Foundations Exam 3

The nurse is discussing contraception with an adolescent patient who asks the nurse: "What if I can't have an orgasm?" What is the nurse's best response?

"A mature sexual relationship does not require a man and woman to achieve simultaneous orgasm."

A nurse practitioner is teaching the student about sexual health and is evaluating the student's knowledge of sexual identity. The practitioner knows that the student understands when the student says which of the following?

"Gender role behavior is the behavior a person conveys about being male or female." Sexual identity encompasses a person's self-identity, biologic sex, gender identity, gender role behavior or orientation, and sexual orientation or preference. Gender role behavior is the behavior a person conveys about being male or female. Biologic sex is the term used to denote chromosomal sexual development. Gender identity is the inner sense a person has of being male or female. Sexual orientation refers to the preferred gender of a person's partner.

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. What should the nurse recommend?

"Get the human papillomavirus vaccine." Human papillomavirus (HPV) is a DNA virus also called genital warts and is a sexually transmitted infection (STI). A vaccine is now available to prevent this disease. Male partners with HPV may or may not have lesions. Women should avoid douching to prevent STIs, as they remove normal protective bacteria in the vagina and increases the risk of getting some STIs. The Norplant system is a contracteptive method and does not prevent STIs.

Which assessment question is most likely to yield clinically meaningful data about a female client's sexual identity?

"How do you feel about yourself as a woman?"

A female client has recently had surgery for cervical cancer and asks the nurse about other ways she can have sex with her husband. What is an accurate statement by the nurse?

"Stimulation of the genitals by the mouth and tongue may be used to reach orgasm." Fellatio is stimulation of the male genitals; cunnilingus is stimulation of the female genitals

A nurse is concluding a sex education class by discussing sexual myths. Which of the following statements by the class lead the nurse to believe that they have understood the material?

"There is no relationship between the size of a man's penis and his ability to satisfy a woman sexually."

The nurse assessing an adolescent's need for further information should ask which of the following questions?

"What questions or concerns do you have about your sexual health?"

A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication?

-Identify the reason for not administering. -Circle the scheduled time on the MAR. -Report the situation to the prescriber.

When administering oral medications, which practices should the nurse follow?

-Perform hand hygiene before and after medication administration. -Stay at the bedside until the client has swallowed all the medications. -Verify the client's response to the medication 30 minutes after administration, or as appropriate for the drug.

A nurse who is administering a piggyback intermittent intravenous infusion of medication to a patient observes that there is a cloudy, white substance forming in the IV tubing. What actions should the nurse take in this situation?

-Stop the IV from flowing and stop administering the medication. -Clamp the IV at the site nearest to the patient. -Replace tubing on primary and secondary infusions.

What are components of a medication order?

-the full name of the client -the date and sometimes the time when the order is written -the dosage of the drug, stated in either the apothecary or metric system

Hypokalemia S/S

. Skeletal muscles are generally the first to demonstrate a potassium deficiency. Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

Which of the following commonly used intravenous solutions is hypotonic?

0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic

The nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered? D5 ¼ NS 3% NS 0.9% NS 0.45% NS

0.9% NS

A nurse is placing an IV in a newly admitted 30-year-old man. Which size catheter (lumen size and length, respectively) is most appropriate? a) 14 gauge, 1 inch b) 24 gauge, 2 inches c) 20 gauge, 1 inch d) 18 gauge, 2 inches

20 g, 1 inch Typical lumen size in an adult is between 18 and 22 gauge. The catheter should be the shortest possible length. Usually 1 to 1.25 inches is sufficient for IV therapy.

Democratic leaders or participative leadership styles are characterized by what?

A sense of equality among leaders and other participants

What is assault?

A threat or an attempt to make bodily contact with another person without person's consent

Patients requiring TPN at home may have what disorders?

AIDS, advanced cancer, dysphagia, or chronic bowel problems

Why is monitoring glucose levels important in a patient using TPN

About 25% of the solution is dextrose/high glucose concentration

The process by which a medication enters the bloodstream.

Absorption

While teaching sex education to a group of high school students, the nurse talks about forms of birth control. Which of the following could the nurse say is 100% effective if practiced correctly and consistently?

Abstinence

This conflict resolution patter involves only one party winning in exchange for something of value.

Accommodating

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptors. ---- The nurses make an arrangement for the preceptor. One nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend.----What type of conflict resolution is this?

Accommodating

This component of TPN prevents metabolic acidosis

Acetate

The new graduate nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Of the following outstanding tasks, which nursing intervention should the nurse complete first? -Dressing change that is 4 hours behind schedule -Discharge papers that are 3 hours behind schedule -Filling out an incident report -Administer a dose of digoxin (lanoxin) that is two hours behind schedule.

Administer a dose of digoxin (lanoxin) that is two hours behind schedule.

What criteria is used to determine the need for TPN?

An inability to achieve or maintain enteral access, motility disorders, intractable diarrhea, impaired absorption of nutrition that has or will be inadequate over 7-14 days

The nurse is justified in assessing for sexual dysfunction among male clients who are receiving what type of medication?

