Unit 4 - Foundation Ch. 25, 30, 31, 34; Patho Ch. 7, 20 - Study Bank Questions (part 1)

A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance? a) Furosemide, a diuretic b) Phenytoin, an anticonvulsant c) Glyburide, an antidiabetic d) Heparin, an anticoagulant

ANS: B Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances.

A patient with a history of seizures who takes phenytoin is at risk for which oral problem? a) Dryness of the mouth b) Bitter taste c) Demineralization of the tooth enamel d) Gingival hyperplasia

ANS: D Phenytoin causes gingival hyperplasia. Medications such as atropine cause dry mouth. Bitter taste can result from drugs such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel.

While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest? a) Inadequate dietary intake b) Normal aging process c) Fungal infection d) Excessive use of silver salts

ANS: A Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish-gray discoloration of the nail plate signals excessive intake of silver salts.

A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration? a) "The portion of your eye called the macula, which is responsible for central vision, is damaged." b) "Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time." c) "The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens." d) "There's an irregular curvature of your cornea, causing your blurred vision."

ANS: A Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? a) Acute b) Chronic c) Intractable d) Neuropathic

ANS: A Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.

How should the nurse classify pain that a patient with lung cancer is experiencing? a) Radiating b) Deep somatic c) Visceral d) Referred

ANS: A Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. Deep somatic pain is localized and can be described as achy or tender. Cutaneous pain occurs in the superficial layers of the skin or subcutaneous tissue. Radiating pain starts at the source and extends to other locations. Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Visceral pain is not well localized and can be described as tight, pressure, or crampy pain.

A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? a) Caution the patient against combining acetaminophen with alcohol. b) Explain that acetaminophen increases the risk for bleeding. c) Advise taking acetaminophen with meals to prevent gastric irritation. d) Explain that physical dependence may occur with long-term oral use.

ANS: A Even in recommended doses, acetaminophen can cause hepatoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. NSAIDs, not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence.

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? a) Stimulate the patient. b) Prepare to administer naloxone (Narcan). c) Administer a dose of pain medication. d) Notify the physician immediately.

ANS: A If the patient's score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patient's respiratory rate is less than 8 breaths/min; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated.

A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed to plan interventions for that symptom? a) Asking the patient whether foods taste different now b) Checking the patient's sense of smell c) Having the patient stand to check for balance d) Assessing for a history of seizures

ANS: A Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related to the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? a) Distraction b) Guided imagery c) Sequential muscle relaxation d) Hypnosis

ANS: A Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state.

The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? a) "I can contract the infection by walking barefoot in the gymnasium's showers." b) "The best way to avoid contracting the infection is to use good handwashing." c) "Wearing unventilated shoes prevents the fungus from gaining contact with my feet." d) "There is really no way to prevent its spread; it's highly contagious."

ANS: A One can contract the infection by walking barefoot in public showers, such as those in the school's gymnasium. Good handwashing does not prevent a person from contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. Although the infection is highly contagious, the spread of infection can be prevented by wearing special footwear in the shower.

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? a) Anticoagulant therapy b) Diabetes mellitus c) Hypertension d) Embolectomy

ANS: A Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm.

Which assessment finding is considered an age-related change? a) Presbycusis b) Hyperopia c) Increased sensitivity to touch d) Increased sensitivity to taste

ANS: A Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain? a) Selective serotonin reuptake inhibitor b) Selective norepinephrine reuptake inhibitor c) Opioid analgesic d) Anti-emetic

ANS: A The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, such as atomoxetine (Strattera), are commonly used for attention deficit-hyperactivity disorder. If a narcotic is used for a long time (oxycodone [Oxycontin]), it may become habit forming (causing mental or physical dependence). Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An antiemetic, such as ondansetron (Zofran), is used to control for nausea and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an antiemetic to control the side effect.

When should the nurse assess pain? a) Whenever a full set of vital signs is taken b) During the admission interview c) Every 4 hours for the first 2 days after surgery d) Only when the patient reports pain

ANS: A The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia.

A patient is prescribed morphine sulfate 4.0 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? a) Monitor the patient's respiratory status. b) Auscultate the patient's heart sounds. c) Check blood pressure in supine and sitting positions. d) Monitor the patient for psychological drug dependence.

ANS: A The nurse should assess the patient's respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to check blood pressure while the patient lies down (supine position) and sits up. Psychological dependence occurs rarely even after long-term prescribed use of morphine. Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drug dependence.

