Fundamentals final

1. Contact precautions are initiated for a patient with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. Gloves and gown B. Gloves and goggles C. Gloves, gown, and shoe protectors D. Gloves, gown, goggles, and mask

1. D. Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

76. The nurse is caring for a hospitalized older adult who is having an allergic reaction. Diphenhydramine (Benadryl) 50 mg by mouth every 4 hours is prescribed. The patient experiences extreme drowsiness and the nurse calls the health-care provider. The nurse is instructed to give one-half the present dose when the next dose is due. Since the diphenhydramine is in the form of a capsule that cannot be cut in half, the nurse acquires diphenhydramine elixir that states that there is 12.5 mg per 5 mL. How much solution should the nurse administer? Record your answer using a whole number. Answer:___________________________mL

10. The ability to metabolize and excrete drugs decreases in older adults. Medications may require a reduction in the size of the dose to prevent toxicity. Solve the problem using ratio and proportion. Desire 25 mg x mL ---------------- = ------ Have 12.5 mg 5 mL 12.5 x = 25 × 5 12.5 x = 125 x = 125 ÷ 12.5 x = 10 mL

22. A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychological development theory, which instruction(s) should the nurse provide to the parent? Select all that apply. A. Set limits on the child's behavior. B. Ignore the child when this behavior occurs. C. Allow the behavior, because this is normal at this age period. D. Provide a simple explanation of why the behavior is unacceptable. E. Punish the child every time the child says "no" to change behavior.

22A, D. According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options B and C do not address the child's behavior. Option E is likely to produce a negative response during this normal developmental pattern.

98. Order: Valium 7.5 mg Supply: Valium 2.5 mg/tab How many tablets, or what portion of a tablet, should be given per dose?

3 tabs/dose

97. The doctor has ordered 500 mL D5W to infuse over 4 hours with a drop factor of 15. How many gtt/min should the patient receive?

31 gtt/min

59. A nurse working in a nursing home is caring for a patient whose wife died several years ago. The nurse believes that the patient is experiencing dysfunctional grieving. Which of the following clinical manifestations by the patient specifically support dysfunctional grieving rather than normal grieving? Select all that apply. A. Focuses on little else but the death of his wife B. Focuses excessively on memories of his wife C. Feels that there is nothing to live for D. Feels sad at the thought of his wife E. Feels tired

A, B, C. Focusing on little else but the death of a love one over a long period of time (2 or more years) supports the inference that the patient is experiencing dysfunctional grieving. Although focusing on memories of a loved one is a component of normal grieving, when it becomes extreme over a long period of time (2 or more years), it supports the inference that the patient is experiencing dysfunctional grieving. Thoughts of having nothing to live for after the death of a loved one can precipitate feelings of suicide ideation. These thoughts can occur with normal as well as dysfunctional grieving. However, such thoughts indicate dysfunctional grieving if they are still present years after the loss of a loved one. Sadness at the thought of a loved one is consistent with both normal and dysfunctional grieving. Feeling tired is associated with normal as well as dysfunctional grieving.

71. A nurse is obtaining a health history and performing a physical assessment of an older adult. Which clinical manifestations associated with aging should the nurse expect? Select all that apply. A. Impaired balance B. Close vision impairment C. Diminished muscle strength D. Intermittent urinary incontinence E. Decreased hearing of low-pitched sounds

A, B, C. Impaired balance is associated with aging because the spinal column begins to deteriorate and vertebral fractures and loss of cartilage between the vertebrae occur; these changes alter the center of gravity and body alignment, resulting in difficulty maintaining balance. Close vision impairment (presbyopia) occurs because the lens becomes less elastic and is no longer able to accommodate to close objects. Diminished muscle strength occurs because body and bone mass decrease. The effects of decreased joint mobility inhibit the ability to exercise to the extent possible when younger. Urinary incontinence is not associated with aging; it is associated with urinary tract infections and decreased tone of the muscles in the pelvis. This can occur at any age, especially in women. Decreased hearing of high-pitched sounds (Presbycusis), not low-pitched sounds, occurs with aging because the hair cells in the cochlea deteriorate with aging.

57. An emergency department nurse is caring for parents whose 15-year-old daughter, while walking to school, was killed by a hit-and-run driver. Identify statements made by the nurse that are based on principles of therapeutic communication. Select all that apply. A. "I am so sorry for your loss." B. "Losing a child is awful. It is okay to cry." C. "I'm here if you want to talk." D. "I hope that the police find the driver and that justice is served." E. "You have to believe that God wanted her close to Him as an angel in heaven."

A, B, C. Stating "I am so sorry for your loss" acknowledges the loss and demonstrates caring. Statement B acknowledges the loss and indicates that it is alright to express feelings. This statement communicates caring and nonjudgmental acceptance of behavior related to grieving. An open-ended statement offers an opportunity for the parents to discuss their feelings. It is a valuable therapeutic communication technique that allows the parents to direct the conversation. Statement D is nontherapeutic. The focus should be on the parents and their feelings of loss. The parents are the central patients in this situation. Statement E is nontherapeutic and is a barrier to communication. It cuts off communication by implying that the parents have to accept the loss of their daughter because God wanted her close to Him as an angel. Also, it is inappropriate to assume that the parents believe in God.

26. The clinic nurse prepares to perform a focused assessment on a patient who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. A. Auscultating lung sounds B. Obtaining the patient's temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the patient's respirations E. Performing a musculoskeletal and neurological examination F. Asking the patient about a family history of any illness or disease

A, B, D. A focused assessment focuses on a limited or short-term problem, such as the patient's complaint. Because the patient is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this patient's complaints. A musculoskeletal and neurological examination also is not related to this patient's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the patient about family history of any illness or disease would be included in a complete assessment.

82. A nurse is assessing a patient who had numerous sutures several days ago for a traumatic injury to the base of the right index finger. Which assessments indicate that the inflammatory response has progressed to an infectious process? Select all that apply. A. Foul odor B. Yellow exudate C. Swelling around the site D. Inability to flex the finger E. Elevated body temperature F. Feeling of heat when touched

A, B, E. A foul odor to a wound indicates infection. The odor is the result of purulent drainage consisting of pyogenic bacteria, protein-rich fluid filled with white blood cells, and cellular debris. Purulent drainage, which may be yellow, green, tan, or brown, indicates that presence of an infectious process. The discharge contains cellular debris, destroyed tissue, phagocytic cells, and microorganisms (pus). The discharge associated with the inflammatory response usually is clear (serous) and contains cellular debris proteins and plasma fluid; it also may contain blood (e.g., serosanguineous, sanguineous). An increased body temperature is a systemic response to an infection. The body is creating a hostile environment that can interfere with the replication of bacterial cells. Swelling around the site is part of the local inflammatory response. Histamine released at the site of the trauma causes vasodilation, and kinins released by destroyed cells increase capillary permeability; both allow fluid to move from the intravascular compartment into the interstitial compartment, resulting in an accumulation of fluid (edema). Edema and pain associated with the local inflammatory response interfere with the ability to flex the finger. Local heat is part of the local inflammatory response. Dilation of blood vessels brings more warm blood to the site and there is an increase in metabolic processes at the site; both increase heat at the site of the injury.

53. A nurse formulates the following goal with a patient: "The patient will ambulate in the hall without experiencing activity intolerance." Which statements address the status of this goal? Select all that apply. A. It is not measurable. B. It is not patient-centered. C. It is missing a parameter. D. It is missing a target time. E. It is a correctly written goal.