Antihypertensive medication

A client informs the nurse that he is leaving the health care facility because he is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask client to sign a release for AMA

Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships.

Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

Which of the following is a recommended guideline for the nurse who is administering a piggyback intermittent intravenous infusion of medication? -Ask the physician to calculate and regulate the infusion with an infusion pump. -Place the additive solution lower than the primary solution container. -Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion. -Using clean technique, remove the cap on the tubing spike and the cap on the port of the medication container.

Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion.

A patient on TPN needs medications administered. There is only one lumen off of the central line. What are the steps needed to administer medication?

Attempt to insert a peripheral IV dedicated to medications. Talk to health care team about a PICC or Midline. Never administer medications through same lumen as TPN

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation?

Authoritarian

This leader assumes complete control over the decisions and activities of the group. What style are they using?

Autocratic

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code? -Democratic Leadership -Laissez-Faire Leadership -Autocratic Leadership -Transactional Leadership

Autocratic Leadership

BETTER Acronym stands for:

B - Bring up the topic of sexuality so that patients know they can discuss sexuality openly. E - Explain that you are concerned with all aspects of patients' lives affected by disease. T - Tell patients sexual dysfunction can happen and that you will find appropriate resources to address their concerns. T - Timing is important to address sexuality with each visit to let patients know they can ask for information at any time. E - Educate patients about the side effects of their treatments and that side effects may be temporary. R - Record your assessment and interventions in patients' medical records.

A registered nurse enters a client's room and observes the unlicensed assistive personnel (UAP) pushing a client down on the bed. The client starts crying and informs the UAP that he needs to go to the bathroom. The UAP holds the client down and tells him he was just in the bathroom. The nurse observing this incident is aware that the UAP's action is an example of:

Battery

What would it be important to implement autocratic leadership during a code blue?

Because it involves the leader assuming control over the decision and activities of the group. During code blue, a leader is needed to direct the actions needed and make quick decisions to positively affect the client.

Why is the IV route the most dangerous for drug administration?

Because it is delivered directly to bloodstream, cannot be recalled, and actions cannot be slowed

What factor is used to calculate drug dosages for a child?

Body Surface Area

nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes? Electronic infusion device Continuous administration Secondary administration Bolus administration

Bolus administration

Which TPN component maintains osmotic pressure?

Calcium

The nurse recommends a barrier method of contraception for a client who is concerned about the side effects of hormonal contraception. Which method might the nurse suggest?

Cervical cap

Spiritual Anxiety

Challenged belief and value system

A nurse is counseling a couple who expressed that they are having difficulty conceiving. Which of the following could the nurse consider as a cause?

Changing developmental stage Changing developmental stages, such as menopause, can interfere with a couple's normal sexual expression. Having sex during menstruation, masturbation, and "petting" or simple stroking as part of foreplay do not affect a couple being able to conceive.

The nurse manager in a critical care unit actively listens to his staff and engages the staff to offer decisions regarding problem solving and implementing these decisions. What type of managerial mindset does this manager exhibit? Collaborative Mindset Reflective Mindset Analytical Mindset Action Mindset

Collaborative Mindset

The nurse prepares to complete an exam on a 25 year old female. The client presents to the community health clinic with complaints of difficulty with urination. The nurse reviews the chart and sees that the client is originally from Africa. The nurse suspects which of the following?

Complications from female genital mutilation (FGM) Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. It is a procedure that has no health benefits for girls and women and can cause severe bleeding, problems urinating, and later cysts, infections, infertility as well as complications in childbirth and increased risk of newborn deaths. The nurse may rule out UTI via urinalysis, however, the nurse would also want to rule out the presence of FGM in order to make sure the client receives appropriate long-term care.

In this conflict resolution both parties are willing to relinquish something of equal value.

Compromise

A nurse is conducting a healthy-living workshop with a group of female college students. Which method of contraception should the nurse recommend as a means of preventing both pregnancy and sexually transmitted infections?

Condoms

A nurse manager and the charge nurse have two employees who disagree with the accomplishment of client care. The manager determines a mutually agreed-upon time to discuss this situation with all the members involved. This activity is called what?

Conflict resolution

A staff nurse works on a medical unit where staff retention is very high. There is a a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which leadership style?

Democratic

What are the common components of TPN?

Dextrose, Amino Acids, Lipids, Acetate, Calcium, Chloride, Folic Acid, Magnesium, Phosphorous, Potassium, Sodium, Vit B Complex, Vit D, Vit K, Micronutrients

What are some health care practices concerning Church of Jesus Christ of Latter Day Saints (Mormons)?

Disapprove of alcohol, tobacco, and caffeinated beverages A special undergarment worn by some members should be removed only in an emergency.

The process by which the medication is delivered to the target cells and tissues is called distribution. The process of chemically changing the drug in the body is called metabolism; it takes place mainly in the liver

Distribution

Spinal cord injuries and sex

Ejaculation and orgasm are most likely to remain with low spinal injuries. Women are more likely to experience orgasm than men, but they complain more about the lack of physical sensations during the excitement phase than do men. Many people find that other erogenous zones become more easily stimulated after the injury.