Which step should the nurse take first when performing otic irrigation in an adult? a) Warm the irrigation solution to room temperature. b) Position the patient so she is sitting with her head tilted away from the affected ear. c) Straighten the ear canal by pulling up and back on the pinna. d) Place the tip of the nozzle into the entrance of the ear canal.

ANS: A The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patient's head. Then continue irrigating until the canal is clean.

For which patient is it most important to provide frequent perineal care? The patient: a) With active lower gastrointestinal bleeding b) Who has had an episode of diabetic ketoacidosis c) Who has a circumcised penis d) With a history of acute asthma

ANS: A The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.

What is typically the most reliable indicator of pain? a) Patient's self-report b) Past medical history c) Description by caregiver(s) d) Behavioral cues

ANS: A The patient's self-report is the most reliable indicator of pain. A patient's facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patient's experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. Sociocultural factors can influence a patient's nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression or anxiety, can influence the perception of pain.

Which structure within the brain is responsible for consciousness and alertness? a) Reticular activating system b) Cerebellum c) Thalamus d) Hypothalamus

ANS: A The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? a) Blood pressure 160/82 mm Hg b) Temperature 100.6°F c) Heart rate 80 beats/min d) Oxygen saturation 95%

ANS: A This patient has an elevation in blood pressure, which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.

The nurse is caring for an immobile patient with chronic, unrelieved pain that is frequently severe. For what potential complication should the nurse monitor? a) Deep vein thrombosis b) Hypotension c) Dehydration d) Hypoglycemia

ANS: A This patient has an existing mobility problem. Unrelieved, chronic pain further contributes to reduced activity, which can lead to venous stasis and hypercoagulation. This combination of factors puts the client at risk for deep vein thrombosis. Hypertension is more likely to result than hypotension. Fluid overload, rather than dehydration, is more likely to occur secondary to excessive aldosterone, ADH, cortisol, angiotensin II, catecholamine, and prostaglandin secretion. Owing to decreased insulin production in immobility, hyperglycemia is more likely to result than is hypoglycemia.

Which action should the nurse be sure to take when preparing a patient for a bed bath? a) Place the nurse call device within reach. b) Cover the patient with the top linens from the bed. c) Have the patient completely bathe himself to promote independence. d) Wash the patient's body without assistance from the patient.

ANS: A When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place prepackaged bathing product, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an "assist bath."

For which patient(s) should the nurse avoid using back massage? Select all that apply. a) One who underwent heart surgery 3 days ago b) One who sustained rib fractures from a fall c) One who underwent a lumbar laminectomy d) One who sustained a leg fracture in a sledding accident

ANS: A, B Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or leg fracture.

Which of the following interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate touch when providing care. c) Turn on bright, fluorescent light for reading. d) Encourage waiting to drink water until after the meal. e) Offer spicy seasoning for the resident to use on food.

ANS: A, B Talking to the patient while providing care is not only important for personal and meaningful interaction, but also reduces social isolation and sensory deprivation. If the patient consents, you can stimulate the sense of touch by brushing his hair or giving a back rub, for example. However, use touch carefully, considering personal and cultural preferences, while observing the patient's reaction. Provide enough light, but avoid glare; use soft, diffuse lighting, not bright, fluorescent light. Teach clients to drink water between bites (not waiting until after the meal) to distinguish the taste of the food more readily. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods and encourage the client's appetite. But avoid overseasoning food with excessively spicy food that overpowers the person's sense of taste.

The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings would increase her suspicion? Select all that apply. a) Disorientation b) Restlessness c) Hallucinations d) Depression e) Preoccupation with somatic complaints

ANS: A, B The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. Sensory deprivation also leads to irritability, confusion, reduced problem-solving, and impaired attention span; but unlike sensory overload, the person with sensory deficit experiences depression, preoccupation with somatic complaints, hallucinations, and delusions.

Sensory changes that occur with aging include which of the following? Select all that apply. a) Decreased number of nerve conduction fibers results in slower reflexes. b) The lens of eye becomes less flexible and less able to focus on near objects. c) Taste buds atrophy and decrease in number, causing decreased ability to perceive taste. d) Impaired regulation of body temperature causes an increased risk for seizures. e) The amount and waxiness of cerumen increases with aging.