A, C, D. The words activity intolerance are vague. Although activity intolerance often is defined as a respiratory rate greater than 24 breaths/min and a pulse rate greater than 95 beats/min after 3 minutes of rest after activity, it is not included in the goal; for example, as evidenced by a respiratory rate below 24 breaths/min and a pulse rate of less than 94 beats/min. In addition, it does not identify how many feet the patient should ambulate. The goal does not identify how many feet the patient should ambulate; this is an important parameter that is missing in this goal. The goal does not identify how many times a day the patient should ambulate in the hall. The goal is patient-centered. It begins with: The patient will. This goal is not correctly written. It should read, "The patient will ambulate in the hall 50 feet three times a day without experiencing activity intolerance, as evidenced by a pulse rate below 94 beats/min and a respiratory rate below 24 breaths/min after 3 minutes of rest after ambulating."

70. An older adult who was hospitalized has been experiencing sundowning syndrome. What interventions should the nurse include in the patient's plan of care? Select all that apply. A. Follow the preset daily routine. B. Hurry through direct patient care. C. Provide a nonstimulating environment. D. Explain in detail what care will be performed. E. Use a motion sensor device on the patient's bed.

A, C, E. Daily routines provide structure and repetition that limit the unknown. Patients are more in control and less anxious if they know what to expect regardless of the time of day, but particularly late afternoon or evening. Fewer stimuli are better that a stimulating environment. Excessive stimuli precipitate confusion, increase anxiety, and exacerbate the sundowning syndrome. A motion sensor will alarm if the patient attempts to get out of bed. The alarm will alert the nurse so that supervision can be provided. The opposite of B is true; an unhurried routine is less demanding and less likely to precipitate anxiety. Simple communication (e.g., declarative statements, short sentences, with one noun and one verb) with just essential information is less confusing.

67. A nurse identifies that patients are experiencing middle-adulthood developmental crises. Which information supports the nurse's conclusion? Select all that apply. A. Inability to carry a wanted pregnancy to term B. Failure to develop friendships with peers C. Demotion to a lesser position at work D. Powerless to postpone gratification E. Unable to discuss eventual death

A, C. The developmental stage of generativity versus stagnation is associated with middle-adult years (ages 25 to 65). During these years people establish a family and promote the growth of others, particularly those in the next generation. Successfully fulfilling lifelong goals involving family parenthood, employment, and role in society is associated with the developmental task of middle adulthood. Development of peer relationships is associated with the developmental task of 6-to-12-year0old children, not middle-aged adults. Inability to postpone gratification is associated with the developmental task of an 18-month-old to 3-year-old child, not a middle-aged adult. Confronting eventual death is associated with the developmental task of an adult 65 years of age or older, not a person in middle adulthood.

83. A nurse is removing personal protective equipment when exiting an isolation room. Place the following steps in the order in which they should be implemented. A. Untie the gown at the waist. B. Release the ties of the mask and dispose of the mask in an appropriate trash container. C. Place fingers of the dominant hand inside cuff of other sleeve and pull gown over nondominant hand. D. Remove one glove by touching the outside of the glove with the other gloved hand and without contaminating oneself; dispose of it in an appropriate trash container. E. With the ungloved hand, slip a finger inside the cuff of the other glove and remove it without contaminating oneself and dispose of it in an appropriate trash container. F. With a gown covered hand, pull gown down over the dominant hand, pull gown down over the dominant hand, folding the gown inward and gathering it together as it is pulled down; dispose of it in an appropriate container.

A, D, E, B, C, F. Tie at the waist is released first while still wearing gloves. The tie at the waist is considered contaminated because it is at or below the level of the waist, which is always considered contaminated. The gloves are removed next as so not to contaminate the hands or the environment. The first glove is removed by touching only the outside of the glove. After the first glove is removed, the second glove is removed by touching only the inside of the contaminated glove. The ties of the mask can be untied with the hand because they are considered clean. The gown is removed by touching only the inside of the gown. A hand can be used by placing the fingers of one hand up inside of the other sleeve and pulling the sleeve down over the hand. With the other hand inside the gown, the gown should be folded downward and gathered inward to itself. The gown acts as a barrier and protects the nurse from contact with the contaminated outer surface of the gown. Gathering the soiled gown together as it's pulled down contains the contaminated surface of the gown. A paper gown is then placed in an appropriate trash container while a material gown is placed in a designated linen hamper. Before leaving the patient's room, the hands are washed.

81. A nurse is assessing a patient who has a wound on the leg as the result of a bicycle accident. Which clinical manifestations indicate a localized inflammatory response? Select all that apply. A. Surrounding area is warm. B. Body temperature is 101.4°F. C. Heart rate is 102 beats/minute. D. Area around the wound is swollen.

A, D. Because of an increase in blood flow to a wound on the leg, the area will feel warm to the touch. A localized swelling around a wound indicates the presence of edema. Vasodilation and increased permeability from the capillaries promote the shift of fluid from the intravascular compartment to the interstitial compartment. Localized swelling around a wound due to vasodilation and increased permeability of the capillaries promote a shift of fluid from the intravascular compartment to the interstitial compartment causing pressure on pain receptors resulting in pain. An increased body temperature is a systemic, not local, response that is associated with infection, not inflammation. An elevated heart rate is a systemic, not localized, response that is associated with infection, not inflammation.

11. The nurse receives a telephone call from postanesthesia care unit stating that a patient is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway. B. Check tubes of drains for patency. C. Check the dressing to assess for bleeding. D. Assess the vital signs to compare with preoperative measurements.

A. The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

61. A nurse is caring for a patient who is dying. The patient is withdrawn and quiet. What should the nurse do? Select all that apply. A. Avoid talking unnecessarily. B. Engage in cheerful dialogue. C. Provide constant reassurance. D. Encourage interaction with family. E. Sit quietly by the bedside periodically.

A, E. The patient is in the phase of withdrawal. Unnecessary talking distracts the dying person from necessary preparation for letting go and should be avoided. Allowing time for silence conserves the patient's energy for focusing on dying. Sitting quietly by the bedside lets the patient know that someone cares and that the patient is not alone. It demonstrates respect for the dying patient who needs to focus on dying. Cheerful dialogue is not therapeutic. The patient is in the withdrawal phase of dying and requires only interaction necessary to meet needs. Reassurance does not need to be constant. A quiet presence demonstrates to the dying person that the nurse is available when needed. Encouraging interaction with family is not therapeutic. It does not meet the needs of a dying person who is in the phase of withdrawal. Unnecessary family interaction distracts the dying person from focusing on preparation for letting go.

10. A patient who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. A. Contact the surgeon. B. Instruct the patient to remain as still as possible. C. Prepare the patient for wound closure. D. Document the findings and actions taken. E. Place a sterile saline dressing and ice packs over the wound. F. Place the patient in a supine position without a pillow under the head.

A,B,C,D. Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the patient, and ask another nurse to contact the surgeon and obtain needed supplies to care for the patient. The nurse places the patient in a low Fowler's position, and the patient is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasocontrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

20. The maternity nurse is providing instructions to a new mother regarding the psychological development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A. Allow the newborn infant to signal a need. B. Anticipate all the needs of the newborn infant. C. Attend to the newborn infant immediately when crying. D. Avoid the newborn infant during the first 10 minutes of crying.

A. According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.

69. Which educational intervention is most specific to teaching older adults? A. Teaching about safety precautions in the home environment B. Providing suggestions about maintaining a healthy diet C. Presenting strategies to avoid the empty nest syndrome D. Exploring actions that support a healthy lifestyle

A. As older adults physically decline, they are prone to falls and accidents in the home environment. Prevention of falls and a safe home environment are essential to explore when teaching older adults. Maintaining a healthy diet is not specific to older adults. A healthy diet should be an educational focus for all age-groups. Presenting strategies to avoid the empty nest syndrome generally is specific to the late-middle-adult age group as children leave home to pursue their educations or live independently. In addition, not everyone has children. Exploring actions that support a healthy lifestyle is not specific to older adults. Leading a healthy lifestyle should be an educational focus for all age-groups.

36. A patient has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the patient fails to eat at least half of a meal because the patient had been losing weight for the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The patient begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? A. Assault B. Battery C. Slander D. Invasion of privacy

A. Assault occurs when a person puts another person in fear of harmful or offensive contract and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the patient's personal affairs or violates confidentiality.

