon exposure to a light source. CN V is the trigeminal nerve, which is responsible for chewing. CN VII is the facial nerve; asymmetrical facial movements indicate damage to this nerve. CN VIII is the vestibulocochlear nerve; decreased hearing acuity or hearing impairment or equilibrium impairment may indicate damage to CN VIII.

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, specifically to avoid the intake of what? milk cheese coffee cabbage

Cabbage Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee should not cause excessive gas problems in moderation. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.

A client's laboratory report shows altered serum calcium concentration. Which hormones are responsible for this condition? Select all that apply. Calcitonin Thyroxine Glucocorticoids Growth hormone Parathyroid hormone

Calcitonin Parathyroid hormone Produced by the thyroid gland, calcitonin decreases the serum calcium concentration if it increases above the normal level. Parathyroid hormones increase and stimulate bones to promote osteoclastic activity and release calcium into the blood in response to low serum calcium levels. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to maintain the organic matrix of bone. Growth hormone helps to increase bone length and determine the amount of bone matrix formed before puberty.

Which information would the nurse include regarding appliance care and maintenance, when teaching a client with a new colostomy? Select all that apply. Change the ostomy pouch on a routine basis. Replace the ostomy wafer weekly or sooner as needed. Remove the ostomy pouch when showering. Empty the ostomy pouch when three-quarters full of stool or gas. Empty the ostomy pouch before exercise and at bedtime.

Change the ostomy pouch on a routine basis. Replace the ostomy wafer weekly or sooner as needed. Empty the ostomy pouch before exercise and at bedtime. Tips for limiting stool leakage are important for the client with an ostomy, in regards to comfort and dignity. Changing the ostomy pouch on a routine basis will decrease the risk of leakage. Twice weekly changes are considered typical. It is also recommended that the skin barrier (wafer) be changed at least once weekly and as needed if sooner, in order to protect the integrity of the skin beneath and around it. Emptying the pouch before activities and before bedtime will also help prevent leakage and overfill. It is recommended to shower or bathe with the pouch on, not off. This helps to maintain the integrity of the wafer and to prevent any stool from leaking onto the skin or into the shower while bathing. Clients should be instructed to have a new pouch at the ready, to be exchanged with the old pouch, after showering. Waiting to empty the pouch until it is more than one-half full increases the likelihood of leakage. Emptying the pouch sooner will prevent overfill and leakage.

The nurse is reviewing the urinalysis reports of four clients with renal disorders.Which client's finding signifies the presence of excessive bilirubin? Client 1 - amber yellow Client 2 - dark smoky color Client 3 - yellow brown to olive green Client 4 - orange red to orange brown

Client 3's urinalysis reports findings of the presence of yellow-brown to olive-green-colored urine which signifies excessive bilirubin. Client 1's urinalysis report findings of the presence of amber-yellow-colored urine signifies a normal finding. Client 2's urinalysis report findings of the presence of dark, smoky-colored urine signifies hematuria. Client 4's urinalysis report findings of orange-red or orange-brown-colored urine indicates the presence of phenazopyridine in the urine.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? Exercise to improve circulation Eat bland foods and avoid spices Consume a high-fiber diet and drink adequate water Use laxatives to avoid constipation and the Valsalva maneuver

Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

An 85-year-old client has a three-day history of nausea, vomiting, and diarrhea. The client develops weakness and confusion and is admitted to the hospital. To best monitor the client's rehydration status, what should the nurse assess? Skin turgor Daily weight Urinary output Mucous membranes

Daily weight A continuous increase in serial weight determinations indicates a movement toward correction in the dehydration; 1 L of fluid weighs 2.2 pounds (1 kilogram). The skin in older adults has less fluid and subcutaneous fat than in younger adults, which results in a subjective and inaccurate assessment of rehydration. In older adults there can be a decrease in renal blood flow and tubular function; therefore, urinary output does not provide an accurate assessment of rehydration therapy. The mucous membranes in older adults are drier than in younger adults because of the decrease in salivary secretions and therefore do not provide an accurate assessment of rehydration therapy.

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? Select all that apply. Guilt Denial Altruism Confusion Helplessness

Denial Confusion Helplessness Shock and disbelief are the initial responses to a traumatic experience; a situational crisis usually is unexpected, and its impact causes disequilibrium. Disequilibrium results in confusion, disorganization, and difficulty making decisions. When a person is unable to cope, helplessness and regression often emerge; a crisis occurs when there is a painful, frightening event that is so overwhelming an individual's usual coping mechanisms are inadequate. Feelings of guilt may emerge later when the individual moves from focusing on the self to increased interaction with others. Concern for others emerges later, after the individual is able to set aside or resolve his or her own needs.

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action? Irrigating the T-tube every hour Changing the dressing every two hours Encouraging coughing and deep breathing Promoting an adequate fluid and food intake

Encouraging coughing and deep breathing In an abdominal cholecystectomy, the incision is high, causing pain when the client is deep breathing. Self-splinting results in shallow breathing, which does not aerate or expand the lungs adequately, particularly the lower right lobe, leading to pneumonia. The client should be encouraged to deep breathe and cough, while splinting the incision with a pillow to help decrease the pain, yet expanding the lungs to decrease atelectasis or pneumonia. The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the primary healthcare provider then removes the tube. The nurse does not change the dressing in the immediate postoperative period; the client's respiratory status takes priority. The client will ingest nothing by mouth immediately after surgery.

