PCC II Final quiz questions
The nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when she states A. "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." B. "I need to be sure to take all the available immunizations to keep me from getting sick." C. "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D. "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."
A. "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." SLE is a hyperimmunity problem. Pathogens trigger the immune response in the body, which can exacerbate the SLE. Immunizations trigger the immune response in the body to help create antibodies. In patients with autoimmune diseases such as SLE, immunizations can exacerbate the disease. SLE is not the result of immunosuppression. Lifestyle changes are required with most chronic illnesses such as SLE. Patients cannot depend on medications alone.
When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? A. "I will be able to regulate when I have stools." B. "I will be able to wear the pouch until it leaks." C. "Dried fruit and popcorn must be chewed very well." D. "The drainage from my stoma can damage my skin."
A. "I will be able to regulate when I have stools."
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."
A. "I will need to isolate any tissues I use so as not to infect my family."
The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? A. "The tube will help to drain the stomach contents and prevent further vomiting." B. "The tube will push past the area that is blocked and thus help to stop the vomiting." C. "The tube is just a standard procedure before many types of surgery to the abdomen." D. "The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best."
A. "The tube will help to drain the stomach contents and prevent further vomiting."
A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" Which of the following would be the nurse's best response? (Select all that apply): A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." B. "You will likely experience euphoria from the medication." C. "You will likely become dependent on this medication and require other medications to control your pain." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." E. "You will not become physically addicted, but you may develop a physiological addiction."
A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." Tolerance is an increasing need for a substance or a lack of effect when a certain dose is given over time. Withdrawal is a syndrome of symptoms that result from stopping the use of a substance. Dependency and psychological addiction do not usually occur with patients that are in pain, because the pain receptors are not being artificially stimulated.
A patient is being treated for drug addiction. The nurse understands that the treatment may include which of the following? (Select all that apply): A. A motivational interview. B. Observing for stress reaction. C. Converting narcotic use from an illicit to a legally controlled drug. D. Observing for delirium tremens. E. Encouraging involvement in Narcotics Anonymous.
A. A motivational interview. B. Observing for stress reaction. E. Encouraging involvement in Narcotics Anonymous. The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.
Select all the organs from the following list that are part of the immune system. (Select all that apply): A. Adenoids. B. Appendix. C. Bone marrow. D. Gallbladder. E. Liver. F. Thyroid gland.
A. Adenoids. B. Appendix. C. Bone marrow. The lymphoid organs of the immune system are the adenoids, appendix, and bone marrow. Other organs of the immune system include the lymph nodes, thymus gland, tonsils, and spleen. The gallbladder, liver, and thyroid gland are not part of the immune system.
The nurse reminds the staff that standard precautions should be used when providing care for which type of patient? A. All patients regardless of diagnosis B. Pediatric and gerontologic patients C. Patients who are immunocompromised D. Patients with a history of infectious diseases
A. All patients regardless of diagnosis
On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response
A. Autoimmune response
The 40-year-old African American woman has had Raynaud's phenomenon for some time. She is now reporting red spots on the hands, forearms, palms, face, and lips. What other manifestations should the nurse assess for when she is assessing for scleroderma? (Select all that apply.) A. Calcinosis B. Weight loss C. Sclerodactyly D. Difficulty swallowing E. Weakened leg muscles
A. Calcinosis C. Sclerodactyly D. Difficulty swallowing
The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities
A. Delaying disease progression
Primary prevention activities a nurse can perform related to substance abuse include (Select all that apply): A. Education to prevent substance abuse. B. Focusing on relapse prevention. C. Identification of risk factors for abuse. D. Medical detoxification. E. Referral to a self-help group for stress relief and meditation.
A. Education to prevent substance abuse. C. Identification of risk factors for abuse. E. Referral to a self-help group for stress relief and meditation. Primary prevention actions are those taken in order to prevent a problem from occurring. Primary prevention involves reducing stress to prevent addiction. Secondary prevention includes screening and early detection for prompt treatment. Referral to a support group might be considered secondary prevention if a patient has screened positive for substance abuse and has agreed to start attending a group. Tertiary prevention includes rehabilitative strategies.
A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first? A. Fecal impaction B. Perineal hygiene C. Dietary fiber intake D. Antidiarrheal agent use
A. Fecal impaction
Which side effects of lithium can be expected at therapeutic levels? A. Fine hand tremor and polyuria B. Nausea and thirst C. Coarse hand tremor and gastrointestinal upset D. Ataxia and hypotension
A. Fine hand tremor and polyuria
When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods? (Select all that apply.) A. Grapes B. Oranges C. Bananas D. Potatoes E. Tomatoes
A. Grapes C. Bananas D. Potatoes E. Tomatoes
The patient with fibromyalgia is suffering with pain at 12 of the 18 identification sites, including the neck and upper back and the knees. The patient also reports nonrefreshing sleep, depression, and being anxious when dealing with multiple tasks. The nurse should teach this patient about what treatments? (Select all that apply.) A. Low-impact aerobic exercise B. Relaxation strategy (biofeedback) C. Antiseizure drug pregabalin (Lyrica) D. Morphine sulfate extended-release tablets E. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])
A. Low-impact aerobic exercise B. Relaxation strategy (biofeedback) C. Antiseizure drug pregabalin (Lyrica) E. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])
The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? A. Maintain a high intake of fluid and fiber in the diet. B. Reduce intake of medications causing constipation. C. Eat several small meals per day to maintain bowel motility. D. Sit upright during meals to increase bowel motility by gravity.