13. The nurse is administering a cleansing enema to a patient with a fecal impaction. Before administering the enema, the nurse should place the patient in which position? A. Left Sims' position B. Right Sims' position C. On the left side of the body, with the head of the bed elevated 45 degrees D. On the right side of the body, with the head of the bed elevated 45 degrees

A. For administering an enema, the patient is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

38. The nurse inspects the color of the drainage from a nasogastric tube on a postoperative patient approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider? A. Dark red drainage B. Dark brown drainage C. Green-tinged drainage D. Light yellowish brown drainage

A. For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish brown color. The presence of bile may cause a green tinge. The health care provider (HCP) should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours preoperatively.

28. A patient admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportation. C. Attempt to persuade the patient to stay "for only a few more days." D. Tell the patient that leaving would likely result in an involuntary commitment.

A. In general, patients seek voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the patient's permission. While it is appropriate to discuss why the patient feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the patient to agree to staying "a few more days" has little value and will not likely be successful. Many states require that the patient submit a written release notice to the facility staff members, who reevaluate the patient's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the patient.

9. The nurse is monitoring the status of a postoperative patient. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats/minute C. Blood pressure of 100/70 mm Hg D. Hypoactive bowel sounds in all four quadrants

A. Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 100/70 mm Hg with a pulse of 86 beats/minute isn't too concerning. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.

29. When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others B. Assist in completing an application for admission C. Supply the patient with written information about their mental illness D. Provide an opportunity for the family to discuss why they felt the admission was needed

A. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the patient's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the patient's admission.

4. A postoperative patient asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative patient can lead to which condition? A. Pneumonia B. Hypoxemia C. Fluid Imbalance D. Pulmonary embolism

A. Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation.

77. A public health nurse is visiting an 80-year-old widow who recently was discharged from a rehabilitation center after recovering from a fall. The woman shares that her three children and their families live several states away. The nurse identifies that the patient looks fatigued, used a walker to her around the house, and lives independently in her own home. She receives a little help from the community in the way of supermarket deliveries and a cleaning person who comes every other week. Which should the nurse identify as the main concern? A. Risk for falls B. Potential for loneliness C. Decline in distant memory D. Hopelessness regarding the situation

A. Risk or falls is the priority. The patient is fatigued, uses a walker, lives alone, and has a history of a fall; these are risk factors for a future fall. Although B is a concern, it is not as important as another option. Older adults generally experience a decline in recent, not distant, memory. No data in the stem indicate that the patient feels hopeless.

79. A nurse is caring for a school-aged child who is to have a bone marrow biopsy. Although a local anesthetic will be used during the biopsy, it may be frightening and uncomfortable for the child. What should the nurse say that will best help the child tolerate the procedure? A. "Let's practice what will happen during the procedure." B. "Do you have any questions about the procedure that you would like to ask?" C. "You need to be strong during the procedure and before you know it will be over." D. "Would you like me to play a disk with your favorite songs during the procedure?"

A. Role-playing enables the child to learn what will happen; it provides an opportunity for the nurse to allay the child's fears and for the child to ask questions and receive answers in a nonthreatening environment. The procedure should be less frightening and threatening when a school-aged child knows what to expect. Asking if the child has any questions is not as good as a response presented in another option. The school-aged child may not know what to ask about the procedure. Stating that the child needs to be strong denies the child's feelings. Although playing a disk with the child's favorite songs during the procedure may be done, it is not the best intervention presented in the options.

37. The nursing instructor asks a nursing student to identify the priorities of care for an assigned patient. Which statement indicates that the student correctly identifies the priority patient needs? A. Actual or life-threatening concerns are the priority. B. Completing care in a reasonable time frame is the priority. C. Time constraints related to the patient's needs are the priority. D. Obtaining needed supplies to care for the patient is the priority.

A. Setting priorities means deciding which patient needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Patient problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the patient, based on the options provided.

54. A nurse is caring for an older adult who is in the last stage of dying. A family member keeps trying to get their father to ingest some soup. Which response by the nurse is most appropriate? A. "Nourishment is not necessary unless your father asks for it because vital organs are in decline." B. "Applying a protective lip balm on the lips supports comfort rather than encouraging eating." C. "You have been very attentive in trying to get your father to take some nourishment." D. "Ice chips or wetting the lips with a small amount of water is all that is necessary."

A. The nurse functions as a patient advocate as well as a teacher when explaining to a family member that nourishment is unnecessary at this stage of dying. In addition, forcing nourishment on a dying person when the person is not interested in eating or drinking may be uncomfortable and even painful. Lack of appetite is difficult for family members of a dying person to understand, especially when food is associated with caring. The nurse should convey this information in a nonjudgmental and gentle manner. Although statement B explains that applying a protective lip balm on the lips supports comfort, it does not explain why food is unnecessary when organs are failing. Although statement C acknowledges the caring demonstrated by the family member, it does not explain why food is unnecessary when organs are failing. By not intervening in the family member's behavior, the nurse failed to meet the needs of the patient. Although statement D states that ice chips or wetting the lips with a small amount of water is all that is necessary, it does not explain why food is unnecessary.

50. Which is the most important outcome of the nursing process? A. Meet the nursing needs of each patient. B. Ensure that unit resources are allocated appropriately. C. Decrease the risk of an error regarding the admitting medical diagnosis. D. Reduce the risk of missing important data when collecting information about the patient.

A. The nurse is responsible for identifying and meeting the nursing needs of each patient. Nurses identify and treat human responses to disease, illness, or injury. Ensuring that unit resources are allocated appropriately is the purpose of a patient classification system that identifies the acuity of patient needs for all the patients on a unit and the amount of resources needed to provide appropriate nursing care. Determining the admitting medical diagnosis is the responsibility of the primary health-care provider, not the nurse. Nurses do not make medical diagnoses. A classification system such as Gordon's functional health patterns, is a framework used by a nurse to organize the collection of data about a patient so that important information is not overlooked.

39. The nurse is preparing to discontinue a patient's nasogastric tube. The patient is positioned properly, and the tube has been flushed with 15 mL of saline to clear secretions. Before removing the tube, the nurse should make which statement to the patient? A. "Take a deep breath when I tell you and hold it while I remove the tube." B. "Take a deep breath when I tell you and bear down while I remove the tube." C. "Take a deep breath when I tell you and slowly exhale while I remove the tube." D. "Take a deep breath when I tell you and breathe normally while I remove the tube."

A. The patient should take a deep breath because the patient's airway will be temporarily obstructed during tube removal. The patient is then to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

32. A patient presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this patient? A. Assessment of vital signs B. Completion of abdominal examination C. Insertion of the prescribed nasogastric tube D. Thorough investigation of precipitating events

A. The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The patient may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority; in addition, the vital signs should be checked before performing this procedure.

44. A patient stands 6 inches from the nurse and begins to talk to the nurse in a loud voice. The nurse feels uncomfortable with this behavior. What is the most appropriate response by the nurse? A. "I would like to talk to you, but you are standing too close to me." B. "If you come closer to me, you will have to stay in your room." C. "You are much too close to me; you must step back." D. "Please step back because you are scaring me."

A. This statement demonstrates interest in the patient while setting limits on behavior. B is inappropriate and threatening. C sets limits but does not validate the patient. D sets limits but does not validate the patient. The nurse's statement about being scared may give the patient the message that the nurse cannot keep the situation safe.

45. A nurse is assisting a moderately cognitively impaired patient with morning care before going to the dining room. What is the nurse's most appropriate verbal intervention to help the patient get dressed? A. "Would you like to put on brown pants or blue pants before you go to breakfast?" B. "Here are your clothes. Would you rather get dressed before or after you have breakfast?" C. "The brown pants look good on you. Put them on and go to the dining room for breakfast." D. "Pick the outfit you would like to wear today and then go to the dining room for your breakfast."