A man 50 years of age has a long history of diabetes, which is poorly controlled. What does diabetes greatly increase the man's risk of experiencing?

Erectile dysfunction

Diabetes and sex

Erectile dysfunction, or impotence, is a great concern among diabetic men.

A nurse can improve his or her skill with time management by doing which of the following?

Evaluating success with accomplishment of goals in client care

How often should you check for adverse effects on the patient receiving continuous infusion?

Every hour

The nurse conducting a community health promotion class on sexuality includes that a person's biological sex is determined by what?

External and internal genitalia

Spiritual Guilt

Failure to live according to religious rules

The external part of catheter should be kept over the dressing to prevent introduction of microorganisms, leading to infection. True/ False

False The external part of the catheter should be kept under the dressing to prevent the introduction of microorganisms, leading to infection.

TPN is a highly concenctrated isotonic solution. True/False

False--It is hypertonic

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise

Spiritual Despair

Feeling that no one (not even God) cares

What is associated with the resolution phase of the male sexual response cycle?

Feelings of relaxation and fulfillment. The resolution phase of the sexual response cycle is associated with feelings of relaxation, fatigue, and fulfillment. The most intense pleasure of a physical nature takes place during orgasm, and the male experiences a refractory period during which he is incapable of sexual response. Blood flow to the penis returns to normal levels during the resolution phase.

What is intracellular fluid?

Fluid inside the cell

What is sensible fluid measurement?

Fluid measurement that can be measured like urination, defection, or wounds

What is extracellular fluid?

Fluid outside the cell

What is insensible fluid measurement?

Fluid that cannot be measured like sweat and water lost in respiration

TPN reduces the activity of what organs?

Gallbladder, pancreas and small intestine.

Hyperphosphatemia

Hyperphosphatemia can result in tetany, anorexia, nausea, muscle weakness, and tachycardia.

What are the requirements for the needle of an IM injection using deltoid site?

IM injections using the deltoid site require a 20- to 25-gauge needle that is between 1" and 1½" in length.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first

Spiritual Anger

Inability to accept illness

The nurse is providing education about sexuality to a group of college freshman. One of the terms he discusses is gender identity. What describes gender identity?

Inner sense of being male or female

If a patient's glucose level is above 150 what might be added to the TPN mixture?

Insulin

Where are Subcutaneous injections administered ?

Into the adipose tissue layer just below the epidermis and dermis.

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

Intradermal

What type of injection has the longest absorption time?

Intradermal

What is the best device to administer TPN?

Intravenously through a central vein with a multi-lumen, non-tunneled catheter into subclavian vein or a PICC line.

What is collaborative mindset?

Involves listening more than talking, and allowing people to take initiative and control their own work

________ fluids are used to increase blood pressure secondary to hypovolemia.

Isotonic (0.9%)

What are the benefits to TPN?

It can promote tissue/wound healing, restore normal metabolic function, and improve a patient's response to surgery

What would be unethical about using transactional leadership during a code blue?

It uses a reward system

The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include?

LGBT youth are 2 to 3 times more likely to attempt suicide. Healthy People 2020 found that LGBT youth are 2 to 3 times more likely to attempt suicide. Lesbians and bisexual females are more likely to be overweight or obese. LGBT populations have higher rates of tobacco, alcohol, and other drug use than other populations. Lesbians are more likely to get preventive services for cancer.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses?

Laissez-Faire

Peripheral Parenteral Nutrition (PPN)

Less concenctrated nutrient solution, for patients who have a malfunctioning GI tract and need short-term nutrition (less than 2 weeks)

These are essential fatty acids and calories for metabolism, wound healing, and red blood cell production

Lipids

A nurse is teaching a sex education class to a group of teenage girls. They ask the nurse about the sexual response cycle in females. Which physiologic response does the nurse tell them is only seen in females?

Loss of muscular control during orgasm causing spastic contractions During the excitement phase, some of the physiologic changes common in both men and women include an increased heart rate and blood pressure. Male and female nipples become hard and erect. In the orgasm phase, females have a loss of muscular control, which causes spastic contractions and twitching of the arms and legs. In the resolution phase, men experience a period during which the body does not respond to continued sexual stimulation, called the refractory period.

Anions carry "-" charge

Major anions are chloride, bicarbonate, and phosphate

Cations carry a "+" charge

Major cations are sodium, potassium, calcium, hydrogen, magnesium

Hypochloremia

Manifestations include hyperexcitability of muscles, tetany, hyperactive DTRs, weakness, and muscle cramps.

Hypophosphatemia

Manifestations include irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma.

Hypercalcemia

Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Severe hypercalcemia (serum calcium ≥17 mg/dL) is an emergency situation because cardiac arrest may result.

Metabolic alkalosis

Metabolic alkalosis = high pH and a high plasma bicarbonate concentration due to a gain of bicarbonate or a loss of hydrogen.