A. Maintain a high intake of fluid and fiber in the diet.
The nurse is caring for a patient experiencing an immune response. She assesses the patient for development of a hyperimmune response because cytotoxic T cells A. May kill healthy cells along with foreign antigens. B. Are the most prevalent type of T lymphocyte. C. Can suppress the immune response. D. Diminish dendritic cell function.
A. May kill healthy cells along with foreign antigens. Cytotoxic T lymphocytes can kill healthy tissue along with antigens. Suppressor T cells help to keep cytotoxic T cells in check. Helper T cells are the most prevalent type of T lymphocyte, not cytotoxic cells. Cytotoxic T lymphocytes do not suppress the immune response but are a factor in optimal immune functioning. Suppressor T lymphocytes help to suppress the function of cytotoxic cells. Dendritic cell function enhances cytotoxic T lymphocyte functioning.
A nurse assesses a 38-year-old patient with joint pain and stiffness who was diagnosed with Stage III rheumatoid arthritis (RA). What characteristics should the nurse expect to observe? (Select all that apply.) A. Nodules present B. Consistent muscle strength C. Localized disease symptoms D. No destructive changes on x-ray E. Subluxation of joints without fibrous ankylosis
A. Nodules present E. Subluxation of joints without fibrous ankylosis
The nurse is caring for four newly diagnosed patients with various connective tissue disorders. The nurse should be most aware of safety issues and interstitial lung involvement in the patient with which diagnosis? A. Polymyositis B. Reactive arthritis C. Sjögren's syndrome D. Systemic lupus erythematosus (SLE)
A. Polymyositis
A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? (Select all that apply): A. Poor eye contact. B. Increased fever. C. Appetite changes. D. Increased white blood cell count. E. Slowed speech.
A. Poor eye contact. C. Appetite changes. E. Slowed speech. Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.
Which strategy by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection? A. Provide a light blanket. B. Encourage a hot shower. C. Monitor temperature every hour. D. Turn up the thermostat in the patient's room.
A. Provide a light blanket.
The treatment team meets to discuss Cody's plan of care. Which of the following factors will be priorities when planning interventions? A. Readiness to change and support system B. Current college performance C. Financial ability D. Availability of immediate family to come to meetings
A. Readiness to change and support system
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should the nurse have the UAP do for the patient? A. Reposition every 2 hours. B. Measure the size of the reddened area. C. Massage the area to increase blood flow. D. Evaluate the area later to see if it is better.
A. Reposition every 2 hours.
A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving? (Select all that apply.) A. Shingles B. Pneumonia C. Meningococcal D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)
A. Shingles B. Pneumonia
The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? A. The patient must be able to see the site. B. Outside the rectus muscle area is the best site. C. It is easier to seal the drainage bag to a protruding area. D. The ostomy will need irrigation, so area should not be tender.
A. The patient must be able to see the site.
The nurse is assessing a patient using the CAGE (Cut, Annoyed, Guilty, and Eye Opener) questionnaire. The nurse suspects possible alcoholism when the patient states: (Select all that apply): A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." C. The patient states, "I go to meetings once or twice a week but continue to drink." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately." F. The patient states, "I can quit whenever I want to."
A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately." The patient may need help admitting that there is a problem. The CAGE questionnaire is designed to objectively assist in assessing problems related to alcohol use. A patient who states that he is going to meetings at Alcoholics Anonymous (AA) is admitting he has a problem, even if he still drinks. A patient who feels he can quit whenever he wants to may be in denial of the problem.
An 82-year-old woman is brought to her physician by her daughter with complaints of some confusion. What testing should the nurse suggest for this patient? A. Urinalysis B. Sputum culture C. Red blood cell count D. White blood cell count
A. Urinalysis
A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by A. Vasodilation. B. Extravasation. C. Neutrophils. D. Exudate.
A. Vasodilation. The inflammatory process results in rubor, or redness, of an area of insult. The body responds to injury by increasing the blood flow to an area through vasodilation. This allows increased oxygen and more nutrients and appropriate white blood cells to reach the area, isolating the area and beginning the immune response. Extravasation is the movement of fluid from its confined space into the surrounding tissue. Neutrophils are one of the most common types of white blood cells. Exudate is the fluid filled with proteins and white blood cells that moves out of the vascular spaces through extravasation.