ANS: A, B, C A decreased number of nerve conduction fibers resulting in slower reflexes, less flexibility of the lens resulting in decreased ability to focus on near objects, and atrophy of taste buds resulting in decreased ability to taste are all sensory changes that occur with aging. Regulation of body temperature is not a sensory deficit. Cerumen is drier and more solid with aging, creating hearing loss.

Which of the following populations are considered high risk for sensory deprivation? Select all that apply, a) The homebound b) Those in prison c) Those who are depressed d) Those experiencing high anxiety e) Those feeling pain

ANS: A, B, C A nonstimulating, monotonous environment increases the risk for sensory deprivation, such as people who are in prison or who are homebound. Patients with depression are at risk for sensory deprivation, as they might be withdrawn from others and activities or less apt to interact within the usual context of their lives. Patients with anxiety often experience sensory overload. Pain lowers the threshold for processing sensory input, which increases the risk for sensory overload.

Which of the following medical conditions has a direct effect on sensory function contributing to sensory deficits? Select all that apply. a) Diabetes b) Hypertension c) Multiple sclerosis d) Breast cancer e) Zinc deficiency

ANS: A, B, C, E Diseases that affect circulation may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. Diabetic retinopathy is the leading cause of blindness among adults ages 20 to 74. Hypertension, too, can damage the retina of the eyes. Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. There is no indication that breast cancer leads to sensory deficits. Zinc deficiency can cause anosmia, which is reduced sense of smell.

Which of the following areas would the nurse include in a mental status assessment for an adult patient? Select all that apply. a) Behavior b) Judgment c) Knowledge d) Reflexes e) Appearance

ANS: A, B, C, E The mental status assessment includes assessment of behavior, appearance, response to stimuli, speech, memory, and judgment. Normal findings include an ability to express and explain realistic thoughts with clear speech, follow directions, listen, answer questions, and recall significant past events. Assessment of reflexes is associated with a complete and in-depth neurological assessment.

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which of the following can trigger seizures? Select all that apply. a) Fever b) Video games c) Sleep deprivation d) Food allergens e) Mood-altering substances

ANS: A, B, C, E The most common reason for seizures in a person with epilepsy is failure to take prescribed antiseizure medication. Other common triggers of seizures are illness and fever, sleep deprivation, stress, and ingestion of mood-altering substances. Additionally, high-contrast patterns and flashing or flickering lights (video games, strobe lights) can provoke seizure activity. Ingesting a food allergen invokes an immunological response with reactions related to anaphylaxis.

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply. a) Place personal objects where the patient can see them. b) Introduce yourself each time you have contact with the patient. c) Encourage the patient to relax while the nurse gives the bath. d) Use short sentences with only a few words. e) Do not offer many choices when it comes to ADLs.

ANS: A, B, D, E Place personal objects, photos, and mementos in the immediate environment, and discuss them with the client. Introduce yourself and state the client's name each time you meet with him; wear a readable (large, plain type) nametag to reinforce your introduction. Also identify the day, date, and time as you interact. Encourage the patient to participate in familiar activities, such as bathing. To promote patient orientation for a patient with confusion (e.g., dementia), use simple communication and offer few choices with ADLs to prevent from overwhelming the patient. While you may sometimes find it necessary to bathe the patient, that intervention wouldn't be expected to improve orientation. Furthermore, encouraging the patient to relax would likely be ineffective in relaxing the patient, and might even elicit anger.

Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. a) Buccal mucosa b) Around the lips c) Palms d) Tongue

ANS: A, C, D In dark-skinned people, cyanosis can be best assessed by examining the palms of the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be inspected

What are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply. a) Increases socialization b) Increases blood pressure c) Decreases pain d) Decreases loneliness e) Decreases insomnia

ANS: A, C, D Many facilities have resident pets or can arrange to have pets visit. Pet therapy can increase socialization, lower blood pressure, and decrease loneliness and perception of pain.

In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? a) Transduction b) Transmission c) Perception d) Modulation

ANS: B Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed.

For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate more touch in the plan of care. c) Give frequent eye care if blink reflex is absent. d) Keep the siderails up and bed in low position. e) Perform diligent oral care by irrigating with diluted mouthwash.

ANS: A, C, D Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. If the patient's blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore, you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

Which factors in a health history place a patient at risk for hearing loss? Select all that apply. a) Being an older adult b) Childhood chickenpox c) Frequent otitis media d) Diabetes mellitus e) Congenital rubella

ANS: A, C, E Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Sensorineural deafness, eye abnormalities, and congenital heart disease are the classic triad that occurs with congenital rubella. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Select all that apply. a) Furosemide, a diuretic b) Digoxin, a cardiotonic c) Famotidine, an antacid d) Aspirin, an analgesic e) Penicillin, an antibiotic

ANS: A, D Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin, famotidine, or penicillin does not place the patient at risk for auditory nerve impairment.