Upon medication administration with an NG tube. The nurse must first verify that the tube is in place and not in the lungs prior to administering the medication. What will she do next?

Next, the nurse can bring the liquids to room temperature. Typically the tube is flushed with 15 to 30 mL of water for adults (5 to 10 mL for children).

What are some health care practices concerning Roman Catholicism?

Only natural means of birth control; abortion, euthanasia, and sterilization are forbidden

A nurse is preparing to administer several prescribed medications to a client. The medications ordered are to be given by the following routes: oral, subcutaneous, intramuscular and intravenous. Place the routes in the proper order from slowest to fastest absorption. Subcutaneous Oral Intravenous Intramuscular

Oral Subcutaneous Intramuscular Intravenous

During the menstrual cycle, when does ovulation typically take place?

Ovulation generally occurs on day 14 when the mature ovum ruptures from the follicle and the surface of the ovary and is swept into the fallopian tube. From day 15 to day 28, the phase in the ovaries is called the luteal phase.

A nurse is taking care of a client who asks if she can have some acetaminophen to help with her headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours for pain. What type of order is this considered? One-time order p.r.n. order STAT order Standing order

P.R.N order

Elaine is a 28-year-old woman pregnant with multiples. She is diagnosed with hyperemesis gravidarum (excessive vomiting during pregnancy). She is unable to keep enteral fluids down. A licensed practitioner orders home IV therapy for 2 weeks. What type of IV access is most appropriate for Elaine and why?

PICC lines are appropriate for long-term therapy and can easily be used in the home environment.

What are PICC lines flushed with?

PICC lines are flushed with normal saline and/or heparin in order to maintain patency by preventing clot formation in the line.

What kind of vein is PPN administered through?

Peripheral

What are complications associated with TPN/PPN?

Pneumothorax, thromboembolism, infection, sepsis, hyper/hypoglycemia, fluid/electrolyte/acid-base imbalances, phlebitis, hyperlipidemia, liver/gallbladder disease

The nurse is caring for a patient diagnosed with human papillomavirus (HPV). What is a symptom of this STI?

Profuse watery vaginal discharge

A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to

Provide access for the administration of insulin

What is Faith?

Refers to a confident belief in something for which there is no proof or material evidence. it is also used to describe a cultural or institutional religion, such as Judaism, Islam, or Confucianism

A school nurse is providing a class on sexually transmitted infections (STIs). What is correct regarding STIs?

STIs are most prevalent among teenagers and young adults. Nearly two- thirds of all STIs occur in people younger than 25 years of age. The incidence of STIs is increasing due to multiple sex partners and sexual activity at a younger age. STIs affect men and women of all backgrounds and economic levels.

Spiritual Alienation

Separated from "faith community"

The nurse is teaching a class about sexuality at a public health clinic. After class the nurse is approached by Cathleen, a 54-year-old female, who eventually discloses to the nurse that she is having a sexual affair with a female partner. The term for an individual's preference for a partner of a particular gender is which of the following?

Sexual orientation Sexual orientation refers to the preferred gender of the partner of an individual. A transvestite is an individual who desires to take on the role or wear the clothes of the opposite sex. Gender role behavior is the behavior a person conveys about being male or female. A transsexual is a person of a certain biologic gender who has the feelings of the opposite sex.

A nurse manager best demonstrates effective leadership characteristic by which action? -Setting rigid goals and adhering to them -Demonstrating interest in the changes needing to be made in the unit -Finding out what resources are available to staff -Sharing a vision for the unit and enlisting support

Sharing a vision for the unit and enlisting support

Hyperchloremia

Signs and symptoms include tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma

The nurse working at a family planning clinic evaluates a client's risk for complications from oral contraceptives. Which of the following places the client at highest risk?

Smokes 1 pack cigerettes per week

Normal levels in body

Sodium-135-145 Potassium-3.5-5.0 Calcium- 4.5-5.1 Magnesium- 1.3-2.3 Chloride- 97-107 Bicarbonate- 25-29 Phosphate- 2.5-4.5

What is diffusion?

Solutes move from area of higher concentration to area of less concentration

Medications and sex

Some medications have side effects that may affect sexual functioning. These include amyl nitrates, anticonvulsants, antidepressants, antihistamines, antihypertensives, antipsychotics, antispasmodics, barbiturates, and narcotics. Recreational drugs including cocaine, ethyl alcohol, and marijuana are used by some to heighten the sexual experience. These drugs can have serious and even deadly side effects. While some use alcohol to release inhibitions and to increase sexual arousal and desire, heavy drinking can decrease libido and negatively impact sexual functioning.

Quid pro quo

Something given or withheld in exchange for something else. Quid pro quo harassment occurs when a person's employment or well-being is dependent on agreeing to unsolicited and unwelcome sexual demands. This type of harassment is typically initiated by a person in a position of authority who offers either direct or indirect reward or punishment based on the granting of sexual favors. Quid pro quo harassment is a clear abuse of power and is legally, morally, and ethically wrong.

