Nursing Semester 1 Unit 4

The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Endoscopy d. Anorectal manometry

ANS: C Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a. Distended abdomen b. Increased skin dryness c. Increased energy levels d. Elevated blood pressure

ANS: B Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with dark colored urine and dry skin. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen could indicate constipation.

A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility myocardial blood flow b. Ventricular filling time/diastolic filling time c. Stroke volume heart rate d. Preload/afterload

ANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output.

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

ANS: C The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic.

A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Teach the teen about the food pyramid. b. Administer antidiarrheal medications with meals. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

AND. D Tertiary-level interventions assist the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent maturational needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill and the food pyramid is usually a primary intervention. Administering antidiarrheal medications may help but is not a tertiary-level or maturational intervention. Admonishing the teen and parents is not a tertiary-level intervention, and because this approach is nontherapeutic, it may cause communication problems.

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

ANS. C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume, and cardiac output. The hemoglobin level would not be affected.

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

ANS. C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta

A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression? a. Salem sump b. Small bore c. Levin d. 8 Fr

ANS: A The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequently used for medication administration and enteral feedings.

The nurse is caring for a patient who is prescribed oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

ANS: A The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to assistive personnel (AP). The nurse is responsible for assessing the patient's respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

ANS: B Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion.

A nurse is caring for a patient whose tissue perfusion is poor as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

ANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. Which action should the nurse implement to assist the patient? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

ANS: A Identifying the cause of a negative perception is the first step in helping an individual to be able to utilize coping strategies. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

ANS: A Meaning-focused coping leads the individual to focus on his/her own values and beliefs to modify the personal interpretation and response to a problem. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.

The nurse is creating a plan of care for an obese patient who is experiencing fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Sensibly reducing daily calorie intake c. Running 30 minutes every morning d. Stopping smoking immediately

ANS: A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.

A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Moderate-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

ANS: A A moderate-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A lowor high-caffeine diet is not as important as the carbohydrate load.

A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

ANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing.

The nurse is caring for a patient experiencing fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

ANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a blue color that means the test is negative." b. "I should not get any urine on the stool I am testing." c. "If I eat red meat before my test, it could give me false results." d. "I should check with my doctor to stop taking aspirin before the test."

ANS: A A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result.

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3-4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." b. "Some people have a slower bowel than others, and this is nothing to be concerned about." c. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." d. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day."

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal. b. Experiences adequate oxygen saturation during exercise. c. Experiences crushing chest pain for more than 20 minutes. d. Experiences tingling in the left arm that lasts throughout the morning.

ANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction.

Which determination is the nurse trying to achieve by monitoring a patient's cardiac output? a. Peripheral extremity circulation b. Oxygenation requirements c. Presence of cardiac dysrhythmias d. Ventilation status

ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output.

A patient in a motor vehicle accident states, "I did not run the red light," despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Compensation

ANS: A Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into nonorganic symptoms. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue.

A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? a. Ewald b. Dobhoff c. Miller-Abbott d. Sengstaken-Blakemore

ANS: A Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric decompression.

A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

ANS: A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non-rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min.

A trauma survivor is requesting sleep medication because of "bad dreams." The nurse is concerned that the patient may be experiencing posttraumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. "Are you reliving your trauma?" b. "Are you having chest pain?" c. "Can you describe your phobias?" d. "Can you tell me when you wake up?"

ANS: A People who have PTSD often have flashbacks, recurrent and intrusive recollections of the event. The other answers involve assessment of problems not specific to PTSD.

The patient is experiencing right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.

A patient is using laxatives 3 times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

ANS: A Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange. b. Regulates tidal volume. c. Produces hemoglobin. d. Stores oxygen.

ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home

ANS: A The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage? 1. Resistance 2. Exhaustion 3. Alarm a. 3, 1, 2 b. 3, 2, 1 c. 1, 3, 2 d. 1, 2, 3

ANS: A The general adaptation syndrome (GAS), a three-stage reaction to stress, describes how the body responds physiologically to stressors through stages of alarm, resistance, and exhaustion

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

ANS: A The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient.

A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum

ANS: A The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination.

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged.

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Malodorous stool d. Continuous output from the stoma

ANS: B Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous.

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds in all four quadrants

ANS: A The nurse's goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one? 1. Obtain baseline vital signs. 2. Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 4. Identify patient using two identifiers. 5. Place patient on left side in Sims' position. 6. Massage around the feces and work down to remove. a. 4, 1, 5, 2, 3, 6 b. 1, 4, 2, 5, 3, 6 c. 4, 1, 2, 5, 3, 6 d. 1, 4, 5, 2, 3, 6

ANS: A The steps for removing a fecal impaction are as follows: identify patient using two identifiers, obtain baseline vital signs, place on left side in Sims' position, apply clean gloves and lubricate, insert index finger into the rectum, and gently loosen the fecal mass by massaging around it and work the feces downward toward the end of the rectum.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a. Hypoactive bowel sounds b. Increased fluid intake c. Soft tender abdomen d. Jaundice in sclera

ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease.