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? Listing low-protein foods that may be included in the diet Explaining that fatty foods may not be tolerated for several weeks Teaching the importance of a low-calorie diet to promote weight reduction Encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal

Explaining that fatty foods may not be tolerated for several weeks Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder, the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. A low-protein diet is not necessary. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. While vitamin C, vitamin A, and zinc are important, they are not the priority.

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply. Fat cells in the urine PaO2 value of 58 mm Hg (7.73 kPa) Hematocrit value of 30% (0.30) Platelet count of 160,000/µL (160 x 109/L) Prothrombin time of 12 seconds

Fat cells in the urine PaO2 value of 58 mm Hg (7.73 kPa) Hematocrit value of 30% (0.30)

Which hormone aids in regulating intestinal calcium and phosphorous absorption? Insulin Thyroxine Glucocorticoids Parathyroid hormone

Glucocorticoids Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

Which client would the nurse state shows symptoms of influenza? Client 1 Client 2 Client 3 Client 4

Headache, muscle aches, fever, chills, fatigue, weakness, sore throat, cough, watery nasal discharge lasting for more than a week, nausea, vomiting, and diarrhea are the signs and symptoms of seasonal influenza, which is an acute, viral respiratory infection. Headache, nasal irritation, sneezing, nasal congestion, watery drainage from the nose, and itchy and watery eyes are the symptoms of rhinitis, an infection of the nose. A client with sinusitis, which is an infection of the sinuses, will show symptoms such as pain over the cheek, pain to the back of the head, and general facial pain that worsens when bending forward, purulent nasal drainage, and fever. Throat soreness and dryness, throat pain, pain on swallowing, difficulty swallowing, and fever are symptoms that may be experienced by a client with tonsillitis, which is an infection of the tonsils.

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing? allergic pyrogenic Hemolytic anaphylactic

Hemolytic A hemolytic transfusion reaction results from a recipient's antibodies that are incompatible with transfused red blood cells; it is called a type II hypersensitivity. The clinical findings are a result of red blood cell hemolysis, agglutination, and capillary plugging. An allergic transfusion reaction is the result of an immune sensitivity to foreign serum protein; it is called a type I hypersensitivity, and associated clinical findings include urticaria, wheezing, dyspnea, and shock. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; associated clinical findings include fever and chills, but not flank pain. An anaphylactic reaction may occur with an allergic transfusion reaction.

A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting? Illusion Hallucination Idea of reference Autistic thinking

Idea of reference An idea of reference, also called a delusion of reference, is a fixed, false personal belief that public events and people are connected directly to the client. An illusion is a misinterpretation of a sensory stimulus. A hallucination is a perceived experience that occurs in the absence of an actual sensory stimulus. Autistic thinking is a distortion in the thought process that is associated with schizophrenic disorders.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? Decreased blood supply Impaired neural functioning Perforation of the bowel wall Obstruction of the bowel lumen

Impaired neural functioning Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply. Impulsiveness Lability of mood Ritualistic behavior Psychomotor retardation Self-destructive behavior

Impulsiveness Lability of mood Self-destructive behavior Clients with borderline personality disorder often lead complex, chaotic lives because of their inability to control or limit impulses. Extremes of emotions, ranging from apathy and boredom to anger, may be displayed within short periods. Impulsive self-destructive acts such as reckless driving, spending money, and engaging in unsafe sex often result in negative consequences. Ritualistic behavior is associated with obsessive-compulsive disorders. Psychomotor retardation is associated with mood disorders such as depression.

A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz (4167 g). The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply. Stranger anxiety Inappropriate clothing Social unresponsiveness Frequent rocking motions Adequate personal hygiene

Inappropriate clothing Social unresponsiveness Frequent rocking motions Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment. The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.

What is the function of limbic system? Influence emotional behavior Regulate autonomic functions Facilitate automatic movements Relay sensory and motor inputs for cerebrum

Influence emotional behavior Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. What should the nurse be prepared to administer? A low-residue diet Intravenous therapy Total parenteral nutrition An oral electrolyte solution

Intravenous therapy Intravenous therapy ensures a well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed via a low-residue diet. Total parenteral nutrition is not necessary at this point, although it may eventually be used. Oral electrolyte solution is not a well-controlled method to correct electrolyte deficiencies.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? Inclusion of transmural involvement of the small bowel wall Higher occurrence of fistulas and abscesses from changes in the bowel wall Pathology beginning proximally with intermittent plaques found along the colon Involvement starting distally with rectal bleeding that spreads continuously up the colon

Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? It indicates dilute urine. It indicates blood in the urine. It indicates concentrated urine. It indicates the presence of myoglobin.

It indicates dilute urine. Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobin.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority? Keep the client nothing by mouth (NPO) Teach the client coughing and deep breathing Inquire whether any red or black stools have been noted Place the client in the supine position with the legs elevated

Keep the client nothing by mouth (NPO) The assessment findings are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Keeping the client NPO is priority. Teaching coughing and deep breathing is not appropriate at this time, even though the client will have surgery. Keeping the client NPO in preparation for surgery is more important than asking about the presence of black, tarry stools or red stools. Although this question should be asked, knowing whether any red or black stools have been noted will not change the medical or nursing care of the client at this time. Drawing up the knees is more comfortable for the client.