A. This statement provides the patient with a simple choice and adequate direction. B does not give the moderately cognitively impaired patient enough guidance. The concept of before versus after may not be understood. C takes control away from the patient. D, the patient may not have the cognitive ability to make this decision. Receiving two directions at once may be overwhelming.

17. The nurse checks for residual before administering a bolus tube feeding of 300 mL to a patient with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? A. Hold the feeding. B. Re-instill the amount and continue with administering the feeding. C. Elevate the patient's head at least 45 degrees and administer the feeding. D. Discard the residual amount and proceed with administering the feeding.

A. Unless specifically indicated, residual amounts equal to or more than ½ of the bolus tube feeding require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

3. The nurse has just reassessed the condition of a postoperative patient who was admitted 1 hour ago to the surgical unit. The nurse plans to intervene on which assessment finding first? A. Urinary output of 20 mL/hour B. Temperature of 37.6° C (99.6° F) C. Blood Pressure of 100/70mm Hg D. Serous drainage on the surgical dressing

A. Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than 30mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F ) and a falling systolic blood pressure, lower than 90mm Hg are usually considered reportable immediately. The patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

87. A nurse is changing a patient's sterile dressing and performing wound irrigation. Which actions by the nurse maintained sterile technique? Select all that apply. A. Wore an eye shield and a gown B. Used a new sterile piston syringe C. Started the flow of irrigating solution just inside the top edge of the wound D. Dried the skin on either side of the wound by using one gauze pad for each swipe E. Held sterile gloved hands below the waist as much as possible during the procedure F. Poured fluid from a previously opened bottle of normal saline sitting on the patient's bedside table

B, C, D. A new sterile piston syringe should be used each time the wound is irrigated to avoid introducing a pathogenic microorganism. The flow of irrigating solution should start at the top inner edge of the wound so that the solution flows down the wound and is collected as it flows out of the wound by gravity. Starting at the inner edge of the wound and not outside the edge of the wound reduces the risk of contamination the wound with pathogenic microorganisms on the skin. Drying the skin on either side of the wound by using one gauze pad for each swipe maintains sterile technique. One gauze pad should be used for each swipe because it prevents cross contamination. Dry skin will allow adherence of the tape used to secure the dressing. Wearing personnel protective equipment does not maintain sterile technique during wound irrigation. Wearing and eye shield and gown protects the nurse from the patient's blood and body fluids.

89. Protective isolation (neutropenic precautions) is prescribed for a patient who is immunocompromised. What should the nurse do? Select all that apply. A. Wear gloves when entering the patient's room. B. Remove fresh flowers from the patient's room. C. Place a N95 respirator on the patient during transport when outside the room. D. Ensure positive room air pressure of the patient's room relative to the corridor. E. Have people with a respiratory infections wear a mask when in the patient's room. F. Ensure that housekeeping staff use a dry mop when cleaning the floor of the patient's room.

B, C, D. Fresh flowers and potted plants harbor molds. They should be removed from the patient's room to limit exposure to microorganisms that could harm the patient. Wearing an N95 respirator protects the patient from airborne pathogens when outside the room. Filtration of air coming into the patient's room, 12 air exchanges per hour, a well-sealed room, and maintaining positive room air pressure relative to the corridor reduces the risk of the presence of airborne pathogens entering the room and placing the patient at risk for infection. Wearing gloves is unnecessary. The nurse does not have to be protected from the patient. People with respiratory infections should not be permitted in the patient's room with or without a mask. Although the floor should be cleaned, it should be wet mopped, not dry mopped. Wet mopping will limit dust and help prevent microorganisms from becoming aerosolized.

30. The emergency department nurse is caring for a patient who has been identified as a victim of physical abuse. In planning care for the patient, which is the priority nursing action? A. Adhering to the mandatory abuse-reporting laws B. Notifying the case worker of the family situation C. Removing the patient from any immediate danger D. Obtaining treatment for the abusing family member

C. Whenever an abused patient remains in the abusive environment, priority must be placed on ascertaining whether the patient is in any immediate danger. If so, emergency action must be taken to remove the patient from the abusing situation. Options A, B, and D may be appropriate interventions, but are not the priority.

84. A nurse in a home health-care agency is teaching a class about infection control to a group of nursing assistants. Which interventions did the nurse include that interrupts the chain of infection at the mode of transmission stage? Select all that apply. A. Maintain a urinary collection bag below the level of the patient's bladder. B. Shut off the handles of water faucets with a clean, dry paper towel. C. Clean bedside tables routinely with a disinfectant. D. Reposition patients every two hours. E. Keep your fingernails short.

B, C, E. Shutting off the handle of a water faucet with a clean, dry paper towel is an action that interrupts the chain of infection at the mode of transmission stage. Microorganisms thrive on the handles of water faucets and are transmitted to others when touched. The mode of transmission stage of the chain of infection is related to how a microorganisms is transferred from an infectious agent to the portal of entry of a host. Microorganisms can thrive on surfaces that the patient uses and be transmitted to a portal of entry in the patient. Microorganisms thrive under fingernails because the area is warm, dark, and moist. Therefore, they should be kept short to prevent the harboring of microorganisms. Also, artificial nails and nail polish should be avoided. Keeping a urinary collection bag below the level of the patient's bladder will prevent backflow of urine into the urinary bladder. This will prevent microorganisms from entering the bladder. Portals of entry in humans include the respiratory, gastrointestinal, reproductive, and urinary tracts and the skin and mucous membranes. Repositioning a patient every 2 hours maintains tissue integrity. This interrupts the chain of infection at the susceptible host stage.

73. For which physical changes associated with aging should a nurse assess when assisting an older adult with a bath? Select all that apply. A. Increased sweat gland activity B. Decreased pigment cells in hair C. Decreased vascularity of the skin D. Increased sebaceous gland activity E. Increased collagen fibers in the dermis

B, C. Hair turns white or gray because pigment cells in hair decrease as a person ages. Decreased vascularity of the skin occurs with aging, causing coolness and pallor. Sweat gland activity decreases, not increases, with aging. Sebaceous gland activity decreases, not increases, with aging. Collagen and elastin in the dermis deteriorate with aging, causing the skin to become wrinkled.

85. Which actions are associated with droplet precautions? Select all that apply. A. Keeping the door of the patient's room closed B. Keeping visitors three feet away from the patient C. Wearing gloves when entering the patient's room D. Wearing a surgical mask when working within three feet of the patient E. Placing a surgical mask on the patient when transporting for procedures

B, D, E. Keeping visitors 3 feet away from the patient is required with droplet precautions to protect visitors from large particle droplets emanating from the patient's respiratory tract. Wearing a mask within 3 feet when working with the patient is required. Placing a surgical mask on the patient when transporting the patient is required. The door to the patient's room must be kept closed with airborne, not droplet, precautions. Gloves are necessary only when coming into contact with body fluids, such as excretions and secretions, mucous membranes, or nonintact skin.

62. An emergency department nurse is caring for a patient who dies unexpectedly. Which of the following should the nurse understand when advising a family member about an autopsy? Select all that apply. A. It can be performed only with the consent of a family member. B. It is an examination of a body to establish the cause of death. C. It is necessary before a certificate of death is issued. D. It is mandatory in the event of a suspicious death. E. It is required in the event of a violent death.

B, D, E. This is the correct definition of autopsy. When a death is suspicious, an autopsy is always done. When a death is the result of violence, an autopsy is always done. Response A is not true. The legal system may seek a court order for an autopsy in some situations. In many situations, such as when the person who dies is under the care of a primary health-care provider for a specific life-threatening illness, an autopsy does not have to be performed. A certificate of death must be completed and filed with the local health department or other government office for every person who dies. This certificate is necessary for legal and insurance purposes.