A nurse is caring for a 6-year-old client on the hematology-oncology floor. During a packed red blood cell transfusion, the client complains of pain at her peripheral IV site. The nurse assesses the site and notices that the site is purple. What is the nurse's best course of action?

Stop transfusion and discontinue peripheral IV. This is a sign of infiltration

A female client tells the nurse that she and her husband have selected periodic abstinence as their choice of contraception. Which of the following is the best method for the nurse to recommend to predict ovulation?

Symptothermal method The best approach to monitoring fertility is a combination of all three methods (temperature, cervical mucus, and calendar), called the symptothermal method.

A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy. What type of effect is this an example of?

Synergistic

Spiritual Loss

Terminal illness; anticipatory grieving; inability to find comfort in religion

The community health nurse is aware that many factors influence a client's decision for contraception. Which of the following is the most likely reason a client would select permanent contraception?

The choice not to start a family.

Traditionally, the male sexual response is thought to be broken up into three phases. Which occurrence is part of the plateau phase?

The circumference of the penis thickens at the coronal ridge and a few drops of fluid appear at the urethral meatus.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? The client has anti-A antibodies. The client has anti-B antibodies. The client is a universal donor. The client has both anti-A and anti-B antibodies.

The client has anti-A antibodies.

complete blood count

The complete blood count determines the total number of red blood cells and values for hemoglobin and hematocrit.

What are some health care practices concerning Hinduism?

The nurse administering medications should avoid touching the patient's lips. Certain prescribed rites are followed after death; disposal of the body is by cremation.

A client is unhappy with the health care provided to him. He approaches the nurse and informs her that he is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What would the nurse's action be in this situation?

The nurse should call the nursing supervisor and inform her about the situation.

What are S/S of hypovolemia

The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen

Urine pH

The pH of urine usually ranges between 4.6 and 8.2. Lower than normal urinary pH can occur with metabolic acidosis, diabetic ketosis, and diarrhea. Higher than normal urinary pH can occur with respiratory alkalosis, potassium depletion, and chronic renal failure

MI and Sex

The primary goal after a myocardial infarction (MI) is to allow the heart ample time to heal. Activities of daily living, including sexual activity, should be resumed gradually, and stressors such as overexertion, alcohol consumption, and emotional upheavals should be avoided. After an uncomplicated MI, sexual activity may begin at about the third week of recovery, beginning with masturbation to partial erection in the male. Generally, this activity is gradually increased until 3 months after the MI, when sexual intercourse may be resumed. A comfortable position that places the least stress on the affected partner should be used.

What are some health care practices concerning Adventists?

The taking of all narcotics and stimulants is prohibited because the body is the temple of the Holy Spirit and should be protected. Many groups prohibit meat. Many regard Saturday as the Sabbath.

How is fluid intake regulated?

Thirst mechanism in hypothalamus

Hypomagnesemia

This abnormality may lead to muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis.

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

To prevent blood clot formation

A client visits a community clinic reporting a foul-smelling vaginal discharge that is thin, foamy, and green in color; itching of vulva and vagina; and burning on urination. Which STI would the nurse suspect?

Trichomonas vaginalis

A nurse leader is working with a client with hypertension who needs to learn about a low-sodium diet. "I understand why I need to eat a low-sodium diet."The nurse recognizes the client is in the unfreezing stage of Lewin's Change theory with his statement. True or False

True

PPN solutions are isotonic and contain only 10% of glucose/dextrose or less. True/False

True

What blood type is a universal donor?

Type O

What does unfreezing mean?

Unfreezing recognizes the need for change

The nurse is assessing the sexual health of a female client age 20 years. During the interview, the client says, "I feel that my vaginal opening constricts whenever I am about to have intercourse. I seem to have no control over it." What would the nurse use when documenting the client's report?

Vaginismus

A patient needs this vitamin to help absorb carbohydrates?

Vit B Complex

Intermittent intravenous medication infusion diluted with a small amount of solution

Volume-Control Administration Set

What is osmosis?

Water moves from less solute area to area with more solute

What should patient education include pertaining to TPN/PPN in the home?

What TPN is used for Adverse reactions/catheter complications When to call PCP Basic line care Equip Maintenance Monitoring patient's weight, I&O, and glucose levels

Collaborating is a "____-_____" situation

Win-Win

What is an atheist?

a person who denies the existence of a higher power

Doxycycline and calcium carbonate have an have what type of relationship

antagonistic

Hostile environment harassment

ccurs when sex- or gender-based behaviors create a hostile, intimidating environment that hurts a person's work performance, classroom performance, or general sense of well-being. In the workplace, for example, the negative behaviors in hostile environment harassment are not directly linked to job-related consequences; instead, the employee's willingness to suffer the experience of the demeaning environment becomes a condition of employment. This type of harassment is not necessarily caused by a person with formal power. Hostile environment is sometimes difficult to identify, as it is not always easy to determine when offensive speech or behavior actually turns to true harassment.