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior? Keep the client under close observation. Arrange for the client to have more visitors. Engage the client in preliminary discharge planning. Observe the client for side effects of the medication.

Keep the client under close observation. As the client's motivation and energy return, the likelihood that suicidal ideation will be acted out increases. There are no data regarding visitation rights; the priority concern is the greater risk for suicide. Although engaging the client in preliminary discharge planning eventually will be done, the priority is determining the potential for suicide. Although the client should be observed for side effects of the medication, the greater risk of suicide takes precedence.

Which type of drugs readily crosses the placenta? 'Polar drugs Ionized drugs Lipid-soluble drugs Protein-bound drugs

Lipid-soluble drugs Drugs that are lipid soluble penetrate the placenta in higher concentrations. Polar drugs are not transferred in higher concentrations through the placenta. Nonionized drugs are more likely to be transferred through the placenta than ionized drugs. Protein-bound drugs remain in the maternal plasma because the molecules are too large to cross the placenta.

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Calices Glomerulus Macula densa Juxtaglomerular cells

Macula densa The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

A client develops gastric bleeding and is hospitalized. Which area should the nurse assess most closely during the history? Usual dietary pattern Recent travel to other countries Medications taken routinely or recently A change in the status of family relationships

Medications taken routinely or recently Some medications, such as aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and prednisone, irritate the stomach lining and may cause bleeding with prolonged use. The client's usual dietary pattern is not the cause of gastric bleeding; it is important to ascertain dietary habits when teaching about diet therapy. Travel to other countries may be related to intestinal irritation, causing diarrhea and intestinal bleeding, not gastric bleeding. Although stress related to family relationships may play a part in the need for treatment, the use of some medications has a more direct relationship.

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when the client states that what is one major disadvantage of ECT? The seizures may cause bone fractures. Relief of symptoms requires many weeks of treatment. Memory is impaired after the treatment. Loss of mental function occurs and continues for a long time.

Memory is impaired after the treatment. Impaired memory is an expected side effect of the therapy. Succinylcholine prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? Tingling of the fingertips and toes Dry and sticky mucous membranes Abdominal cramping and irritability Muscle weakness and cardiac dysrhythmias

Muscle weakness and cardiac dysrhythmias Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia or hyperkalemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

A nurse is caring for a client with a hiatal hernia. Which risk factor should the nurse assess for in this client? Obesity Alcoholism Chronic bronchitis Esophageal varices

Obesity Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Alcoholism may cause gastritis, an enlarged liver, or pancreatitis, but not a hiatal hernia. Inflammation of the bronchi will not weaken the diaphragm. Esophageal varices result from increased portal pressure; they do not cause a hiatal hernia.

For two months a client has been taking nonprescription medications and has made dietary changes for symptoms of gastritis. Following assessment by a primary healthcare provider, a diagnosis of extensive carcinoma of the stomach is made. The client asks how the disease got so advanced. On which information about carcinoma of the stomach should the nurse base a response? Presents symptoms of severe pain for the client when in the early stages of the disease process Is a risk factor for clients who have an absence of pylori in the stomach Usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area Often is diagnosed late because symptoms are nonspecific during the early stages

Often is diagnosed late because symptoms are nonspecific during the early stages This cancer usually is asymptomatic in the early stages; the stomach accommodates the mass. Gastric cancer is painless in its early stages. There is an increased risk of developing stomach cancer if the client has an infection with H. pylori. Hodgkin disease, not gastric carcinoma, usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area.

Which part of the female reproductive system produces testosterone in females? Uterus Ovary Fallopian tube Ovarian follicle

Ovary Testosterone is an androgen, and in females, androgens are produced by the ovaries and adrenal glands. The uterus holds the fetus during pregnancy. Fallopian tubes facilitate fertilization of oocyte and sperm. An ovarian follicle is a collection of oocytes in the ovary.

Which is an abnormal finding of the urinary system? Nonpalpable left kidney Presence of bowel sounds Nonpalpable urinary bladder Pain in the flank region upon hitting

Pain in the flank region upon hitting Normally, a blow in the flank region should not elicit pain. Pain in the flank region upon hitting indicates kidney infection or polycystic kidney disease. But the client experiences pain when his/her flank area is hit; therefore, this is an abnormal finding. The left kidney is covered by the spleen and is not palpable, which is a normal finding. The client has bowel sounds. However, no alteration of bowel sounds is seen. Therefore it is a normal finding. The urinary bladder is not normally palpable, unless it is distended with urine.

A nurse is performing the initial history and physical examination of a client with a diagnosis of duodenal ulcer. Which type of pain does the nurse expect the client to describe? Pain that is relieved with eating Pain that is worse with antacids Pain that is relieved with sleep Pain that is worse one hour after eating

Pain that is relieved with eating Duodenal ulcer pain is relieved with food and antacids and often awakens the client at night when sleeping. Gastric ulcer pain is worse with eating or one hour after eating.

