Exam 1 RNSG 1533 COGNITION AND COPING

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on

A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations

17. The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window. Which nursing diagnosis should the nurse assign as the highest priority? a. Risk for injury related to altered perception b. Ineffective health maintenance related to drug use c. Powerlessness related to loss of behavioral control d. Ineffective denial related to lack of control of life situation

A

A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving a car accident."

A

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds' overweight, but I can live with it."

A

A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to a. provide for the patient's safety. b. encourage clarification of feelings. c. respect the patient's personal space. d. offer an outlet for the patient's energy

A

A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. What finding does the nurse expect? a. Nausea and diarrhea b. Tremors and seizures c. Lethargy and disorientation d. Delusions and hallucinations

A

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing . Hyperarousal c. Avoidance d. Psychosis

A

An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

A

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease

A

Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

A

A patient who had been experiencing significant stress learned to use progressive muscle relaxation and deep breathing exercises. When the patient returns to the clinic 2 weeks later, which finding most clearly shows the patient is coping more effectively with stress? a. The patient's systolic blood pressure has changed from the 140s to the 120s mm Hg. b. The patient reports, "I feel better, and that things are not bothering me as much." c. The patient reports, "I spend more time napping or sitting quietly at home." d. The patient's weight decreased by 3 pounds

A Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiological response to stress, has diminished. The patient's report regarding activity level is subjective; sitting quietly could reflect depression rather than improvement. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiological changes from stress and may not reflect improved coping with stress. The patient's weight change could be a positive or negative indicator; the blood pressure change is the best answer

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

A Physical safety is the highest priority

Physical assessment of a patient diagnosed with bulimia often reveals a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweigh

A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patients speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years

A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia

A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the medication orders, which drug should the nurse administer first? a. Thiamine (vitamin B1 ) 100 mg daily b. Lorazepam (Ativan) 1 mg as needed c. Folic acid (Vitamin B9 ) 0.4 mg daily d. Dextrose 5% in 0.45 saline at 125 mL/hr

A Thiamine is given to all patients with alcohol intoxication to prevent Wernickes encephalopathy. Because Wernickes encephalopathy can be precipitated by the administration of glucose solutions, the thiamine should be given before (or concurrently with) the 5% dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated BAC. Folic acid may also be administered, but is not as important as thiamine.

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week

A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure

A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurse's office, furnished with chairs, files, magazines, and bookcases

A Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe

A patient who has a history of ongoing opioid abuse is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication will the nurse administerimmediately? a. Naloxone (Narcan) b. Diazepam (Valium) c. Clonidine (Catapres) d. Methadone (Dolophine)

A, don't miss this.

Which changes reflect short-term physiological responses to stress? (Select all that apply.) a. Muscular tension, blood pressure, and triglycerides increase. b. Epinephrine is released, increasing heart and respiratory rates. c. Corticosteroid release increases stamina and impedes digestion. d. Cortisol is released, increasing glucogenesis and reducing fluid loss. e. Immune system functioning decreases, and risk of cancer increases. f. Risk of depression, autoimmune disorders, and heart disease increases.

A,B,C,D E,F are long term effects.

An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? (Select all that apply.) a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopia

A,B,C,D When individuals feel "stressed-out," they often have accompanying somatic complaints, especially associated with sleep, eating, and headache or back pain. Changes in vision, such as myopia, would not be expected

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

A,B,C,E The child's symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security

The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside

A,B,C,E,F

A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? (Select all that apply.) a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

A,B,E The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns

A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.) a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach

A,C,D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication

A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

A,C,D,F

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) a. Refer the nurse to a peer assistance program. b. Confront the nurse in the presence of a witness. c. Immediately terminate the nurse's employment. d. Relieve the nurse of responsibilities for patient care. e. Require the nurse to undergo immediate drug testing

A,D

A nurse leads a psychoeducational group for patients experiencing depression. The nurse plans to implement an exercise regime for each patient. The rationale to use when presenting this plan to the treatment team is that exercise a. has an antidepressant effect comparable to selective serotonin reuptake inhibitors. b. prevents damage from overstimulation of the sympathetic nervous system. c. detoxifies the body by removing metabolic wastes and other toxins. d. improves mood stability for patients with bipolar disorders.