The 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's complaints and the nurse's assessment, the nurse associates these findings with which of the following? a) Strabismus b) Cataracts c) Glaucoma d) Presbyopia

ANS: B A cataract is a cloudy film over the lens of the eye resulting in blurred vision, sensitivity to glare and bright light, halos around lights, fading or yellowing of colors, and image distortion. Tinnitus is ringing in the ear unrelated to vision. Presbyopia is a change in vision associated with aging in which a person is less able to accommodate to near objects. Glaucoma is a condition involving increasing pressure in the eye that can lead to loss of peripheral vision and even blindness, if not treated. Strabismus ("crossed-eyes") is the condition wherein one eye deviates from a fixed image.

After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: a) Pediculosis b) Alopecia c) Dandruff d) Hirsutism

ANS: B Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women.

Which side effects associated with opioid use may improve after taking a few doses of the drug? a) Constipation b) Drowsiness c) Dry mouth d) Difficulty with urination

ANS: B Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use.

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? a) Skin was softened from prolonged exposure to moisture. b) Superficial layers of skin were absent. c) Epidermal layer of skin was rubbed away. d) Lesion caused by tissue compression was present.

ANS: B Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or shearing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

The nurse has been teaching a parent about stimuli to develop her infant's auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred? a) Cuddling b) Speaking c) Feeding d) Soothing

ANS: B Exposure to voices, music, and ambient sound helps develop the infant's auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should: a) Have him sign a permission form b) Check to see whether the patient is taking anticoagulants c) Tell him that only a family member may shave a patient d) Position him flat in bed

ANS: B If the patient is taking anticoagulant medication or has a bleeding disorder, he is at risk for bleeding. You should use an electric razor, not a disposable razor that may nick the patient's skin.

A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? a) Call for assistance to help the patient into the bathtub. b) Wait for the patient to calm down, and then give him a towel bath. c) Allow the patient to go without bathing for a day or two. d) Ask another staff member to attempt the tub bath.

ANS: B Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patient's agitation, as consistency of caregivers is important for patients with dementia.

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating? a) Chemoreceptors b) Photoreceptors c) Proprioceptors d) Mechanoreceptors

ANS: B Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

Which characteristic about pain would the nurse most consider when developing a pain management plan for a patient with chronic lower back pain? a) An objective experience that disrupts daily living that can be measured with altered vital signs b) An unpleasant sensory and emotional experience association with actual or potential tissue damage, or described in terms of such damage c) A generalized response of the body as a result of trauma or damage to the tissues resulting in discomfort d) An emotional response to tissue damage that differs significantly from one individual to another

ANS: B The International Association for the Study of Pain (IASP) defined pain as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.'' This definition emphasizes that pain is a complex experience. Pain is a subjective experience; unlike a pulse or blood pressure, you cannot measure pain objectively. Pain is not a generalized response but rather a neurological response. Although a patient with chronic back pain would experience an emotional response, the sensation of pain is primarily physiological, involving transmission of an impulse along a pain pathway.

A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate? a) Risk for Infection b) Risk for Impaired Skin Integrity c) Risk for Deficient Fluid Volume d) Impaired Skin Integrity

ANS: B The epidermis contains melanin, a pigment that protects against the sun's ultraviolet rays; therefore, a person with insufficient melanin is at risk for Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn, only that a risk factor is present. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection.

Which of the following is a correct step in removing and cleaning a hearing aid? a) Clean only the external surfaces, not the canal portion. b) Clean the top part of the canal portion of the device. c) Insert a wax loop or toothpick into the hearing aid itself. d) Remove the battery before taking the hearing aid from the ear.

ANS: B The nurse should clean the top part of the canal portion of the hearing aid using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. Nothing should be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth. The hearing aid should be turned off before removing it from the ear, but the battery is not removed at that step of the procedure. It would not likely be possible to remove the battery while the device was still in the ear.

A patient who underwent a left above-the-knee amputation reports pain in his left foot. The nurse should document this finding as what type of pain? a) Psychogenic b) Phantom c) Referred d) Radiating

ANS: B The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person that does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations.

Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? a) Acute Pain secondary to surgery b) Acute Pain (abdominal) secondary to surgery for colon cancer c) Chronic Pain secondary to cancer diagnosis d) Chronic Pain (abdominal) secondary to abdominal surgery

ANS: B The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

A patient prescribed an NSAID, naproxen (Aleve, Naprosyn), for treatment of arthritis reports stomach upset. What should the nurse instruct the patient to do? a) Notify the prescriber immediately. b) Take the medication with food. c) Take the medication with 8 ounces of water. d) Take the medication before bedtime.

ANS: B The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen.

The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient reporting a severe headache. When should the nurse reassess the patient's pain? a) 15 minutes after administration b) 60 minutes after administration c) 90 minutes after administration d) Immediately before the next dose is due

ANS: B The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due.

Which pain management task can be safely delegated to nursing assistive personnel? a) Assessing the quality and intensity of the patient's pain b) Evaluating the effectiveness of pain medication c) Providing a therapeutic back massage d) Administering oral dose of acetaminophen

ANS: C The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patient's pain, monitoring the patient's response to pain management strategies, administering medications (including over-the-counter preparations), or evaluating the pain management plan.

A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse? a) Oral pain medication once every 6 to 8 hours b) Patient-controlled analgesic c) Oral pain medication instead of the IV form d) Only nonpharmacological pain measures

ANS: B The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic, as is possible with PCA. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse.

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: a) Experiences less pain than in earlier stages of cancer b) Cannot communicate the character of his pain effectively c) Knowledges pain at a later time than when it occurs d) Relies on caregiver to provide pain relief without asking

ANS: B There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to habitually ask for it or reliance on others; rather, it is likely owing to inability to effectively express to the caregiver that analgesia is needed.

After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patient's problem? a) Disturbed Sensory Perception b) Unilateral Neglect c) Risk for Peripheral Vascular Dysfunction d) Acute Confusion

ANS: B This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

After undergoing dural puncture while receiving epidural pain medication, a patient reports a headache. Which action can help alleviate the patient's pain? a) Encourage the client to ambulate to promote flow of spinal fluid. b) Offer caffeinated beverages to constrict blood vessels in his head. c) Encourage coughing and deep breathing to increase CSF pressure. d) Restrict oral fluid intake to prevent excess spinal pressure.

ANS: B Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a "spinal headache" after epidural anesthesia.

During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to: a) Bathe the patient more frequently. b) Use an emollient on the dry skin. c) Massage the skin with warm water. d) Discourage fluid intake.

ANS: B Use an emollient on the dry skin Using an emollient will aid in soothing dry skin. Frequent bathing will increase dryness, as will discouraging fluids. Massaging skin with water will not play a role in improving dry skin.

Which of the following is/are a benefit of bathing? Select all that apply. a) Constricts blood vessels b) Increases depth of respirations c) Provides opportunity for assessments d) Reduces sensory input

ANS: B, C Bathing presents an opportunity to perform a variety of assessments. Bathing also dilates blood vessels near the skin's surface, increasing circulation. Moreover, bathing stimulates the depth of respirations and provides sensory input.

Which actions can the nurse take to prevent sensory overload? Select all that apply. a) Leave the television on low volume to block out other noises. b) Minimize ambient light in the patient's room. c) Plan care to provide periods of sleep. d) Speak with a moderate tone of voice. e) Restrict caffeine intake during hospitalization.

ANS: B, C, D, E To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. Medications and some substances that stimulate the CNS may also contribute to sensory overload, such as caffeine.

The nurse in the intensive care unit enters her patient's room and observes the patient is experiencing a seizure. What are the most appropriate interventions by the nurse? Select all that apply. a) Insert a padded tongue depressor in the patient's mouth. b) Turn the patient to his side. c) Restrain the patient to control his jerking movements. d) Loosen any restrictive clothing. e) Pad the siderails of the patient's bed.

ANS: B, D, E When a seizure is occurring, the nurse would turn the patient to his side to prevent aspiration and loosen any restrictive clothing; also pad the head, foot, and siderails of the bed and place oral suction at the bedside. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). Also do not attempt to restrain the patient, as this may result in muscle and joint injury.

Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? a) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. b) The patient will rest quietly when undisturbed. c) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. d) The patient will receive pain medication every 2 hours as prescribed.

ANS: C A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numericalscore gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patient's pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome.