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney? Calyx Papilla Renal pelvis Renal column

Papilla Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

Which hormone is released in response to low serum levels of calcium? Renin Erythropoietin Parathyroid hormone Atrial natriuretic peptide

Parathyroid hormone If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis. Renin is a hormone released in response to decreased renal perfusion; this hormone is responsible for regulating blood pressure. Erythropoietin is released by the kidneys in response to poor blood flow to the kidneys; it stimulates the production of red blood cells. Atrial natriuretic peptide is produced by the right atrium of the heart in response to increased blood volume. This hormone then acts on the kidneys to promote sodium excretion, which decreases the blood volume.

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? Acute gastritis Diabetes mellitus Partial gastrectomy Unhealthy dietary habits

Partial gastrectomy Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. The beta cells of the pancreas are not involved in secretion of intrinsic factor. Dietary intake does not affect the production of intrinsic factor.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior? Providing thickened liquids to minimize the risk of aspiration Documenting intake and output each shift to monitor hydration Reinforcing appropriate social boundaries through staff role modeling Performing passive range-of-motion exercises three times a day for effective joint health

Performing passive range-of-motion exercises three times a day for effective joint health Waxy flexibility is an excessive and extended maintenance of posture that can lead to a variety of problems, including joint trauma. Passive range-of-motion exercises focus on the effective management of joint mechanics. Although aspiration precautions, documentation of intake and output, and staff role modeling may address issues experienced by a client with schizophrenia, passive range-of-motion exercises address waxy flexibility.

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? Disturbed self-esteem Potential for self-harm Dysfunctional verbal communication Impaired perception of environmental stimuli

Potential for self-harm Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus.

The nurse is educating new parents about circumcision. Which structure of the penis would this nurse tell the parents is removed during circumcision? Glans Prepuce Epididymis Vas deferens

Prepuce Circumcision is a procedure that involves removal of the prepuce, a skin fold over the glans. The glans is the tip of the penis. The epididymis is the internal structure that promotes transportation of the sperm. The vas deferens carries the sperm from the epididymis to the ejaculatory duct.

Which hormone is crucial in maintaining the implanted egg at its site? Inhibin Estrogen Progesterone Testosterone

Progesterone Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization? Board game Project involving drawing Small aerobic exercise group Card game with three other clients

Project involving drawing An art project that may be worked on successfully at one's own pace is appropriate for a depressed client. A board game or card game with three other clients require too much concentration and may increase the client's feelings of despair. This client is probably experiencing psychomotor retardation, and at this time an aerobic exercise group would not be appropriate.

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. Touching the client to provide reassurance Providing a structured environment for the client Ensuring that the client's nutritional needs are met Engaging the client in conversation about current affairs Designing activities that require the client to maintain contact with reality

Providing a structured environment for the client Ensuring that the client's nutritional needs are met Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorder are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine? Risk for self-injury Potential for seizure Danger of dehydration Probability of injuring others

Risk for self-injury The greatest risk in cocaine withdrawal is risk for self-injury. The risk for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. People in cocaine withdrawal, although irritable, are more apt to hurt themselves than others.

The nurse interviews a young client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? Select all that apply. Ritualistic behaviors Desire to improve self-image Supportive parent-child relationship Low achievement in school and little concern for grades Satisfaction with and a desire to maintain current weight

Ritualistic behaviors Desire to improve self-image Clients with anorexia nervosa typically have a history of ritualistic behaviors, rigidity, and meticulousness, reflecting a need for control. Clients with anorexia nervosa have a disturbed self-image and always see themselves as fat and needing further weight loss. The relationship between parent and child is often not supportive but instead conflicted. Usually there is high achievement and great concern about grades. Usually there is dissatisfaction with weight and a desire to lose weight.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? Stating, "You must take your medicine now." Saying, "I'll be back in a few minutes so we can talk." Explaining why it is necessary to take the medication. Withholding the medication before notifying the primary healthcare provider.

Saying, "I'll be back in a few minutes so we can talk." Saying, "I'll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept logical explanations when angry. Alternative nursing interventions should be attempted before withholding the medication and notifying the primary healthcare provider, although these may become necessary.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse? Reflecting feelings Making observations Seeking consensual validation Attempting to place events in sequence

Seeking consensual validation Seeking consensual validation is a technique that prevents misunderstanding so that both the client and the nurse can work toward a common goal in the therapeutic relationship. Reflection of feelings is used to increase client awareness but should not be used when the nurse is unsure of what the client is saying. Making observations refers more to nonverbal than to verbal communication. Placing events in a sequence helps organize content, but ideas should be clarified first by means of validation if the nurse is unsure of the meaning of what is being said.

Which electrolyte deficiency triggers the secretion of renin? Sodium Calcium Chloride Potassium

Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

Upon palpation, the nurse identifies spongy swelling caused by synovial fluid. Which joint was most likely palpated? Biaxial joint Pivotal joint Synovial joint Temporomandibular joint

Temporomandibular joint The temporomandibular joint is palpated by asking the client to open his or her mouth; the nurse checks for any pain or weakness in the face. Common abnormal findings include tenderness, crepitus (a grating sound), and a spongy swelling caused by excess synovial fluid. Biaxial joints help in the gliding movement of the wrist. Pivot joints permit rotation in the radioulnar area. Synovial joints provide movement at the point of contact of articulating bones such as the hip, shoulders, and knees.