A. β-Endorphins produced during exercise result in improvement in mood and lowered anxiety. The other options are not accurate.

The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis

ANS: B The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or "mind flight" may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur.

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails

B

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met

B

A patient experiencing significant stress associated with a disturbing new medical diagnosis asks the nurse, "Do you think saying a prayer would help?" Select the nurse's best answer. a. "It could be that prayer is your only hope." b. "You may find prayer gives comfort and lowers your stress." c. "I can help you feel calmer by teaching you meditation exercises." d. "We do not have evidence that prayer helps, but it wouldn't hurt."

B

A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear b. Risk for injury c. Self-care deficit d. Disturbed thought processes

B

A patient nervously says, "Financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off." The patient's pulse is 112/minute; respirations are 26/minute; and blood pressure is 166/88. Which nursing intervention will the nurse implement? a. Advise the patient, "Go to sleep 30 to 60 minutes earlier each night to increase rest." b. Direct the patient in slow and deep breathing using abdominal muscles. c. Suggest the patient consider that a new job might be better than the present one. d. Tell the patient, "Relax by spending more time playing with your pet."

B

A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family

B

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

B

A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion . Flashback c. Nightmare d. Auditory hallucination

B

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others

B

Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake

B

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

B

A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

B Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties

The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia? a. "I'm sure I will get over not wanting to leave home soon. It takes time." b. "Being afraid to go out seems ridiculous, but I can't go out the door." c. "My family says they like it now that I stay home most of the time." d. "When I have a good incentive to go out, I can do it.

B Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently

B A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol level of 300 mg/dL (0.30 g/dL). The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs

A patient tells the nurse, "I will never be happy until I'm as successful as my older sister." The nurse asks the patient to reassess this statement and reframe it. Which reframed statement by the patient is most likely to promote coping? a. "People should treat me as well as they treat my sister." b. "I can find contentment in succeeding at my own job level." c. "I won't be happy until I make as much money as my sister." d. "Being as smart or clever as my sister isn't really important."

B Finding contentment within one's own work, even when it does not involve success as others might define it, is likely to lead to a reduced sense of distress about achievement level. It speaks to finding satisfaction and happiness without measuring the self against another person. Focusing on salary is simply a more specific way of being as successful as the sister, which would not promote coping. Expecting others to treat her as they do her sister is beyond her control. Dismissing the sister's cleverness as unimportant indicates that the patient continues to feel inferior to the sibling.

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine

B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents

A hospitalized patient diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings

B Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress

A patient who has severe Alzheimers disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patients care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

B Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past.

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

B. Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior

A patient says, "One result of my chronic stress is that I feel so tired. I usually sleep from 11:00 PM to 6:30 AM. I started setting my alarm to give me an extra 30 minutes of sleep each morning, but I don't feel any better and I'm rushed for work." Which nursing response would best address the patient's concerns? a. "You may need to speak to your doctor about taking a sedative to help you sleep." b. "Perhaps going to bed a half-hour earlier would work better than sleeping later." c. "A glass of wine in the evening might take the edge off and help you to rest." d. "Exercising just before retiring for the night may help you to sleep better."

B Sleeping later in the morning may disturb circadian rhythms and in this case is adding, rather than reducing, stress. Going to bed earlier and arising at the usual time alleviates fatigue more effectively. Sedatives may offer some benefit but are a short-term intervention with potential side effects, and other nonpharmacological interventions might work as well or better. Exercise earlier in the evening could induce tiredness and ease the process of falling asleep, but doing so right before bedtime would stimulate and interfere with sleep. Alcohol is sedating but potentially addictive; encouraging its use could increase the risk of using alcohol maladaptively as a response to stress in general

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

B The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Symptoms of withdrawal from opioids for which the nurse should assess include a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache

B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family

Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

B The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

B. Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

B. Confabulation

A 71-year-old patient with Alzheimers disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses station. d. Ask the patient why the wandering episodes have occurred.