A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? a) Tub bath b) Complete bed bath c) Towel bath d) Bed bath

ANS: C A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patient's energy.

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. a) 32-year-old admitted with a closed head injury b) 76-year-old admitted with septic shock c) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago d) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

ANS: C Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical-thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical-thinking skills of a registered nurse to detect respiratory compromise quickly.

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" What is the best response by the nurse? a) "This means that your eye pressure readings are quite high and may be indicative of glaucoma." b) "These are numbers associated with left and right eye readings for identifying macular degeneration." c) "This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance." d) "This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close."

ANS: C Myopia, or nearsightedness, means that the person is able to see close objects well but not distant objects. For example, a person with 20/100 vision can see an object from 20 feet away that a person with normal sight could see from a distance of 100 feet. Hyperopia, or farsightedness, implies that the eye sees distant objects well. A person with hyperopia may have 20/10 vision—he can see an object form 20 feet that a normal eye can see from 10 feet. Glaucoma is a type of vision loss caused by increased pressure in the anterior cavity of the eyeball resulting in loss of peripheral vision. The fraction 20/100 is unrelated to glaucoma. Macular degeneration is the loss of central vision due to damage to the macula lutea, the central portion of the retina. This results in loss of central and near vision. The fraction 20/100 is unrelated to identifying macular degeneration.

The nurse is caring for a patient with chronic low back pain. The patient reports taking 800 mg of ibuprofen tid for the past 12 years. For this patient, which lab result is most important for the nurse to review? a) WBC with differential b) Serum sodium, potassium, chloride, and CO2 c) Hemoglobin and hematocrit d) Platelet count

ANS: C NSAIDS can irritate the gastric mucosa, causing bleeding, which will be reflected in the hemoglobin and hematocrit levels. White blood cell count is an indicator of infection and is not likely to be impacted by long-term NSAID use. Serum electrolytes are not likely to be impacted by long-term NSAID use unless the patient experiences kidney damage. Platelet count is usually not impacted by NSAIDs, although platelet aggregation may be increased; however, this does not affect the number of platelets.

What physiological process causes the severe pain of menstrual cramps? a) Mechanical stimuli b) Thermal stimuli c) Prostaglandin activity d) Histamine activity

ANS: C NSAIDs inhibit prostaglandin activity that is largely the cause of menstrual cramping. Mechanical stimuli include external forces that result in pressure or friction. This pain is not caused by external sources. Thermal stimuli are those caused by heat or cold, which does not apply to menstrual cramps. Histamine activity is part of the process of inflammation, but is not involved in menstrual cramps, nor are histamines impacted by NSAIDs.

A patient who sustained rib fractures in a motor vehicle accident is stating that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? a) Metabolic alkalosis b) Pneumothorax c) Pneumonia d) Hemothorax

ANS: C Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting.

Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient? a) Lavender b) Roman chamomile c) Rosemary d) Ylang-ylang

ANS: C Rosemary is stimulating and uplifting for many people. Lavender, Roman chamomile, and ylang-ylang are used to promote relaxation.

The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? a) Encouraging family members to visit only during the day b) Applying wrist restraints during periods of agitation c) Playing soft, calming music during the evening d) Administering lorazepam (a tranquilizer)

ANS: C Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

A patient develops a respiratory rate 6 breaths/min after receiving IV hydromorphone (Dilaudid) 2.0 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? a) Physostigmine (Antilirium) b) Flumazenil (Romazicon) c) Naloxone (Narcan) d) Protamine sulfate

ANS: C The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous system depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin.

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? a) Limit oral hygiene to one time a day. b) Teach the patient to combine foods in each bite. c) Assess for sores or open areas in the mouth. d) Instruct the patient to avoid salt substitutes.

ANS: C The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient's artificial eye. What should the nurse ask the patient to do to best position him for this procedure? a) Lean forward and rest the arms on the overbed table. b) Sit back in the chair and tilt the head back. c) Move to the bed and lie down. d) Stand up and lean over the bed.

ANS: C The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall on the bed instead of the floor. Sitting back in the chair would allow access to the eye but would not protect the artificial eye from falling to the floor. Leaning forward and resting the arms on an overbed table, as well as standing up and leaning over the bed, would not provide the nurse access to the eye to remove the prosthesis.

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? a) Place the cold pack directly on the skin over the ankle. b) Apply the cold pack to the ankle for 30 minutes at a time. c) Check the skin frequently for extreme redness. d) Keep the cold pack in place for at least 24 hours.