46. A nurse is caring for a patient with low self-esteem. What can the nurse do to promote the patient's self-esteem? Select all that apply. A. Provide simple choices. B. Assist with setting achievable goals. C. Teach the patient relaxation techniques. D. Point out the patient's past achievements. E. Help the patient to identify personal strengths.

B, D, E. When goals are attained, it promotes motivation and positive feelings of achievement. These in turn promote a positive self-esteem. Past achievements are accomplishments that promote positive feelings, which promote a positive self-esteem. Reviewing personal strengths accentuates the positive. Personal strengths provide a foundation on which to build future strengths. The approach in A is not necessary for a patient with low self-esteem. This approach is more appropriate for people who are depressed and do not have the emotional energy to make decisions. In C, learning relaxation techniques will not directly influence self-esteem. Learning relaxation techniques directly relates to reducing anxiety in people who are anxious or experiencing a panic attack.

52. The day after surgery, a patient says to the nurse, "Since surgery yesterday, I have been having pain when I urinate." Which two types of data is this information? Select all that apply. A. Objective data B. Subjective data C. Tertiary source of data D. Primary source of data E. Secondary source of data

B, D. Hematuria is objective information because it is measurable, observable, or verifiable. Subjective data are information that only the patient can report, such as feelings, sensations, or concerns. A patient is a primary, not tertiary source of information. Tertiary sources of data refer to sources such as a textbook, research studies, nursing journals, or policy or procedure manuals. The patient is a primary, not secondary source of data. A secondary source is someone other than the patient, such as a family member or friend.

106. When performing a physical assessment for a patient with scoliosis, which physical characteristic should the nurse expect to find during the assessment? a. Nonprotruding, symmetric scapulae b. Exaggerated curvature of the thoracic vertebrae c. Lateral deviation of the spinous processes d. Shoulders and scapulae at a horizontal position

C. the nurse would find lateral deviation of the spinous processes in a patient with scoliosis. Exaggerated curvature of the thoracic vertebrae is called kyphosis. Non-protruding, symmetric scapulae are normal findings of the thorax. Shoulders and scapulae at a horizontal position are also normal findings.

66. A nurse is caring for several older adults. Which statements by older adults indicate the conflict of ego integrity versus despair according to Erik Erikson's theory of development? Select all that apply. A. "I really don't trust any of my doctors and their treatment plan." B. "I wish that I took more vacations before I got too sick to travel." C. "I don't care what the doctor says; I will do it my way or no way." D. "I hope that in my next lifetime I get the chance to become a doctor." E. "I feel that I will never get better because nothing ever goes well for me."

B, D. Statement B expresses regret. Regrets often leave a person with a feeling of loss or despair. Integrity versus despair is the task of the older adult. The person reviews life experiences and is either encouraged and views life as meaningful or has a sense of loss and regret. Nonachievement of a goal, such as becoming a doctor, may leave a person with a sense of loss or regret. Response A indicates mistrust of others, which may be associated with unsuccessful achievement of the task of trust versus mistrust related to Erik Erikson's theory of development. Response C indicates willfulness, which may be associated with unsuccessful achievement of the task of autonomy versus shame and doubt. Response E indicates pessimism, which may be associated with unsuccessful achievement of the task of autonomy versus shame and doubt.

24. The long-term care nurse is performing assessments on several of the geriatric residents. Which are normal age-related physiological change(s) the nurse expects to note in this age group? Select all that apply. A. Increased heart rate B. Decline in visual acuity C. Decreased respiratory rate D. Decline in long-term memory E. Increased susceptibility to urinary tract infections F. Increased incidence of awakening after sleep onset

B, E, F. Anatomical changes to the eye affect the individual's ability, leading to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect urinary tract increase an older patient's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, age-related change. Older persons experience as increased incidence of awakening after sleep onset.

68. An older adult is living in a nursing home because of multiple chronic health problems. Which nursing actions are appropriate to assist the older adult to achieve the task associated with Erikson's stage of integrity versus despair? Select all that apply. A. Engage the patient in social activities. B. Encourage the patient to reminiscence. C. Provide the patient with opportunities to make choices. D. Teach the patient the importance of balancing exercise and rest. E. Give the patient recognition for accomplishments attained during life.

B, E. Acceptance of one's worth and viewing one's life as meaningful is the task of the older adult. Engaging the older adult in reminiscing enables the patient to discuss his or her past life and develop a sense of satisfaction with the life that was lived. Additional tasks of this age group include adjusting to physical decline and losses, establishing new roles, and preparing for death. Expressing appreciation for a patient's life accomplishments allows the patient to view the past life as meaningful. People often develop self-respect and a sense of integrity when respected by others. The developmental stage of the older adult is integrity versus despair. Although engaging the patient in social activities is important, it is not the intervention that will help the patient achieve the major task associated with the older adult. Although providing the patient with opportunities to make choices is important because it supports self-esteem, it is not the intervention that will help the patient achieve the major task associate with the older adult. Although teaching the patient about balancing exercise, rest, and sleep is important, it is not the intervention that will help the patient achieve the major task associated with the older adult.

35. An infant born with an imperforate anus returns from surgery with a colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding? A. Elevate the buttocks. B. Document the findings. C. Apply ice immediately. D. Call the health care provider.

B. A fresh colostomy stoma would be red and edematous, but this would decrease with time. The colostomy site then becomes pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse should document these findings because this is a normal expectation. Options A, C, and D are inappropriate and unnecessary interventions.

107. On assessment of a middle-aged patient, where should the nurse expect to auscultate bronchovesicular lung sounds? a. Throughout all lung fields b. In the main bronchi. c. In the lower lobes bilaterally d. In the upper and middle lobes bilaterally

B. Bronchovesicular sounds are heard in the main stem bronchus. Vesicular sounds are heard from the bronchioles and lobes peripherally; bronchial sounds are hear in the trachea and thorax

91. The nurse is preparing to care for a patient with a diagnosis of metastatic cancer and notes documentation in the patient's chart that the patient is experiencing cachexia. Which finding would the nurse expect to note on assessment of the patient? A. An elevated blood pressure and ascites B. Sunken eyes and a hollow cheek appearance C. Periorbital edema and swelling around the ears D. Generalized edema and the presence of weight gain

B. Cachexia is severe malnutrition. A patient with cachexia will present with sunken eyes and hollow cheek appearance. All other options are indicative of fluids volume excess.

42. Many people who are independent and perform all of their activities of daily living become dependent and demanding when physically ill and hospitalized. Which defense mechanism should the nurse conclude they are exhibiting? A. Denial B. Regression C. Compensation D. Reaction formation

B. During a crisis, one may regress to a stage that provokes less anxiety in an attempt to cope with an unacceptable situation. Regression to a childlike, demanding stage can occur under stress. Patients may use denial during an illness, but this generally will not make them dependent and demanding. Compensation is a mechanism that is used to make up for a lack in one area by emphasizing capabilities in another. Reaction formation is used when a patient acts in a way opposite to internal feelings.

64. A nurse identifies that an older adult has long, torturous, yellow toenails. What should the nurse do? A. File the patient's toenails with an emery board. B. Get a referral to a podiatrist to trim the toenails. C. Cut the toenails straight across with a nail clipper. D. Soak the patient's feet in hot water to soften the toenails.

B. Long, torturous, yellow toenails often are associated with problems such as impaired arterial circulation to the feet or a fungal infection. The nails usually are thick, brittle, and difficult to trim. These toenails should be cut by an appropriate practitioner. Filing the toenails with an emery board is unsafe and may injure already impaired tissues. Cutting the toenails straight across with a nail clipper is unsafe and may injure already impaired tissues. Patient's with normal nails may provide self-care in the home by cutting the toenails straight across. This technique prevents ingrown toenails. Yellow toenails indicate that the patient may have inadequate perfusion to the distal extremities. Often, this is accompanied by altered sensation in the extremities. Warm, not hot, water should be used to wash feet to prevent injury to impaired tissues. A podiatrist may prescribe that the feet be soaked for a short period of time just prior to clipping because it can soften the toenails.