A nurse is helping parents who have a child with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments? a. Time-management skills b. Speech articulation skills c. Routine preventative health visits d. Assertiveness training for the family

ANS: A Time-management skills are most related to homework assignment completion. Time-management techniques include developing lists of prioritized tasks. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress. Assertiveness includes skills for helping individuals communicate effectively regarding their needs and desires, but it does not help with homework assignments.

A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardi

ANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional -endorphins.

ANS: A When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.

Which risk factor for cardiopulmonary disease should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

ANS: A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender.

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) a. Cancer b. Diabetes c. Infections d. Allostasis e. Low blood pressure

ANS: A, B, C Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person's susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress.

A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a. A risk factor is smoking. b. A risk factor is high intake of animal fats or red meat. c. A warning sign is rectal bleeding. d. A warning sign is a sense of incomplete evacuation. e. Screening with a colonoscopy is every 5 years, starting at age 50. f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50.

ANS: A, B, C, D Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of incomplete evacuation, and unexplained abdominal or back pain. A flexible sigmoidoscopy is every 5 years, starting at age 50, while a colonoscopy is every 10 years, starting at age 50.

When conducting a health history assessment, which information would be viewed as most important as related to the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting

ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a. Record times when the patient is incontinent. b. Help the patient to the toilet at the designated time. c. Lean backward on the hips while sitting on the toilet. d. Maintain normal exercise within the patient's physical ability. e. Apply pressure with hands over the abdomen, and strain while pushing. f. Choose a time based on the patient's pattern to initiate defecation-control measures.

ANS: A, B, D, F A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient's pattern to initiate defecation-control measures. Maintaining normal exercise within the patient's physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The live, attenuated nasal spray is given to people over 50. f. The vaccines are recommended for all people 6 months and older

ANS: A, F Annual (yearly) flu vaccines are recommended for all people 6 months and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia.

A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. "Let's call 9-1-1 because this freshman student is suicidal." b. "Give the freshman student this list of university and community resources." c. "I recommend that you help the freshman student start packing bags to go home." d. "You must make an appointment for the freshman student to obtain medications."

ANS: B A nurse can help reduce situational stress factors for individuals. Inform the patient about potential resources. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 9-1-1 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

ANS: B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

ANS: B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax.

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, "No way, I'm not crazy." What is the nurse's best response? a. "Many times, disasters can create mental health problems, so you really should participate with your family." b. "Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique." c. "Don't worry now. The psychiatrists are well trained to help." d. "This will help your family communicate better."

ANS: B Crisis intervention is a type of brief therapy that is more directive than traditional psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The other options do not properly reassure the patient and build trust. Giving advice in the form of "you really should participate" is inappropriate. "Don't worry now" is false reassurance. While crisis intervention may help families communicate better, the goal is to return to precrisis level of functioning; family therapy will focus on helping families communicate better.

The nurse plans to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

ANS: B Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Emptying the pouch at least once every 7 days. c. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma

ANS: B The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

ANS: B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. "The patient is angry about the dementia diagnosis." b. "The patient is losing sphincter control due to the dementia." c. "The patient forgets where the bathroom is located due to the dementia." d. "The patient wants to leave the hospital."

ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? a. Speak with the patient's family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient

ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

The nurse is caring for a patient who has had a tracheostomy tube inserted. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

ANS: B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider.

Before being administered a cleansing enema an 80-year-old patient says "I don't think I will be able to hold the enema." Which is the next priority nursing action? a. Rolling the patient into right-lying Sims' position b. Positioning the patient in the dorsal recumbent position on a bedpan c. Inserting a rectal plug to contain the enema solution after administering d. Assisting the patient to the bedside commode and administering the enema

ANS: B If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims' position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe

A patient is receiving opioids for pain. Which bowel assessment is a priority? a. C. difficile b. Constipation c. Hemorrhoids d. Diarrhea

ANS: B Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. Clostridium difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as frequently as constipation.

A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. General adaptation syndrome (GAS) b. Posttraumatic stress disorder (PTSD) c. Acute stress disorder d. Alarm reaction

ANS: B Posttraumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional detachment and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Acute stress disorder is a similar diagnosis that differs from PTSD in duration of symptoms. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events

ANS: B Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances.

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation.

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? a. Delegate complex nursing tasks to nursing assistive personnel. b. Strengthen friendships outside the workplace. c. Write for 10 minutes in a journal every day. d. Use progressive muscle relaxation

ANS: B Strengthening friendships outside of the workplace, arranging for temporary social isolation for personal "recharging" of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating complex nursing tasks to nursing assistive personnel is an inappropriate.