ANS: C The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time. The patient should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur.

The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? a) Avoid bathing the patient. b) Use cool water for bathing. c) Provide care in short intervals. d) Rub briskly when towel drying.

ANS: C The nurse should provide care in short intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the child's ear canal? a) Up and back b) Straight back c) Down and back d) Straight upward

ANS: C The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward.

A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? a) Trigeminal b) Glossopharyngeal c) Olfactory d) Vagus

ANS: C The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

The nurse conducting a pain assessment for a patient would recognize deep somatic pain as which of the following? a) Achy b) Superficial c) Radiating d) Crampy

ANS: C The pain occurs because of potentially damaging stimuli, so it is nociceptive; it originates in the bone so it is somatic; and arthritis is chronic because it is usually lifelong resulting from joints that do not correct once they have been damaged.

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? a) Self-Care Deficit: Dressing and Grooming b) Impaired Adjustment c) Risk for Injury d) Activity Intolerance

ANS: C The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit: Dressing and Grooming, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient, but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.

The home health nurse is developing a plan of care for her patient with a visual impairment. What is the priority nursing diagnosis for this patient? a) Self-Neglect b) Social Isolation c) Risk for Falls d) Risk for Imbalanced Nutrition: Less Than Body Requirements

ANS: C The priority nursing diagnosis for a patient with a visual impairment is Risk for Falls. The patient, owing to a visual impairment, may have deficits with feeding, dressing, and social interaction; however, the highest priority is promoting safety and reducing the patient's risk for falls.

A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? a) Perception b) Transduction c) Transmission d) Modulation

ANS: D Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation).

The nurse uses his hands to direct energy fields surrounding the patient's body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention? a) Tactile distraction was performed and appeared effective in reducing pain. b) Guided imagery was effective to relax the patient and reduce the pain. c) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. d) Sequential muscle relaxation was performed; patient states pain is less.

ANS: C Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain.

The nurse is about to bathe a female patient who has an intravenous line, and needs to remove her gown. The nurse should: a) Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown. b) Cut the gown with scissors to allow the arm to be easily removed from gown. c) Thread the bag and tubing through the gown sleeve, keeping the line intact. d) Disconnect the tubing, thread it through the gown, and reconnect the tubing.

ANS: C Thread the bag and tubing through the gown sleeve, keeping the line intact. If the patient has an IV line and is wearing a gown that does not have snap-open sleeves, the nurse should remove the gown first from the arm without the IV, then lower the IV container, and pass the gown over the tubing and the container, taking care to keep the container above the level of the patient's arm. Using this technique will keep blood from backing up into the IV line. Manipulating the IV equipment may change the flow rate; flow rate must be maintained as prescribed. The nurse should not disconnect the IV tubing; this breaks the sterile system and provides a portal of entry for pathogens.

A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response? a) Histamine b) Prostaglandin c) Bradykinin d) Serotonin

ANS: C Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and not involved in the inflammatory response.

The nurse is assessing an elderly male in the nursing home. What question will the nurse ask this patient to best assess his level of orientation? a) "Will you please repeat these three words for me: glasses, rocket, truck?" b) "Can you tell me the date of your retirement from your workplace?" c) "What is your name and today's date? Can you tell me where you are?" d) "What did you eat for breakfast this morning?"

ANS: C To assess level of orientation, the best question is to ask the patient for his name, date, and his current location. Asking the patient to repeat a sequence of words (e.g., glasses, rocket, truck) assesses recall and recent memory. Asking a patient for the date of retirement assesses long-term memory but does not reflect the patient's orientation status to the present time and situation. Asking a patient what he ate for breakfast assesses short-term memory only.

Which of the following tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply. a) Irrigating the ear of a child with impacted cerumen b) Administering eye drops for a patient in a coma c) Obtaining vital signs every 15 minutes after a seizure d) Padding the sides of a bed for seizure precautions e) Suctioning the patient's oropharynx after a seizure

ANS: C, D A CNA may obtain vital signs and suction the patient's oropharynx postseizure and may perform the tasks of setting up seizure precautions, which includes padding the side of the bed to prevent injury. A CNA may not perform ear irrigation or administer eye drops, as these interventions require knowledge, skills, and assessment of the professional nurse.

Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? a) 99°F (37.2°C) b) 102°F (38.9°C) c) 103°F (39.4°C) d) 105°F (40.6°C)

ANS: D Bath water temperature should be 105°F (40.6°C) to prevent chilling, burning, and excess drying of the skin.