During a routine physical exam, a male client informs the nurse that he frequently participates in anal intercourse with his new girlfriend. The nurse discusses this practice with the client by informing him that:

condoms are recommended for anal intercourse.

When a man cannot achieve an erection, the phase of the sexual response in which the man is experiencing difficulty is:

excitement phase

People whose biologic sex at birth is contrary to the gender they identify with are diagnosed with...

gender dysphoria

Respiratory acidosis

high PaCO2 due to alveolar hypoventilation.

Respiratory alkalosis

low PaCO2 due to alveolar hyperventilation

Metabolic acidosis

low pH (increased hydrogen ion concentration) and a low plasma bicarbonate concentration due to a gain of hydrogen or loss of bicarbonate.

The process of chemically changing the drug in the body is called ___________; it takes place mainly in the liver

metabolism

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will the nurse be looking?

muscle cramping and tetany

What is total parenteral nutrition (TPN) ?

nutritional therapy that bypasses the gastrointestinal tract for patients who are unable to take food orally; meets the patient's nutritional needs with a highly concentrated, hypertonic nutrient solution administered intravenously through a central vein

What is an agnostic?

one who holds that nothing can be known about the existence of a higher power.

Autocratic and authoritarian are similar because they both are

primarily directive

Sexual harassment

unwelcome behavior that is based on one's sex or gender. This type of harassment usually occurs in the context of an asymmetrical relationship in which one person has more formal power than the other (e.g., a faculty member over a student) or more informal power (e.g., one peer over another). Sexual harassment can be directed toward people of any age, either gender, and any sexual orientation. There are two forms of sexual harassment: quid pro quo and environmental harassment (also called a "hostile" environment).

Competition involves a "____-____" situation in conflict resolution

win-lose

The nurse is teaching a male adolescent how to use a condom. Which teaching points would the nurse include?

• "If the condom does not have a nipple receptacle, leave a small space at the end for semen to collect." • "Use a condom with every act of intercourse." • "Immediately after ejaculation remove the condom and discard it."

An Emergency Department nurse wants to become competent to care for rape victims. The nurse determines that she must evaluate which of the following characteristics in herself?

• Comfort with her sexual identity • Knowledge of reproductive anatomy and physiology • Therapeutic communication skills • Ability to practice reasonable sexual expression

The nurse is advising an adolescent male about sexual myths that have him concerned. Which statements describe accurate client education regarding these concerns?

• No male or female should feel pressured into sexual activity at any age. • Nocturnal emissions are normal in men of all ages. • Masturbation or self-stimulation is a natural and healthy outlet for sexual urges.

The nurse is discussing the use of hormonal contraception with a woman who just delivered twins and is not ready to get pregnant in the near future. Which methods might the nurse recommend?

• Oral contraceptives • Norplant system • Depo-Provera • Vaginal ring

Which statements describe sexual dysfunction in males or females?

• Premature ejaculation is a condition in which a man consistently reaches ejaculation or orgasm before or soon after entering the vagina. • Retarded ejaculation refers to the man's inability to ejaculate into the vagina or delayed intravaginal ejaculation. • Vaginismus is painful intercourse. • Vulvodynia is a chronic vulvar discomfort or pain characterized by burning, stinging, irritation, or rawness of the female genitalia that interferes with sexual activity.

The nurse is preparing to conduct a screening for acquired immunodeficiency syndrome (AIDS)on a 30 year old male. The nurse knows to include which of the following in the assessment?

• Sexual orientation • Night sweats • Fatigue • Diarrhea

The nurse knows that a physical examination of the reproductive or genitourinary system is necessary for patients under the following circumstances:

• Unusual lump, discharge, or appearance of the genital organs • Suspected pregnancy • Change in urinary function • No contact with a healthcare provider in over two years

Herpes simplex virus type 1 and 2 "Cold sores" Herpes

•A DNA virus •Lesions develop mostly in oral and genital areas. •Appear as single or multiple painful vesicles, which rupture and form ulcer-like lesions; these form scabs as they heal. •First infections last about 10 to 14 days, whereas subsequent infections are shorter in duration. •Recurrences are usually preceded by prodromal symptoms of tingling and fullness.

Human papillomavirus (HPV) Condylomata acuminate Genital warts Venereal warts

•A DNA virus; vaccine now available. •Pale, soft, papillary lesions found around the internal and external genitalia and perianal and rectal areas of the body; vary in size •Profuse watery vaginal discharge, dyspareunia, intense pruritus, and vulvar irritation •Women with HPV are at risk for cervical cancer. •Male partner may or may not have lesions.

Treponema pallidum Syphilis

•A spirochete detected through serologic blood test (VDRL, RPR, STS) •Three stages to disease if left untreated Primary: Single painless genital lesion 10 days to 3 months after exposure Secondary: Generalized skin rash, enlarged lymph nodes, fever that may appear 2 to 4 weeks after appearance of primary lesion; may last for several years Latent: Usually no clinical symptoms present for as long as 20 years; may continue to involve and damage neurologic and cardiovascular organs; dementia, confusion, paralysis, and paresis may occur.