A client confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client? The client intends to frighten the nurse. The client wants attention from the staff. The client feels safe and can share feelings with the nurse. The client is fearful of the impulses and is seeking protection from them.

The client is fearful of the impulses and is seeking protection from them. Clients frequently report suicidal feelings so the staff will have the chance to stop them. They are really asking, "Do you care enough to stop me?" It may be true that the client feels safe and can share feelings with the nurse, but, more importantly, the client is seeking help and protection. It may be true that the client wants to frighten the nurse or wants attention from the staff, but these are unlikely motivations for the behavior.

A client reports severe itching with redness and wheals on the uncovered parts of the legs after sleeping in an old bed. The primary healthcare provider prescribes antihistamines and topical corticosteroids. Which assessment finding made by the nurse supports the intervention? Spreading, ring-like rash with erythema border after 3 to 4 weeks Presence of burrows with erythematous papules with possible vesiculation Utricaria grouped in threes surrounded by vivid flare, transforming into persistent lesion Progression of minute red points to papular wheal-like lesions with secondary excoriation

Utricaria grouped in threes surrounded by vivid flare, transforming into persistent lesion Bedbugs reside in furniture, bedding, and walls and usually feed during night time. Bedbug bites manifest as urticaria grouped in threes surrounded by vivid flare, transforming into persistent lesion. Severe itching due to bedbug bites is treated with antihistamines or topical corticosteroids. Tick bites manifest as spreading, ring-like rash with erythema border after 3 to 4 weeks and are treated with oral and intravenous antibiotics. Scabies manifest with the presence of burrows with erythematous papules with possible vesiculation and interdigital web crusting. It is treated with 5% permethrin topical lotion. Head lice bites manifest as minute, red, noninflammatory points flush with the skin that progress to papular wheal-like lesions with secondary excoriation in intrascapular region. These bites are treated with γ-benzene hexachloride or pyrethrins.

A client with liver dysfunction states, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. Which vitamin does the nurse conclude the client needs? Vitamin D Vitamin E Vitamin A Vitamin K

Vitamin K Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors. Vitamin D and E are not involved in the clotting process. Vitamin A is not involved in the clotting process, even though the transformation of carotene to vitamin A takes place in the liver.

A client with the diagnosis of bipolar disorder, manic episode, attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? Doing a needlepoint project Joining a brief swimming competition Walking around the facility with a nurse Playing a board game with another client

Walking around the facility with a nurse Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question? Malignant growth Pocket of undigested food particles Sac filled with pus from necrotic pancreatic tissue Walled-off space of pancreatic enzymes and exudate

Walled-off space of pancreatic enzymes and exudate A pseudocyst of the pancreas is a walled-off space that contains fluid, pancreatic enzymes, tissue debris, and inflammatory exudate. A malignant growth is cancer. A pseudocyst is not a pocket of undigested food particles. A pancreatic abscess is a sac filled with pus from necrotic pancreatic tissue.

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? Warfarin Nifedipine Nitrofurantoin Phenazopyridine

Warfarin Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.

key points

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1. Which statement demonstrates a well-structured attempt at limit setting? a. "Hitting me when you are angry is unacceptable." b. "I expect you to behave yourself during dinner." c. "Come here, right now!" d. "Good boys don't bite."

a. "Hitting me when you are angry is unacceptable."

4. What assessment question should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply. a. "How did you cope when your father deployed with the Army for a year in Iraq?" b. "Who did you go to for advice while your father was away for a year in Iraq?" c. "How do you feel about talking to a mental health counselor?" d. "Where do you see yourself in 10 years?" e. "Do you like the school you go to?"

a. "How did you cope when your father deployed with the Army for a year in Iraq?" b. "Who did you go to for advice while your father was away for a year in Iraq?" d. "Where do you see yourself in 10 years?"

4. When considering community suicide prevention programs, what population should the nurse plan to service with regular suicide screenings? Select all that apply. a. 10- to 34-year-olds b. Males c. College-educated adults d. Rural population e. Native American

a. 10- to 34-year-olds b. Males e. Native American

2. Which interventions will help make the environment on the unit safer for suicidal patients? Select all that apply. a. All windows are kept locked. b. Every shower has a breakaway shower rod. c. Eating utensils are counted when trays are collected. d. Patient doors are kept open. e. Staying within listening distance of the patient.

a. All windows are kept locked. b. Every shower has a breakaway shower rod. c. Eating utensils are counted when trays are collected. d. Patient doors are kept open.

7. In pediatric mental health there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply. a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit c. Markedly increased funding d. Premature termination of services

a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit d. Premature termination of services

4. The older patient is discussing chronic pain and asks the primary care provider for a prescription. Which medication should the nurse anticipate being ordered rather than an opioid? a. Gabapentin b. Acetaminophen c. Morphine d. Fentanyl

a. Gabapentin

3. What are the nursing responsibilities to a patient expressing suicidal thoughts? Select all that apply. a. Instituting one-to-one observation. b. Documenting the patient's whereabouts and mood every 15 to 30 minutes. c. Ensuring that the patient has no contact with glass or metal utensils. d. Ensuring that patient has swallowed each individual dose of medication. e. Discussing triggers of depression.

a. Instituting one-to-one observation. b. Documenting the patient's whereabouts and mood every 15 to 30 minutes. c. Ensuring that the patient has no contact with glass or metal utensils. d. Ensuring that patient has swallowed each individual dose of medication.