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old female with three final examinations on the same day c. A 40-year-old female with major depressive disorder d. An 80-year-old male in an assisted-living environment

ANS: B Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs? a. Administer a soapsuds enema every 2 hours. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan.

ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

ANS: B The conduction system originates with the SA node, the "pacemaker" of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network.

A patient experiencing left-sided hemiparesis has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

ANS: B The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiological integrity.

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth

ANS: B The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway.

A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate? a. "It is probably just coincidental that your blood sugar is high when you are ill." b. "Stressors such as illness cause the release of hormones that increase blood sugar." c. "Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times." d. "Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level."

ANS: B The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Obtaining an order for digital removal of stool c. Positioning the patient on the left side d. Inserting a rectal tube

ANS: B When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be applicable or effective for this patient.

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

ANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation, the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate

ANS: B, C, D The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

Which patient will the nurse assess most closely for an ileus? a. A patient with a fecal impaction b. A patient with chronic cathartic abuse c. A patient with surgery for bowel disease and anesthesia d. A patient with suppression of hydrochloric acid from medication

ANS: C Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive.

The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy. b. Suggest that the patient consider a support group for widows. c. Suggest that the patient learn stress reduction breathing exercises. d. Suggest that the patient take prescribed antianxiety medications. e. Assist the patient in identifying support systems. f. Notify the provider to evaluate the need for antianxiety medications

ANS: B, C, E Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.

A nurse is following the How-to Guide to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Delirium monitoring d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis

ANS: B, C, E The key components of the Institute for Healthcare Improvement (IHI) How-to Guide are: Elevation of the head of the bed (HOB)—elevation is greater than 30 degrees Daily "sedation vacations" and assessment of readiness to extubate Peptic ulcer disease prophylaxis Venous thromboembolism prophylaxis Daily oral care with chlorhexidine Delirium monitoring Early ambulation Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.

A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? a. Provide information to the patient. b. Allow time for the patient's friends. c. Ask about the patient's priority needs. d. Find support for the family and patient.

ANS: C Take time to understand a patient's meaning of the precipitating event and the ways in which stress is affecting his life. For example, in the case of a woman who has just been told that a breast mass was identified on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and finding support may be implemented after finding out what the patient wants or needs.

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

ANS: C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

ANS: C Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

ANS: C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity.

The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? a. Reports decreased diarrhea. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.

ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence).

A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A child about to receive a normal saline enema b. A teenager about to receive loperamide for diarrhea c. A dehydrated older patient about to receive a hypertonic enema d. A middle-aged patient with myocardial infarction about to receive docusate sodium

ANS: C A hypertonic enema is contradicted in a dehydrated patient since it will pull fluid out of the body; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent

A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? a. Prevent gaseous distention. b. Prevent constipation. c. Prevent colon infection. d. Prevent lower bowel inflammation.

ANS: C A medicated enema is a neomycin solution, that is, an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathartics help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the lower colon.

A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

ANS: C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain.

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is flush with the skin. c. Stoma is purple. d. Stoma is moist.

ANS: C A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.

The nurse performing a fecal occult blood test should take what action? a. Test the quality control section before testing the stool specimens. b. Apply liberal amounts of stool to the guaiac paper. c. Report a positive finding to the provider. d. Don sterile disposable gloves.

ANS: C Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

ANS: C Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

The nurse will irrigate a patient's nasogastric (NG) tube. Which action should the nurse take? a. Instill solution into pigtail slowly. b. Check placement after instillation of solution. c. Immediately aspirate after instilling fluid. d. Prepare 60 mL of tap water into Asepto syringe

ANS: C After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue "pigtail" air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids

A nurse is planning care for a patient that uses displacement as a defense mechanism. Which information should the nurse consider when planning interventions? a. This copes with stress directly. b. This evaluates an event for its personal meaning. c. This protects against feelings of worthlessness and anxiety. d. This triggers the stress control functions of the medulla oblongata.

ANS: C Ego defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and offer psychological protection from a stressful event. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

ANS: C Environmental and social stressors often lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool? a. Bright red blood b. Dark black blood c. Microscopic d. Mucoid

ANS: C Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Broccoli and cheese soup with potato bread b. Turkey and mashed potatoes with brown gravy c. Grape and walnut chicken salad sandwich on whole wheat bread d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

ANS: C Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown.

A nurse is checking orders. Which order should the nurse question? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema for a patient with fluid volume excess c. A Kayexalate enema for a patient with severe hypokalemia d. An oil retention enema for a patient with constipation

ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

ANS: C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction.

In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors

ANS: C Maturational factors and situational factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas

ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

A patient experiencing a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

ANS: C No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

ANS: C Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement

A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

ANS: C Patients taking warfarin for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking Gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle.