Cervical intraepithelial neoplasia (CIN) Cervical cancer

•Abnormal Pap smears •Women with multiple sex partners, women who began sexual activity before age 18, and women whose partners have multiple female partners •Asymptomatic •Possible vaginal bleeding or spotting

Sexual behavior ranges from adaptive to maladaptive. Adaptive responses meet what following criteria?

•Between two consenting adults •Mutually satisfying to both •Not psychologically or physically harmful to either •Lacking in force or coercion •Conducted in private Maladaptive sexual responses are behaviors that do not meet one or more of the criteria for adaptive responses.

Neisseria gonorrhoeae "The clap" or "the drip" Gonorrhea

•Gram-negative bacteria•Both men and women may not have symptoms. •Symptoms in men: purulent penile discharge, dysuria, frequency of urination •Symptoms in women: dysuria, abnormal menses, vaginal discharge, pelvic inflammatory disease •Symptoms of pharyngitis if oral sex was practiced •May be accompanied by chlamydial infection •Detected by gonorrhea culture of cervix or penile discharge from men •Newborns exposed at birth are at risk for blindness and pneumonia. •Untreated gonorrhea can result in infertility, skin rash with lesions, and acute arthritis.

Acquired immunodeficiency syndrome (AIDS)

•Human immunodeficiency virus (HIV) •Positive ELISA and Western Blot tests •Incidence high in IV drug users and homosexual and bisexual men; increasing heterosexual transmission •Fatigue, diarrhea, weight loss, enlarged lymph nodes, fever, anorexia, and night sweats

Trichomoniasis "Trich" Trichomonas vaginalis

•Protozoan with flagella •Identified on wet-mount microscopic examination of vaginal discharge •May be identified on Pap smear •Usually asymptomatic in male patients •Foul-smelling vaginal discharge, thin, foamy, and green in color, causes itching of vulva and vagina, burning on urination and dyspareunia; "strawberry" cervix may be seen on speculum examination

Chlamydia trachomatis Nongonococcal urethritis (NGU) Chlamydia

•The most prevalent STI to date •Intracellular bacteria •Vaginal discharge, burning on urination, urinary frequency, dysuria, and urethral soreness •Many women do not have symptoms.

Examples of hostile environment harassment

•Unwelcome sexually oriented and gender-based behaviors •Sexual bantering •Sexual jokes •Offensive pictures and language •Sexual innuendoes •Sexual behavior

The registered nurse (RN) wants to delegate a task to an unlicensed assistive personnel (UAP) but is unsure if the task can be delegated. What is the best resource for the RN to use in determining if the task is appropriate? -The nurse practice act or facility's policy and procedures -The nurse mentor or preceptor -The nurse manager -Medical Practice Act

The nurse practice act or facility's policy and procedures

Why can't a nurse delegate assessment of a rash to a UAP?

The nurse should be the only one doing assessment of conditions of a patient

What are the three spiritual needs that underlie all religious traditions and are common to all people:

1. Need for meaning and purpose 2. Need for love and relatedness 3. Need for forgiveness

What is the significance of a Magnet status hospital?

A hospital that has achieved Magnet status has recognition of quality client care that is provided by nursing staff who are professional and well-qualified

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptors.--The nurses decide to share the preceptor. The preceptor will precept one nurse at the beginning of the orientation and precept the other nurse at the end of the orientation.-- Which approach to conflict resolution are they using?

Compromise

Laissez- Faire is also called

Non-directive leadership

A voluntary process by which a nursing education program is recognized as having met certain standards by the National League for Nursing Accrediting Commission and/or the American Association of Colleges of Nursing

Accreditation

What is reflective mindset?

Allows managers to mentally digest experiences and reflect on them in a different way

What is battery?

An assault carried out that is willful, angry and violent

What is spirituality?

Anything that pertains to a person's relationship with a nonmaterial life force or higher power

The nurse is getting accustomed to the role of nurse manager. What are requirements for this nursing role? Select all that apply. -Creating schedules for the unit -Managing the unit's operational budget -Introducing methods to improve staff efficiency -Evaluating the success of the unit policies -Making Careplans for individual patients -Passing out medications

Creating schedules for the unit Managing the unit's operational budget Introducing methods to improve staff efficiency Evaluating the success of the unit policies

What is directive leadership?

Describes a leader who makes all the decisions and tells followers what to do

A nurse informs the client that he has no choice and must take his bath in the morning. What type of leadership does this exemplify?

Directive

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?

Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached

When should goals and priorities be established?

Beginning of each day

The nurse is working at a facility that is applying for Magnet® Recognition. The nurse recognizes that research supports Magnet® hospitals as having which direct effect on client care? -Higher nurse retention -Better patient outcomes -Shorter length of stays -High job satisfaction scores

Better patient outcomes Hint: All are correct pertaining to Magnet hospitals but which had a direct effect on patient care.

A nurse who demonstrates advanced expertise in a content area of nursing through special testing. This is an example of?