C

A nurse gives anticipatory guidance to the family of a patient diagnosed with mild early stage Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

C

A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

C

A patient newly diagnosed as HIV-positive seeks the nurse's advice on how to reduce the risk of infections. The patient says, "I went to church years ago and I was in my best health then. Maybe I should start going to church again." Which response will the nurse offer? a. "Religion does not usually affect health, but you were younger and stronger then." b. "Contact with supportive people at a church might help, but religion itself is not especially helpful." c. "Studies show that spiritual practices can enhance immune system function and coping abilities." d. "Going to church would expose you to many potential infections. Let's think about some other options."

C

A patient reports, "I am overwhelmed by stress." Which question by the nurse would be most important to use in the initial assessment of this patient? a. "Tell me about your family history. Do you have any relatives who have problems with stress?" b. "Tell me about your exercise. How much activity do you typically get in a day?" c. "Tell me about the kinds of things you do to reduce or cope with your stress." d. "Stress can interfere with sleep. How much did you sleep last night?"

C

A patient tells the nurse, "My doctor thinks my problems with stress relate to the negative way I think about things and suggested I learn new ways of thinking." Which response by the nurse would support the recommendation? a. Encourage the patient to imagine being in calm circumstances. b. Provide the patient with a blank journal and guidance about journaling. c. Teach the patient to recognize, reconsider, and reframe irrational thoughts. d. Teach the patient to use instruments that give feedback about bodily functions.

C

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

C

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination

C

When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.

C

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. Donepezil b. Rivastigmine c. Memantine d. Galantamine

C Memantine is a NMDA receptor antagonist (moderate to late stage alzheimers) Donepezil, Rivastigmine and galantamine are cholinesterase inhibitors.(alzheimers mild to moderate)

A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is most appropriate? a. Insert an IV line and infuse fluids. b. Promote oral intake to 3000 mL/day. c. Provide a quiet, well-lit environment. d. Administer opioids to provide sedation.

C The patients symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

C Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers

C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

Which nursing diagnoses are most applicable for a patient diagnosed with severe late stage Alzheimer's disease? (Select all that apply.) a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

C,D,E

Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks

C,D,E PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way

A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? a. "I don't know why I do mean things." b. "I have always had poor impulse control." c. "That person should not have provoked me." d. "I'm really a coward who is afraid of being hurt."

C.

A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? a. feelings of responsibility for the health of family members b. approval-seeking behavior from friends and family c. persistent thoughts about bacteria, germs, and dirt d. needs to avoid interactions with others

C.

A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action. a. Ask, "I'm not sure what you mean. Give me an example." b. Capture the patient in a basket-hold to increase feelings of control. c. Tell the patient, "Stop running and take a deep breath. I will help you." d. Assemble several staff members and say, "We will take you to seclusion to help you regain control."

C.

A patient is being evaluated for Alzheimers disease (AD). The nurse explains to the patients adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

C.

A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

C. The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality

According to the Recent Life Changes Questionnaire, which situation would most necessitate a complete assessment of a person's stress status and coping abilities? a. A person who has been assigned more responsibility at work b. A parent whose job required relocation to a different city c. A person returning to college after an employer ceased operations d. A man who recently separated from his wife because of marital problems

C. A person returning to college after losing a job is dealing with two significant stressors simultaneously. Together, these stressors total more life change units than any of the single stressors cited in the other options.

A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment? a. Drug Abuse Screening Test (DAST-10) b. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) c. Screening Test-Geriatric Version (SMAST-G) d. Mini-Mental State Examination

C. Because the abuse of alcohol is a common factor associated with the development of pancreatitis, the first assessment step is to screen for alcohol use using a validated screening questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored specifically to the needs of the older adult. If the patient scores positively on the SMAST-G, then the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides more general information regarding substance use. The Mini-Mental State Examination is used to screen for cognitive impairment.