A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea

a. Intense nausea b. Diaphoresis d. Confusion e. Dyspnea

5. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. a. Limited language skills b. Level of cognitive development c. Level of emotional development d. Parental denial that a problem exists e. Severity of the typical mental illnesses observed in young children

a. Limited language skills b. Level of cognitive development c. Level of emotional development

Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy

a. Pupils are dilated d. Extreme anxiety

6. Pam, the nurse educator, is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (5) restrictive: a. With the patient identify the behaviors that are unacceptable and consequences associated with harmful behaviors b. Placing the patient in physical restraints c. Allowing the patient to take a time-out and sit in his or her room d. Offering a PRN medication by mouth e. Placing the patient in a locked seclusion room

a1 d2 c3 e4 b5

Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Eileen is so upset."

b. "Gambling activates the reward pathways in my brain."

1. Which patient statement does not demonstrate an understanding of a suicide safety plan? a. "I know that when I start thinking about my dad, I'm going to start thinking about killing myself." b. "Going for a really long, hard run helps clear my mind and stops the suicidal thoughts." c. "My sister is always there for me when I start getting suicidal." d. "I keep the suicide prevention phone number in my wallet."

b. "Going for a really long, hard run helps clear my mind and stops the suicidal thoughts."

1. During an interview with a patient, which question asked of an older adult is associated with the Patient Self-Determination Act? a. "Who besides yourself may have access to your medical information?" b. "Have you discussed your end-of-life choices with your family or designated surrogate?" c. "Do you have the information you need to make an informed decision about your treatment?" d. "How can I help you feel comfortable about this interview and any decisions you need to make?"

b. "Have you discussed your end-of-life choices with your family or designated surrogate?"

3. Cognitive-behavioral therapy is going well when a 12-year- old patient in therapy reports to the nurse practitioner: a. "I was so mad I wanted to hit my mother." b. "I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd." c. "I forgot that you told me to breathe when I become angry." d. "I scream as loud as I can when the train goes by the house."

b. "I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd."

5. Which statement by an older patient with a mild neurocognitive disorder demonstrates a safe response to beginning a new medication? a. "I read the information the pharmacist gave me when I got the prescription filled." b. "My daughter comes with me to appointments so that we get all the information we need." c. "I know I can call my doctor if I think of any questions later." d. "I always follow the instructions on the medication bottle."

b. "My daughter comes with me to appointments so that we get all the information we need."

7. Martin is a 23-year-old male with a new diagnosis of schizophrenia, and his family is receiving information from a home health nurse. The topic of education is suicide prevention, and the nurse recognizes effective teaching when the mother says: a. "Persons with schizophrenia rarely commit suicide." b. "Suicide risk is greatest in the first few years after diagnosis." c. "Suicide is not common in schizophrenia due to confusion." d. "Most persons diagnosed with schizophrenia die of suicide."

b. "Suicide risk is greatest in the first few years after diagnosis."

9. Marco, age 83, has dementia and difficulty feeding himself despite the fact that there is nothing wrong with his motor functions. Which term should the nurse use to document this finding? a. Aphasia b. Apraxia c. Agnosia d. Disinhibition anergia

b. Apraxia

10. Kara is a 23-year-old patient admitted with depression and suicidal ideation. Which intervention(s) would be therapeutic for Kara? Select all that apply. a. Focus primarily on developing solutions to the problems leading the patient to feel suicidal. b. Assess the patient thoroughly and reassess the patient at regular intervals as levels of risk fluctuate. c. Avoid talking about the suicidal ideation as this may increase the patient's risk for suicidal behavior. d. Meet regularly with the patient to provide opportunities for the patient to express and explore feelings. e. Administer antidepressant medications cautiously and conservatively because of their potential to increase the suicide risk in Kara's age group. f. Help the patient to identify positive self-attributes and to question negative self-perceptions that are unrealistic.

b. Assess the patient thoroughly and reassess the patient at regular intervals as levels of risk fluctuate. d. Meet regularly with the patient to provide opportunities for the patient to express and explore feelings. e. Administer antidepressant medications cautiously and conservatively because of their potential to increase the suicide risk in Kara's age group. f. Help the patient to identify positive self-attributes and to question negative self-perceptions that are unrealistic.

10. Adolescents often display fluctuations in mood along with undeveloped emotional regulation and poor tolerance for frustration. Emotional and behavioral control usually increases over the course of adolescence due to: a. Limited executive function b. Cerebellum maturation c. Cerebral stasis and hormonal changes d. A slight reduction in brain volume

b. Cerebellum maturation

Maxwell is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Maxwell has been working for 36 hours straight without eating and has consumed eight double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome

b. Dehydration and caffeine overdose

The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low stimulus environment. d. Advocate for at least 3 months of treatment.

b. Manage the patient's withdrawal symptoms well.