8. The nurse assesses a patient's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, painful skin

B. Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The patient also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing patient conditions such as diabetes mellitus or immunocompromised may place the patient at risk.

56. After several years of caring for his wife who has Alzheimer's disease, a man admits his wife to a nursing home because he no longer is able to provide the level of care that she needs. When visiting his wife, he begins to cry softly and makes the following comment to the nurse: "I always thought that we would have time to enjoy retirement, but I spent the last few years caring for my wife who no longer knows who I am. I worry about my wife, who is slowly dying, but I am very tired and need some relief." What type of grief is the man experiencing? A. Normal grief B. Anticipatory grief C. Complicated grief D. Dysfunctional grief

B. The husband is experiencing anticipatory grief. The wife is still alive, and the husband is grieving for goals that were not accomplished as well as what will come in the future. Anticipatory grief often includes depression, worrying, and beginning adaptation to changes that will be caused by the future death. The husband is not experiencing normal grief. The grief experienced by the patient's husband not only reflects components of normal grief but also includes components that are associated with another type of grief. The husband is not experiencing complicated (dysfunctional) grief. Complicated grief is associated with excessive intensity of emotion or maladaptive responses for more than 2 years. The husband is not experiencing dysfunctional (complicated) grief. Dysfunctional grief is associated with excessive intensity of emotion or maladaptive responses for more than 2 years.

49. Three days after a stressful event, a person can no longer remember what there was to worry about. What defense mechanism should the nurse conclude that the person may be using? A. Regression B. Repression C. Displacement D. Intellectualization

B. The person's inability to recall is an example of repression, which is the unconscious and involuntary forgetting of painful events, ideas, and conflicts. There is nothing that demonstrates regression, a return to an earlier, more comfortable developmental level. There is nothing that demonstrates displacement, the shifting of feelings from an emotionally charged situation to a relatively safe substitute (usually someone or something perceived as less powerful). There is nothing that demonstrates intellectualization, the use of thinking, ides, or intellect to avoid emotions.

58. A nurse is caring for a patient who has no family and has been battling ovarian cancer for 5 years. The patient is now in the terminal stage of the disease and is told that there are no viable curative care options left and is offered a referral to a hospice facility. The nurse sits with the patient after the primary health-care provider leaves. Which statement by the nurse is most appropriate after exploring the patient's feelings? A. "It is unfortunate that there no longer any medical therapies that can be done." B. "Let's explore what we can do together to control your pain and make you comfortable." C. "You'll find that the staff members at the hospice agency will become like family to you." D. "The agency the doctor suggested is excellent, and the people who work there are very supportive."

B. This statement focuses is therapeutic because it offers hope and empowers the patient to participate in a plan to control pain and support. Statement A focuses on the fact that nothing more can be done and is a nonsupportive approach in this situation. Statement C is an assumption that places on emphasis on the staff members of the hospice agency rather than on the patient. Statement D shifts the focus away from the patient and the patient's needs.

94. The nurse should begin the assessment of the toddler by: A. Doing the most painful sections first. B. Explaining that the assessment will not be painful. C. Engaging the toddler in games to develop rapport. D. Talking to the parent.

C

95. It is important to plot the school-age child's height and weight on a standardized growth chart because: A. Growth spurts are very predictable. B. Boys and girls grow at the same times and rates. C. Individual children will grow according to their own curve. D. We want the child to be able to compare their height and weight to their classmates.

C

96. Which is the single most important factor to consider when communicating with children? A. presence of the child's parent B. child's physical condition C. child's developmental level D. child's nonverbal behaviors

C

88. A nurse is collecting equipment for several procedures that need to be performed. For which procedure should the nurse wear sterile gloves? Select all that apply. A. Collecting a urine specimen from a closed drainage system for a culture and sensitivity test B. Instilling solution into a nasogastric tube to reestablish patency of the catheter C. Suctioning the oropharynx to maintain airway patency D. Obtaining a specimen for blood glucose monitoring E. Changing a dressing on a central venous catheter F. Inserting a urinary catheter

C, E, F. Suctioning the oropharynx to maintain airway patency is a sterile procedure. A foreign object is being placed in to the oropharynx, which makes the patient vulnerable to being exposed to microorganisms. A central venous catheter causes a break in the skin, and the catheter enters a large vein of the body. These factors place the patient at risk for a systemic infection, and therefore the nurse must wear sterile gloves and maintain sterile technique when changing this dressing. Inserting a urinary catheter requires the nurse to wear sterile gloves and maintain sterile technique because the catheter is entering a sterile body cavity. Sterile equipment (e.g., sterile syringe and sterile specimen container) and clean gloves should be used by the nurse to collect a urine specimen from a closed urinary drainage system for a culture and sensitivity test. Instilling solution into nasogastric tube to reestablish patency of the catheter is not a sterile procedure. Clean gloves should be worn by the nurse while performing this procedure.

21. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychological development theory, the nurse should make which response? A. "You need to be concerned." B. "You need to monitor the child's behavior closely." C. "At this age the child is developing his own personality." D. "You need to provide more praise to the child to discourage this behavior."

C. According to Erikson, during school-age years (6 to 12 years of age), the child begins to move towards peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options A, B, and D are incorrect responses.

63. What action should the nurse include in the plan of care that is a common hygiene need of all older adults? A. Remove the bottom denture first. B. Assist with daily bathing. C. Apply a skin moisturizer. D. Use deodorant soap

C. Applying moisturizer to the skin of an older adult will make skin supple and less dry. The skin of older adults generally is drier because the oil-producing sebaceous glands are less active. Dentures are not common to all older adults. In addition, the top denture should be removed and reinserted before the bottom denture because it is larger. A daily bath is not necessary because oil-producing sebaceous glands are less active in older adults, making skin drier. Frequent bathing dries skin even further. Older adults should not use deodorant soap because it dries already- dry skin.

51. A patient is admitted to the emergency department with epigastric pain. The nurse asks the patient to identify the intensity of pain using a scale of 0 to 10, with 0 being pain free and 10 reflecting excruciating pain. Which step of the nursing process does this action reflect? A. Analysis B. Planning C. Assessment D. Implementation

C. Assessment is the first step in the nursing process, which involves the collection of information. Analysis is the second step of the nursing process. Analysis of information occurs after information is collected during the first step of the nursing process, assessment. A plan of care is formulated after nursing assessments are conducted and conclusions made about the information collected. Nursing care is implemented after a plan of care is formulated in the planning step of the nursing process.

14. The nurse is preparing to insert a nasogastric tube into a patient. The nurse should place the patient in which position for insertion? A. Right side B. Low Fowler's C. High Fowler's D. Supine with the head flat

C. During insertion of a nasogastric tube, the patient is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the patient should vomit. The right side, and low Fowler's and supine positions place the patient at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

6. A preoperative patient expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the patient and the nurse? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure to you." C. "Can you share with me what you've been told about your surgery?" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

C. Explanations should begin with the information that the patient knows. By providing the patient with individualized explanations of care and procedures, the nurse can assist the patient in handling anxiety and fear for a smooth preoperative experience. Patients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option A does not focus on the patient's anxiety. Explaining the entire surgical procedure may increase the patient's anxiety. Option D avoids the patient's anxiety and focuses on postoperative care.

92. The patient is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: A. Dyspnea B. Diarrhea C. Sore throat D. Constipation

C. External radiation therapy affects the area being radiated. With neck cancer, the most likely side effect would be a sore throat.

12. The nurse develops a plan of care for a patient with deep vein thrombosis. Which patient position or activity in the plan should be included? A. Out-of-bed activities as desired B. Bed rest with the affected extremity kept flat C. Bed rest with elevation of the affected extremity D. Bed rest with the affected extremity in a dependent position

C. For the patient with deep vein thrombosis, elevation of the affected leg facilitated blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur when walking.