A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with fresh pineapple and iced tea c. Turkey sandwich on whole wheat bread and iced tea d. Fish sticks with sweet corn and soda

ANS: C Patients with colostomies have no diet restrictions other than the diet discussed for normal healthy bowel function, with adequate fiber and fluid to keep the stool softly formed. Fried foods can irritate digestion. Foods high in fiber will be useful later in the recovery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cabbage could cause this problem

Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a. Keep fiber low. b. Eat large meals. c. Increase fluid intake. d. Chew food thoroughly

ANS: C Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority; liquid is the priority

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

ANS: C Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being

The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? a. Primary b. Secondary c. Tertiary d. Quad

ANS: C Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. At the primary level of prevention, you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Quad level does not exist.

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? a. Ego defense model b. Immunity model c. Neuman Systems Model d. Pender's Health Promotion Model

ANS: C The Neuman Systems Model uses a systems approach, and it helps you understand your patients' individual responses to stressors and also families' and communities' responses. Every person develops a set of responses to stress that constitute the "normal line of defense." This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body's natural protection mechanism. Pender's Health Promotion Model focuses on promoting health and managing stress.

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift

ANS: C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease.

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. Descending

ANS: C The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30-60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

ANS: C The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)? a. Performing the first postoperative pouch change b. Maintaining a nasogastric tube c. Administering an enema d. Digitally removing stool

ANS: C The skill of administering an enema can be delegated to an AP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an AP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel.

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

ANS: C The steps for nasotracheal suctioning are as follows: verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube? a. Instill Xylocaine into the nares once a shift. b. Tape tube securely with light pressure on nare. c. Lubricate the nares with water-soluble lubricant. d. Apply a small ice bag to the nose for 5 minutes every 4 hours

ANS: C The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.

An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.

ANS: C Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite) describes conversion defense mechanism. The nurse must assess the patient fully for emotional conflict and stress before implementing any nursing interventions (acupuncture or exercise program). Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.

An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b. Tape an occlusive moisture barrier pad to the patient's skin. c. Apply a skin protective ointment after perineal care. d. Massage the skin with light kneading pressure

ANS: C Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.

A nurse is caring for a patient being treated for sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)

ANS: C, D Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. AC, PSV, and SIMV are invasive mechanical ventilation and are not routinely used on patients with sleep apnea. AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient's strength, effort, and lung mechanics. PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient's spontaneous breaths

A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination b. Administering a colon cleansing product 6 hours before the examination c. Obtaining an order for a pain medication before the test is performed d. Removing all of the patient's metallic jewelry

ANS: D No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.

The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care? a. A 25-year-old patient with diarrhea b. A 30-year-old patient with Clostridium difficile c. A 40-year-old patient with an ileostomy d. A 70-year-old patient with stool incontinence

ANS: D The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

A patient is experiencing a fecal impaction. Which portion of the colon will the nurse assess? a. Descending b. Transverse c. Ascending d. Rectum

ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the healthcare provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management.

ANS: D Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "You should schedule a colonoscopy as soon as possible." c. "Are you under a lot of stress?" d. "Do you take iron supplements?"

ANS: D Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5 year old with excessive drooling from epiglottitis b. A 5 year old with an asthma attack following severe allergies c. A 24 year old with a right pneumothorax following a motor vehicle accident d. A 24 year old with acute respiratory distress syndrome requiring mechanical ventilatio

ANS: D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5-year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax.

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. "This tool will let us compare your stress to other patients in the hospital." b. "This tool is short because it only measures the negative stressors you are experiencing." c. "You will need to ask your parents about stressors you had as a child to complete this tool." d. "This tool will help assess recent positive and negative events you are experiencing."

ANS: D Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats/min Respiratory rate: 26 breaths/min Blood pressure: 140/106 Which hormones should the nurse consider as the most likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

ANS: D During the alarm stage, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate.

A nurse is caring for a patient experiencing stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? a. Select nursing interventions and promote patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions and achieve expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

ANS: D During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? a. Singing b. Massaging back c. Listening to music d. Visualizing peaceful settings

ANS: D Guided imagery is used as a means to create a relaxed state through the person's imagination. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

The nurse is assessing a patient diagnosed with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

ANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle used are all normal findings in a patient with emphysema

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

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

A patient recovering from a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed

ANS: D Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain-relief measures should be given; however, preventative action should be taken to prevent constipation.

What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing

ANS: D Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics cause fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem.

The nurse is caring for a patient diagnosed with C. difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? a. Appropriate disposal of contaminated items in biohazard bags b. Monthly inservices about contact precautions c. Mandatory cultures on all patients d. Proper hand hygiene techniques

ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly inservices place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

ANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%.

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum

ANS: D The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

ANS: D The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due to working, but this should not directly affect the patient.