10. You are caring for Ellie, age 91, whose provider has written a "DNR-CCO" order. Which nursing action would be appropriate if Ellie were to go into cardiac arrest? a. Immediately call for the code team b. Notify the attending physician and family of the change in status c. Administer prescribed medication morphine for pain control d. Initiate cardiopulmonary resuscitation

b. Notify the attending physician and family of the change in status

8. Sigmund Freud, Karl Menninger, and Aaron Beck theorized that hopelessness was an integral part of why a person commits suicide. A more recent theory suggest suicide results from: a. Elevated serotonin levels b. The diathesis-stress model c. Outward aggression turned inward d. A lack of perfectionism

b. The diathesis-stress model

9. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: a. Time-out is an important part of April's baseline discipline. b. Time-out is no longer an effective therapeutic measure. c. April enjoys time-out, and acts out to get some alone time. d. Time-out will need to be replaced with seclusion and restraint.

b. Time-out is no longer an effective therapeutic measure.

6. Anxiety problems in older adults can manifest as a fear of falling, greatly influencing an older adult's personal freedom. A home health nurse checking on a patient with mild dementia and anxiety related to falling should question which new order? a. Yoga and tai-chi b. Xanax c. Relaxation techniques d. Electric wheelchair

b. Xanax

2. Which statement made by a nurse requires immediate correction by the supervisor? a. "Many older patients are depressed." b. "Retirement is a difficult time for older patients." c. "Cognitive decline is normal in patients who are 65 and older." d. "Sleep-related problems are often reported by older adults."

c. "Cognitive decline is normal in patients who are 65 and older."

6. Gladys is seeing a therapist because her husband committed suicide 6 months ago. Gladys tells her therapist, "I know he was in pain, but why didn't he leave me a note?" The therapist's best response would be: a. "He probably acted quickly on his impulse to kill himself." b. "He did not want to think about the pain he would cause you." c. "He was not able to think clearly due to his emotional pain." d. "He thought you may think it was an accident if there was no note."

c. "He was not able to think clearly due to his emotional pain."

9. Which person is at the highest risk for suicide? a. A 50-year-old married white male with depression who has a plan to overdose if circumstances at work do not improve. b. A 45-year-old married white female who recently lost her parents, suffers from bipolar disorder, and attempted suicide once as a teenager. c. A young single white male who is alcohol dependent, hopeless, impulsive, has just been rejected by his girlfriend, and has ready access to a gun he has hidden. d. An older Hispanic male who is Catholic, is living with a debilitating chronic illness, is recently widowed, and who states, "I wish that God would take me too."

c. A young single white male who is alcohol dependent, hopeless, impulsive, has just been rejected by his girlfriend, and has ready access to a gun he has hidden.

Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is: a. Risk for injury/Remains free from injury b. Ineffective denial/Accepts responsibility for behavior c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs d. Risk for suicide/Expresses feelings, plans for the future

c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs

8. Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his "nice" mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect

c. Resilience

3. Considering psychosocial role theory, which patient demonstrates healthy adjustment to aging? a. The 70-year-old who is training for a 5-mile running race b. The older adult who controls diabetes with diet and exercise c. The retiree who volunteers 3 days a week at the local library d. The 80-year-old who is upbeat and hopeful during chemotherapy for lung cancer

c. The retiree who volunteers 3 days a week at the local library

Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time

c. Tolerance

7. Fred is an older adult with spinal stenosis and who is being treated with a short-term prescription of opioids for an acute episode of back pain. His nurse recognizes additional teaching is necessary when Fred states: a. "Sitting up straight seems to reduce the pain." b. "Sometimes I use a heating pad on my back." c. "Once I get moving for the day my pain gets better." d. "My wife and I share my Norco for our aches and pains."

d. "My wife and I share my Norco for our aches and pains."

What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

8. Ling works as a registered nurse in an Alzheimer's care home. Ling has a specialized rapport-building technique she uses called reminiscence. She uses this technique by: a. Telling the residents stories about her grandparents' lives. b. Playing music from the residents' formative years. c. Reviewing movies that the residents enjoy. d. Encouraging the residents to talk about pleasurable past events.

d. Encouraging the residents to talk about pleasurable past events.

5. Research supports which intervention implemented on a long-term basis significantly reduces the incidence of suicide and suicide attempts in a patient diagnosed with bipolar disorder? a. A selective serotonin reuptake inhibitor (SSRI) b. Electroconvulsive therapy (ECT) c. One-on-one observation d. Lithium