15. The nurse is preparing to administer medications through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? A. Position the patient in supine to assist in medication absorption. B. Aspirate the nasogastric tube after medication administration to maintain patency. C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. D. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

C. If a patient has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for the medication absorption. The patient should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

31. The nurse is providing care to a Puerto Rican-American patient who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this patient? A. Restrict the number of family members visiting at one time. B. Inform the family that emotional outbursts are to be avoided. C. Make the necessary arrangements so family members can visit. D. Contact the health care provider to speak to the family regarding their behaviors.

C. In the Puerto Rican-American culture, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, the correct option is the one that identifies a culturally sensitive approach on the part of the nurse. Options A, B, and D are inappropriate nursing interventions.

34. The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying patient and family? A. The nurse encourages the patient and family to identify and discuss feelings openly. B. The nurse assists the patient and family in carrying out spiritually meaningful practices. C. The nurse makes decisions for the patient and family to relieve them of unnecessary demands. D. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

C. Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option A describes encouraging discussion of feelings and is likely to enhance communications. Option B is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option D is also an effective technique because the patient and family need to know that someone will be there who is supportive and nonjudgmental. The correct option describes the nurse removing autonomy and decision making from the patient and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could impair communication further.

16. The registered nurse is preparing to insert a nasogastric tube in an adult patient. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. Mark the tube at 10 inches. B. Mark the tube at 32 inches. C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

C. Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the patient's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube.

41. The nurse is caring for a patient who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? A. Restricting fluids B. Placing a pillow under the knees C. Encouraging active range-of-motion exercises D. Applying a heating pad to the lower extremities

C. Patients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized patients. Basic preventative measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the patient well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

23. The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older patient with hearing loss. Which should the nurse tell the UAP about older patients with hearing loss? A. They are often distracted B. They have middle ear changes C. They respond to low-pitched tones D. They develop moist cerumen production

C. Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older patient has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older patient. Options A, B, and D are not accurate characteristics related to aging.

25. A Spanish-speaking patient arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? A. Have one of the patient's family members interpret. B. Have the Spanish-speaking triage receptionist interpret. C. Page an interpreter from the hospital's interpreter services. D. Obtain a Spanish-English dictionary and attempt to triage the patient.

C. The best action is to have a professional hospital based interpreter translate for the patient. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the patient is actually saying. Also, patient confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as an interpreter.

75. What safety instruction addresses a major cause of accidental death among people from all developmental levels? A. Resist pressure to engage in high-risk activities. B. Rise slowly to a standing position. C. Wear a seatbelt when in a car. D. Cut all food into small pieces.

C. The leading cause of accidental death in infants, toddlers, preschoolers, school-aged children, adolescents, and adults is motor vehicle accidents. Motor vehicle accidents are one of the leading causes of injuries in older adults after falls. Seatbelts reduce the incidence of morbidity and mortality. Instructing a person to resist high-risk activities is most appropriate for adolescents who are vulnerable to peer pressure because they want to be accepted and belong. Instructing a person to rise slowly to a standing position is most appropriate for older adults because their voluntary and autonomic reflexes have declined and made them vulnerable to orthostatic hypotension and falls. Many foods are small or soft and do not need to be cut into small pieces. Although cutting food into small pieces is advisable for everyone, it is most significant in infants and toddlers. Risk for chocking is the greatest between 6 months and 3 years of age.

78. A nurse is teaching a group of older adults about safety precautions. What instruction should the nurse give them to prevent the leading cause of injuries in older adults? A. Have your vision evaluated yearly. B. Limit drinking alcohol to one glass a day. C. Rise slowly when moving from a sitting to a standing position. D. Wash your hands with an antimicrobial soap several times a day.

C. The leading cause of injuries in older adults is falls that usually occur when moving from sitting to standing or when transferring from a bed to a chair. Although having vision evaluated yearly is advisable, diminished vision is not the leading cause of falls in older adults. The influence of alcohol is not the leading cause of falls in older adults. Washing the hands with an antimicrobial soap helps prevent infections, not injuries.

2. The nurse on the day shift walks into a client's room and finds the patient unresponsive. The patient is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? A. Open the airway. B. Give the client oxygen. C. Start chest compressions. D. Ventilate with a mouth-to-mask device

C. The next nursing action would be to start chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.

47. Which response by the nurse is most effective when attempting to reduce a patient's hostility about an event? A. "I am here to help you." B. "You need to calm down." C. "What can I do now to help address the situation?" D. "Do you think you can be objective at this time?"

C. This is the best response because it indicates that the nurse is ready to do something immediately and asks the patient to participate in making a suggestion. A, although this response conveys a desire to help, it does not move toward what should be done next. B is confrontational and may escalate the patient's hostility. D is confrontational; it is a judgmental statement regarding the patient's hostility.

90. A 4-year-old is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. The nurse understands that which diagnostic study should confirm this diagnosis? A. Platelet count B. Lumbar puncture C. Bone marrow biopsy D. White blood cell count

C. This is the definitive diagnosis test used for ALL; all others will aide in the diagnosis, but a BM biopsy will confirm diagnosis.

55. An elderly woman who lost her husband suddenly due to a massive heart attack one week ago came back to the emergency department to thank the nurses for being so kind to her husband. The woman stated, "I am very lonely and can hardly believe that he is gone." Which is an appropriate response by the nurse? A. "I am sure that you have many loving memories that will help when you feel sad." B. "The senior center has various programs to join so you are involved with others." C. "You will be experiencing feelings of grief and loss as you journey forward." D. "Take one day at a time because things will get better as time goes on."

C. This response acknowledges that the woman is grieving. Also, it focuses on the journey moving forward, subtly indicating a future without her husband. Response A denies the woman's feelings. Also, it is an assumption that the woman has loving memories of her husband. Response B denies the woman's feelings and offers a suggestion that is unrealistic at this time. The woman is in the shock and disbelief stage of grieving and most likely is not ready to become involved with new social groups. Response D is false reassurance. Although it is best to take things one day at a time, things may not get better as time goes on.

65. A middle-aged adult fell in the driveway at home and came to the emergency department to ensure that he had not sustained a bone fracture. Which statement made by a patient to the emergency department nurse indicates the developmental task of this age group? A. "If I get a cast, my fiancé will be furious because we're getting married next month and this will ruin the pictures." B. "I don't want you to call my place of employment about health insurance coverage." C. "I must be out of here in a few hours because I have to coach my son's baseball team." D. "If my arm is broken, my friends will get another guy for our golf foursome."

C. This statement is related to the task of generativity versus self-absorption associated with middle adulthood. This task is associated with giving back to the community. Statements A, B, and D are unrelated to the task of generativity versus self-absorption associated with middle adult-hood.

80. A nurse is caring for a patient who is reporting pain in the jaw as a result of cardiac ischemia. What word should the nurse use to describe this pain when writing progress notes? A. Cutaneous B. Radiating C. Referred D. Visceral

C. When heart ischemia is felt as pain in the jaw, it is identified as referred pain. Referred pain occurs when pain arises in one site but is felt in a distant site. Cutaneous pain is associated with superficial cuts of the skin or subcutaneous tissue. Radiating pain is when pain arises in one site and extends to another site. For example, sciatic pain from the lumbar vertebrae or pain associated with lymphatic streaking. Visceral pain occurs when deep internal pain receptors are stimulated, such as during labor or in response to cancer of the abdominal organs.

48. A nurse is caring for a patient who experienced numerous panic attacks. Place the following nursing interventions in the order that they should be performed when caring for this patient. A. Identify which nursing interventions reduce the patient's anxiety level. B. Maintain a nonjudgmental approach when caring for the patient. C. Stay with the patient when the patient is having a panic attack. D. Explore own feelings about people who have panic attacks. E. Assess the patient's level of anxiety.