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? a) Otosclerosis b) Conduction deafness c) Presbycusis d) Central deafness

ANS: D Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

The nurse caring for a fussy newborn uses which of the following interventions to calm the baby and reduce sensory overload? a) Rubbing the baby's back b) Singing and rocking the baby c) Hanging a black and white mobile d) Swaddling the baby tightly

ANS: D In the first months of life until the autonomic nervous system matures, newborns are easily overstimulated by the loud noises, bright light, high-contrast objects (e.g., black and white mobile), and stroking sensitive areas (back and bottom of feet). Stroking the back or bottom of feet can be too much for the baby to handle. Newborns experience sensory overload, particularly when more than one sense is involved, such as singing (auditory) and rocking (kinesthetic).

The pediatric nurse is caring for a 4-year-old child who is experiencing chronic pain secondary to tissue injury from past sickle cell anemia crises. Which of the following nonpharmacological pain reduction interventions might the nurse implement? Have the child: a) Perform vigorous activity b) Practice visualization c) Listen to rap music d) Watch a funny movie

ANS: D Laughter from watching a funny movie is likely to result in pain reduction without causing stress on the joints. Strenuous exercise would likely aggravate the pain experience and potentially cause injury. Visualization is associated with the endogenous analgesia system but might not be effective in a young child. Rap music is a form of distraction that would cause excitation rather than relaxation, so this would not be effective.

A patient with Raynaud's disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief? a) Cordotomy b) Rhizotomy c) Neurectomy d) Sympathectomy

ANS: D Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynaud's disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission.

A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint? a) Exophthalmos b) Anosomia c) Insomnia d) Xerostomia

ANS: D The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosomia is losing the sense of smell. Insomnia is inability to sleep.

The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? a) "Cleanse only those areas likely to cause odor." b) "Provide the patient with warm water for washing his perineum." c) "Wash the patient's back, buttocks, and perineum first." d) "Bathe the patient from head to toe, cleanest areas first."

ANS: D The nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm water and allow him to wash his perineum when giving an assisted bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of "clean to dirty."

Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit? a) Install blinking lights to alert an incoming phone call. b) Have gas appliances inspected regularly to detect gas leaks. c) Wear properly fitting shoes and socks. d) Avoid using throw rugs on the floors.

ANS: D The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? a) Use nonpharmacological therapy while waiting 3 more hours before next dose. b) Administer an additional 800 mg oral dose of ibuprofen right away. c) Do nothing because the patient's facial expression indicates he is comfortable. d) Notify the prescriber that the current pain management plan is ineffective.

ANS: D The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescriber's order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is.

Which intervention is helpful when caring for a patient with impaired vision? a) Suggest the patient use bright overhead lighting. b) Advise the patient to avoid wearing sunglasses when outdoors. c) Do not offer large-print books, as this may embarrass the patient. d) Place the patient's eyeglasses within easy reach.

ANS: D The nurse should place the patient's eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful.

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care? a) Supine b) Prone c) Semi-Fowler's d) Side-lying

ANS: D The nurse should position an unconscious patient in a side-lying position to provide mouth care to prevent aspiration. Supine, prone, and semi-Fowler's positions are unsafe positions for providing mouth care for the unconscious patient.

Which of the following interventions would be most appropriate for a patient who has an eye infection with moderate amount of discharge? a) Using hydrogen peroxide to clean the eye b) Wiping from the outer canthus to the inner canthus c) Positioning the patient on the same side as the eye to be cleansed d) Using a different wipe to cleanse each eye

ANS: D To prevent cross-contamination, a different wipe should be used for each eye. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. Water or normal saline should be used for cleansing the eye of any discharge.

When making an occupied bed, which of the following is most important for the nurse to do? a) Keep the bed in the low position. b) Keep the siderail raised on both sides of the bed. c) Move back and forth between the sides of the bed when adjusting linens. d) Use a bath blanket or sheet to maintain patient warmth and privacy.

ANS: D Use a bath blanket or sheet to maintain patient warmth and privacy. When making an occupied bed, the nurse should cover the patient with a bath blanket, if available, or leave the top sheet over the patient. Covering the patient prevents chilling and preserves modesty. Keeping the bed in the low position and working over raised siderails may strain the nurse's back. Continually moving from side to side is disorganized and time consuming.