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. . depression. . dementia

C. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

C. The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with the experience of driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system

A patient diagnosed with emphysema has severe shortness of breath and needs portable oxygen when leaving home. Recently the patient has reduced activity because of fear that breathing difficulty will occur. A nurse suggests using guided imagery. Which image should the patient be encouraged to visualize? a. Engaging in activity without using any supplemental oxygen b. Sleeping comfortably and soundly, without respiratory distress c. Feeling relaxed and taking regular deep breaths when leaving home d. Having a younger, healthier body that knows no exercise limitations

C. The patient has dysfunctional images of dyspnea. Guided imagery can help replace the dysfunctional image with a positive coping image. Athletes have found that picturing successful images can enhance performance. Encouraging the patient to imagine a regular breathing depth and rate will help improve oxygen-carbon dioxide exchange and help achieve further relaxation. Other options focus on unrealistic goals (being younger, not needing supplemental oxygen) or restrict her quality of life.

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary gland

C. The individual will find this experience stressful. The hypothalamus functions as the command-and-control center when receiving stressful signals

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"

D

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

D

A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety

D

For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Prepare to implement physical controls. d. Provide calm, brief, directive communication.

D

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

D

The nurse is concerned about a postoperative patients risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

D

What is the priority need for a patient diagnosed with severe, late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

D

Which assessment finding would alert the nurse to ask the patient about alcohol use? a. Low blood pressure b. Decreased heart rate c. Elevated temperature d. Abdominal tenderness

D

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use

A patient tells the nurse, "I know that I should reduce the stress in my life, but I have no idea where to start." What would be the best initial nursing response? a. "Physical exercise works to elevate mood and reduce anxiety." b. "Reading about stress and how to manage it might be a good place to start." c. "Why not start by learning to meditate? That technique will cover everything." d. "Let's talk about what is going on in your life and then look at possible options."

D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. Further assessment is indicated before potential solutions can be explored. Suggesting exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

D.

When a nurse asks a newly admitted patient to describe social supports, the patient says, "My parents died last year and I have no family. I am newly divorced, and my former in-laws blame me. I don't have many friends because most people my age just want to go out drinking." Which action will the nurse apply? a. Advise the patient that being so particular about potential friends reduces social contact. b. Suggest using the Internet as a way to find supportive others with similar values. c. Encourage the patient to begin dating again, perhaps with members of the church. d. Discuss how divorce support groups could increase coping and social support.

D. High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships affect a person's coping negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping her cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose her to predators misrepresenting themselves to take advantage of vulnerable persons

A patient is brought to the Emergency Department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are pulse (P) 72 and respiration (R) 16. After being informed surgery is required for the broken leg, which vital sign readings would be expected? a. P 64, R 14 b. P 68, R 12 c. P 72, R 16 d. P 80, R 20

D. In times of stress, the sympathetic nervous system takes over (fight or flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs

The adult child of a patient diagnosed with major depressive disorder asks, "Do you think depression and physical illness are connected? Since my father's death, my mother has had shingles and the flu, but she's usually not one who gets sick." Which answer by the nurse best reflects current knowledge? a. "It is probably a coincidence. Emotions and physical responses travel on different tracts of the nervous system." b. "You may be paying more attention to your mother since your father died and noticing more things such as minor illnesses." c. "So far, research on emotions or stress and becoming ill more easily is unclear. We do not know for sure if there is a link." d. "Negative emotions and prolonged stress interfere with the body's ability to protect itself and can increase the likelihood of illness."

D. Research supports a link between negative emotions and/or prolonged stress and impaired immune system functioning. Activation of the immune system sends proinflammatory cytokines to the brain, and the brain in turn releases its own cytokines that signal the central nervous system to initiate myriad responses to stress. Prolonged stress suppresses the immune system and lowers resistance to illness. Although the adult child may be more aware of issues involving the mother, the pattern of illnesses described may be an increase from the mother's baseline

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

D. Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone

D. Naltrexone.

Which action will help the nurse determine whether a new patients confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

b. CAM Test for delirium.