D, B, E, C, A. Nurses must understand their own feelings before they can provide appropriate, nonjudgmental nursing care to others. Nurses must not impose their own feelings and beliefs on patients. When nurses are nonjudgmental, they provide and accepting attitude that promotes trust and further development of the nurse-patient relationship. Assessment is the first step of the nursing process. Although there are commonalities of nursing care for all the levels of anxiety, there are specific nursing interventions associated with different levels of anxiety. The patient's level of anxiety will direct the nurse toward appropriate nursing interventions. If the nurse identifies that a patient is in the panic stage of anxiety, it would be unsafe to leave the patient unattended. The patient could harm self or others. The action in A reflects the evaluation step of the nursing process. Evaluation involves assessing a patient's status after nursing care is provided.

18. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the patient begins to cough and has difficulty breathing. What is the most appropriate nursing action? A. Quickly insert the tube. B. Notify the health care provider immediately. C. Remove the tube and reinsert when the respiratory distress subsides. D. Pull back on the tube and wait until the respiratory distress subsides.

D. During the insertion of a nasogastric tube, if the patient experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

5. A patient with a perforated gastric ulcer is scheduled for surgery. The patient cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this patient? A. Obtain a court order for the surgery. B. Have the charge nurse sign the informed consent immediately. C. Send the patient to surgery without the consent form being signed. D. Obtain a telephone consent from a family member, following agency policy.

D. Every effort should be made to obtain permission from a responsible family member, to perform surgery if the patient is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witness then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a patient who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a patient may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options A and C are not appropriate in this situation. Also, agency policy regarding informed consent should always be followed.

7. The nurse is conducting preoperative teaching with a patient about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the patient? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

D. For optimal lung expansion with the incentive spirometer, the patient should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the patient inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

27. On review of the patient's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which patient behavior? A. Fearfulness regarding treatment measures. B. Anger and aggressiveness directed toward others. C. An understanding of the pathology and symptoms of the diagnosis. D. A willingness to participate in the planning of the care and treatment plan.

D. In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectation is that the patient will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patient's understanding of their illness, only of their desire for help.

19. The clinic nurse is preparing to discuss the concepts of Kohlberg's theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level? A. Peer pressure B. Social pressure C. Parent's behavior D. Punishment and reward

D. In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child is bad, the child is punished. Options A, B, and C are incorrect for this stage of development.

93. The recommended order for introduction of solid foods is: A. Fruits & vegetables, rice cereal, eggs, meat B. Eggs, rice cereal, meat, fruit C. Meat, eggs, rice cereal D. Rice cereal, pureed fruits & vegetables, meat

D. Introducing the easiest type of food for baby to breakdown is best. Their GI tracts are so underdeveloped, but rice cereal is typically the first solid food to introduce. Babies should not start eating solid foods until 4-6 months of age.

43. The spouse of a patient who is dying tells the nurse, "Even though I want to visit, I can come only once a week because I have work and have a dog that I need to walk and feed." Which defense mechanism does the nurse identify the spouse using? A. Projection B. Sublimation C. Compensation D. Rationalization

D. Rationalization is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. Projection is the denial of emotionally unacceptable feelings and the attribution of traits to another person. Sublimation is the substitution of a socially acceptable behavior for an unacceptable feeling or drive. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

86. A nurse is providing teaching to a patient who is taking an antibiotic for a bacterial infection. Which is important for the nurse to teach the patient to do to help prevent resistance to this antibiotic in the future? A. "Eat some food when taking the medication." B. "Assess yourself for signs of a superinfection." C. "Take the pills evenly spaced around the clock." D. "Complete the entire regimen of medication prescribed."

D. Taking the entire regimen of antibiotic eradicates the pathogens that have invaded the body. Stopping the medication early promotes the development of resistant bacteria. Taking antibiotic with food prevents gastric irritation, not resistant bacteria. A superinfection is and infection occurring in a person who already is experiencing an infection. These signs generally include furry overgrowth on the tongue, vaginal discharge, and foul smelling stool. Evenly spacing doses of antibiotic medication maintains a therapeutic blood level of the drug; it does not prevent bacterial resistance.

40. The nurse has administered approximately half of an enema solution to a preoperative patient when the patient complains of pain and cramping. Which nursing action is most appropriate at this time? A. Reassure the patient and continue the flow. B. Raise the enema bag so that the solution can be instilled quickly. C. Discontinue the enema and notify the health care provider (HCP). D. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

D. The enema fluid should be administered slowly. If the patient complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. Although patient reassurance is important, continuing the flow is inappropriate. Slow enema administration and stopping the flow temporarily, if necessary, decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping. There is no need to discontinue the enema and notify the HCP at this time.

74. A nurse identifies that a patient is experiencing a developmental crisis specifically associated with middle adulthood. Which assessment identified by the nurse supports this conclusion? A. Inability to postpone satisfaction B. Incapable of facing one's morality C. Problems maintaining peer relationships D. Difficulty achieving a sense of fulfillment

D. The most important developmental task of middle adulthood is successfully achieving goals that involve family, career, and society. A developmental crisis occurs when a middle-aged adult has difficulty achieving these goals. Children between the ages of 18 months and 3 years are concerned with learning how to delay satisfaction, not middle-aged adults. Coping with death is one of the developmental tasks of older adults, not middle-aged adults. Developing peer relationships is a development task of children who are 6 to 12 years of age as well as adolescents, not middle-aged adults.

33. The nurse is teaching a patient with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the patient to avoid which position that could aggravate breathing? A. Sitting up and leaning on a table B. Standing and leaning against a wall C. Sitting up with the elbows resting on knees D. Lying in a supine position

D. The patient should use the positions outlined in options A, B, and C. These allow for maximal chest expansion. The patient should not lie on the back because it reduces movement of a large area of the patient's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

72. Which statement by an adult child about the adult child's 90-year-old father indicates ageism? A. "My father was always egocentric, but it has gotten worse as he has gotten older." B. "My father's physical status has progressively declined these last few years." C. "I am so tired of him constantly talking about past experiences." D. "I would rather die than reach the useless age of my father."

D. This comment reflects ageism because it assumes older adults are useless. Ageism is negative attitudes and beliefs about alder adults that include stereotyping, prejudice, or discrimination against people based on their age. A may occur as people age and is referred to as an exacerbation of a person's premorbid personality. This statement does not reflect ageism. All systems of the body gradually decrease in size and function as one ages (e.g., decreased mass and strength in both bones and muscles, decreased joint mobility, impaired balance and coordination). Statement B does not reflect ageism. The adult child may be frustrated by the father's behavior, but the adult child's statement in C is not a reflection of ageism.

60. A nurse is caring for a man with terminal pancreatic cancer. The wife is upset because her husband is quiet and withdrawn and is always suggesting that she go to the cafeteria to get something to eat. Which response by the nurse is therapeutic? A. "Maybe he just wants to sleep, and it is his way of asking you to leave so it is quiet." B. "Would you like the dietary department to bring you something during meal times?" C. "Why don't you bring a bag lunch tomorrow so that he sees that you are not missing a meal?" D. "Try not to take it personally because people who are dying often interact minimally with loved ones."

D. This response focuses on the underlying reason for the husband's behavior. Withdrawal is very common as the person works on the emotional-spiritual-mental process of dying. There is a tendency to sleep more and talk less, and there is a letting go of interest in surroundings and loved ones. This is the dying person's effort to let go of life and to get prepared for death. Response A is not therapeutic because it does not focus on the underlying reason for the husband's behavior. Also, it places the wife on the defensive by subtly saying that her presence is interfering with the husband's attempts to sleep. Response B is not therapeutic because it does not focus on the underlying reason for the husband's behavior. Response C is not therapeutic because it does not focus on the underlying reason for the husband's behavior. Also, it is confrontational and may shut off communication.

108. Which cranial nerve is responsible for pupil constriction and raising the eyelids?

D. oculomotor CN III