d. Lithium

Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change

d. Not ready to change

2. Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis

d. Tennis

ch 11 childhood and neurodevelopmental disorders pg 171-190, 566-583

• One in five children and adolescents in the United States suffers from a major mental illness that causes significant impairments at home, at school, with peers, and in the community. • Factors known to affect the development of mental and emotional problems in children and adolescents include genetic influences, biochemical (prenatal and postnatal) factors, temperament, psychosocial developmental factors, social and environmental factors, and cultural influences. • The characteristics of a resilient child include an adaptable temperament, the ability to form nurturing relationships with surrogate parental figures, the ability to distance the self from emotional chaos in parents and family, good social intelligence, the ability to perceive a future, and problem-solving skills. • Use seclusion and restraint as last resorts after less restrictive interventions have failed and only in the case of dangerous behavior toward self or others. Seclusion and restraint require continuous monitoring by trained staff and must not be used as a punishment. Notify parents/guardians if such measures are used. • Communication disorders are a deficit in language skills acquisition that creates impairments in academic achievement, socialization, or getting self-care. • Motor disorders are manifested by impairments in gross and fine motor skill acquisition. They can range from mild to profound in severity. Purposeless, repetitive movements that interfere with daily living activities characterize stereotypic movement disorders. • Tics are sudden, nonrhythmic, and rapid motor movements or vocalizations. Tic disorders vary in severity and degree of interference with the child's social and academic functioning. • Learning disorders may be in the areas of reading, mathematics, or written expression with performance in those areas below the level expected for the age and cognitive level. Interventions are designated in an Individualized Education Program (IEP) and provided through special education in public schools. • Autism spectrum disorder typically occurs within the first 3 years of life, yielding deficits in social interaction and communication skills. Children with autism spectrum disorder are referred to early intervention programs and continue to receive school-based services as they enter the public education system. • Attention-deficit/hyperactivity disorders are evidenced by symptoms of inattentiveness and/or hyperactivity and impulsivity that are developmentally inappropriate. These disorders cause the child problems in a number of settings, such as home, school, and community. ADHD is treated primarily with stimulant medications and behavioral therapies. • Treatment of childhood and adolescent disorders requires a multimodal approach in almost all instances, and family involvement is seen as critical to improvement in outcomes. • Nurses can be important advocates for children with severe emotional and behavioral disorders.

substance-related and addictive disorders varcolis pg 407-429

• Substance-related and addictive disorders are complex brain diseases characterized by craving, seeking, and using regardless of consequences. • Most substance use disorders are characterized by addiction, intoxication, tolerance, and withdrawal. • The cause of substance use is a combination of biological and environmental factors. • Assessment of patients with substance use problems needs to be comprehensive and aimed at identifying common medical and psychiatric comorbidities. • Clients with a co-occurring diagnosis have more severe symptoms, experience more crises, and require longer treatment for successful outcomes. • Substance use affects the family system of the patient and may lead to codependent behavior in family members. • Relapse is an expected complication of substance use, and treatment includes a significant focus on teaching relapse prevention. • Successful treatments include an integrated approach, self-help groups, psychotherapy, therapeutic communities, and psychopharmacotherapy. • Nurses need to be aware of their own feelings about substance use so that they can provide empathy and hope to patients. • Nurses are at higher risk for substance use disorders and should be vigilant for signs of impairment in colleagues to ensure patient safety and referral to treatment for the chemically dependent nurse. • A variety of settings are helpful in meeting the needs of individuals who are trying to maintain recovery from alcohol.

suicide & nonsuicidal self injury ch 25 mental health

• Suicide is a significant public health problem in the United States and should be approached as a "never event." • Specific biological, psychosocial, and cultural factors increase the risk of suicide. • Treating the coexisting psychiatric disorder may help most patients with suicidal ideation. • Certain health conditions and psychiatric diagnoses are associated with increased risk for suicide. • Every suicide attempt must be taken seriously even if the person has a history of multiple attempts. • Nursing care of the patient who is suicidal is challenging but rewarding. Patients' desperate feelings evoke intense reactions in staff, but most people with suicidal behaviors respond to treatment and do not complete suicide. • If a patient completes suicide, family, friends, and healthcare workers are traumatized and need postvention in terms of support, possibly including referrals for psychiatric treatment. • Nonsuicidal self-injury is a problem that is becoming increasingly important, especially among young people. • Treatment of patients with suicidal and nonsuicidal self-injury behaviors involves an interdisciplinary team working together to implement plans of care developed with support of the patient's family and friends.

older adult behavioral health ch 31 mental health

• The older adult population is increasing exponentially. • The increase in the number of older adults poses a challenge not only to nurses but also to the entire healthcare system to respond to the special needs of this population. • Attitudes toward older adults are often negative, reflecting ageism—a bias against older adults based solely on age. Ageism occurs at all levels of society and even among healthcare providers, which affects the way we render care to our older patients. • Maintaining a positive regard that demonstrates respect will improve interactions with older adults. • Nurses who care for older adults in various settings may function at different levels. All should be knowledgeable about the process of aging and be aware of the differences between normal and abnormal aging changes. • The Patient Self-Determination Act established guidelines and a philosophy of care that call for patients to be free from unnecessary use of drugs and physical restraints. • The use of more than five medications doubles the risk of an adverse reaction. • Accurate pain assessment is important, and the nurse must remember that older adults tend to understate their pain. • Nurses working with older adult patients with concurrent mental health problems should be knowledgeable about psychotherapeutic approaches relevant for the older adult. • When it comes to dying and death, older adults' wishes and those of their families are frequently ignored. The implementation of the Patient Self-Determination Act, passed in 1990, allows patients autonomy and dignity in death. • A variety of treatment settings are available to older adults. The level of disability, cognitive abilities, and psychiatric disorders influence the choice of setting.