Certification

Which is not a primary intracellular electrolyte?

Chloride, along with sodium and bicarbonate, are the primary ECF electrolytes

Hypermagnesemia

Clinical manifestations include nausea, vomiting, weakness, flushing, lethargy, loss of DTRs, respiratory depression, coma, and cardiac arrest.

Which management style forces actions upon staff?

Coercive

The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which conflict resolution styles does the nurse manager display?

Collaborating

What is analytical mindset?

Encourages introspection so that one can recognize biases and see things in a unique way

The nurse educator is presenting a lecture on the Occupational Safety and Health Act. What is OSHA primarily responsible for?

Helps reduce workforce injuries and illness in the workplace

A new nurse should look back over her day and determine what was accomplished. What is the significance of this?

Helps set a time line for the next day

A nursing facility has recently implemented new policies regarding nurse-to-patient ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change?

Hold a unit meeting to discuss how the changes will benefit staff

What is "smoothing"?

Is an effort to complement the other part and focus on agreement rather than disagreement, thus reducing emotion in conflict. (rarely resolved)

Hypocalcemia

Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures.

What is action mindset?

Mobilizes energy to change while being sensitive about the capabilities of the team and the direction that is needed.

What are Lewin's Three stages of change?

Moving, freezing, and unfreezing

Hyperkalemia S/S

Nerve conduction as well as muscle contractility can be affected. Skeletal muscle weakness and paralysis may occur. A variety of cardiac irregularities may result, including cardiac arrest if hyperkalemia is not corrected

A nurse on a telemetry unit is admitting a client and has an unlicensed assistive person (UAP) helping with the admission process. Which task can the nurse delegate to the UAP? -Obtain client history -Obtaining medications taken at home -Obtain rate and rhythm of heart rate -Obtaining an admission weight for the client utilizing the client's bed scale

Obtaining an admission weight for the client utilizing the client's bed scale

Refreezing makes the change...

Operational

A nurse manager tells her staff that they need to increase response time to client requests by five minutes, beginning tomorrow. The time to begin this activity has been established by the manager and her staff. This action involves goal setting. What leadership style is noted with the implementation of goal setting?

Participative Leadership

What are the negative attributes of Laissez-Faire leadership?

Tends to increase conflicts and anxiety during times of change

Hypernatremia S/S

The cells of the central nervous system are especially affected, resulting in signs of neurologic impairment, including restlessness, weakness, disorientation, delusion, and hallucinations. Permanent brain damage, especially in children, can occur

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states she will begin to count caloric intake beginning with the next meal. The client also states intentions to begin an exercise program with friends. Which statement illustrates Lewin's stage of unfreezing?

The client acknowledges the need to lose weight.

The case manager works in a facility that supports a participative leadership style. Which of the following should the nurse recognize as an example of democratic leadership style?

The interdisciplinary health care team collectively developing plans of care for clients

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse ensures that the client's family signs the consent form. In some states this is the responsibility of the physician

What are a nurse managers' duties?

The nurse manager is responsible for managing the unit's operational budget, improving staff efficiency, creating the schedule, and evaluating the effectiveness of unit policies.

Hyponatremia S/S

This shift of fluid leads to swelling of the cells, with resulting confusion, hypotension, edema, muscle cramps and weakness, and dry skin. Cerebral edema can lead to seizures. Permanent neurologic damage and death can result from severe hyponatremia

All of the following are steps to enhance what skill: Establish goals Evaluate ability to meet goals Identify tasks that can be delegated Establish a timeline Evaluate success of the plan Use evaluation for future goals

Time Management

Which of the following clients would be a candidate for total parenteral nutrition

Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing

This leader creates intellectually stimulating practice environments, challenging themselves and others to grow personally and professionally. What style are they using?

Transformational

What is waters primary function?

Transport of nutrients to cells and waste from cells, transports hormones, enzymes, blood platelets, RBCs, and WBCs. Facilitate cellular metabolism. Acts as a solvent of electrolytes and non electrolytes. Maintains body temperature, facilitates digestion and promotes elimination, and acts as tissue lubricant

Staff nurses are developing innovative solutions to problems. Does this statement reflect the expected functioning at a hospital with Magnet status?

Yes

The nurse recognizes that a new mother is having difficulty breastfeeding her baby. The nurse provides assistance by demonstrating various positions to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Is the statement, "The new mother attempts to breastfeed the baby again using the techniques recently acquired and is successful", conducive to Lewin's stage of refreezing?

Yes

What is a living will?

an instructive form of advance directive; that is, it is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery.

Defamation of character is

an intentional tort in which one party makes derogatory remarks about another that harms the other party's reputation.

The Health Care Quality Improvement Act of 1986 was enacted

to encourage health care practitioners to identify and discipline practitioners who engage in unprofessional conduct, and to restrict the ability of incompetent practitioners to move from state to state without disclosure of the practitioner's previous performance.

What are advance directives?

written statements identifying a competent person's wishes concerning terminal care