What should the nurse teach the patients in the assisted living facility to decrease their risk for antibiotic-resistant infection? (Select all that apply.) A. Wash hands frequently. B. Take antibiotics as prescribed. C. Take the antibiotic until it is gone. D. Take antibiotics to prevent illnesses like colds. E. Save leftover antibiotics to take if needed later.
A. Wash hands frequently. B. Take antibiotics as prescribed. C. Take the antibiotic until it is gone.
What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? A. Withhold medication and notify the physician. B. Continue to administer medication as ordered. C. Advise the client to limit fluids for 12 hours. D. Advise the client to curtail salt intake for 24 hours.
A. Withhold medication and notify the physician.
Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of A. impaired peristalsis. B. irritation of the bowel. C. nasogastric suctioning. D. inflammation of the incision site.
A. impaired peristalsis.
A desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors would be A. making no attempts at self-harm within 12 hours of admission. B. sleeping soundly for 12 of the next 24 hours. C. willingly taking prescribed medication as offered by staff within 24 hours of admission. D. demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.
A. making no attempts at self-harm within 12 hours of admission.
The priority nursing diagnosis for a hyperactive manic client during the acute phase is A. risk for injury. B. ineffective role performance. C. risk for other-directed violence. D. impaired verbal communication.
A. risk for injury.
To plan care for a manic client the nurse must consider that lithium cannot be started until A. the physical examination and laboratory tests are analyzed. B. the initial doses of antipsychotic medication have brought behavior under control. C. seclusion has proven ineffective as a means of controlling assaultive behavior. D. electroconvulsive therapy can be scheduled to coincide with lithium administration.
A. the physical examination and laboratory tests are analyzed.
An acute phase nursing intervention aimed at reducing hyperactivity is redirecting the client to A. write in a diary. B. exercise in the gym. C. direct unit activities. D. orient a new client to the unit.
A. write in a diary.
When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which statement? A. "I should take the Naprosyn as prescribed to help control the pain." B. "I should try to stay standing all day to keep my joints from becoming stiff." C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."
B. "I should try to stay standing all day to keep my joints from becoming stiff."
Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. "You will need to get rid of your pets." B. "You should sleep in an air-conditioned room." C. "You would do best to stay indoors during the winter months." D. "You will need to dust your house with a dry feather duster twice a week."
B. "You should sleep in an air-conditioned room."
A patient who is given a bisacodyl (Dulcolax) suppository asks the nurse how long it will take to work. The nurse replies that the patient will probably need to use the bedpan or commode within which time frame after administration? A. 2-5 minutes B. 15-60 minutes C. 2-4 hours D. 6-8 hours
B. 15-60 minutes
A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? A. 7:00 AM, 10:00 AM, and 1:00 PM B. 8:00 AM, 12:00 PM, and 4:00 PM C. 9:00 AM and 3:00 PM D. 9:00 AM, 12:00 PM, and 3:00 PM
B. 8:00 AM, 12:00 PM, and 4:00 PM
A patient presents to the clinic with observable edema and erythema of the left forearm. On palpation, the nurse finds the area very warm and tender. The nurse understands that the patient is experiencing A. An allergic reaction. B. A complement cascade. C. IgE reactions. D. Clonal diversity.
B. A complement cascade. A complement cascade is responsible for the dilation of blood vessels and leaking of fluid from the vascular system to the area of insult, resulting in the swelling and redness associated with an inflammatory response. An allergic reaction can cause edema and erythema, but the question does not provide enough information to determine the specific cause of the swelling and redness. IgE is a specific immunoglobulin associated with signs and symptoms of allergic rhinitis. Clonal diversity refers to the maturation process of cells.
A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? A. Instruction on irrigating a colostomy B. Administration of a cleansing enema C. A high-fiber diet the day before surgery D. Administration of IV antibiotics for bowel preparation
B. Administration of a cleansing enema
The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations? (Select all that apply.) A. Assessment of lung sounds B. Assessment of sexual behavior C. Assessment of living conditions D. Assessment of drug and syringe use E. Assessment of exposure to an ill person
B. Assessment of sexual behavior D. Assessment of drug and syringe use
The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? A. Presence of HIV antibodies B. CD4+ T cell count below 200/μL C. Presence of oral hairy leukoplakia D. White blood cell count below 5000/μL
B. CD4+ T cell count below 200/μL
Because the incidence of Lyme disease is very high in Wisconsin, the public health nurse is planning to provide community education to increase the number of people who seek health care promptly after a tick bite. What information should the nurse provide when teaching people who are at risk for a tick bite? A. The best therapy for the acute illness is an IV antibiotic. B. Check for an enlarging reddened area with a clear center. C. Surveillance is necessary during the summer months only. D. Antibiotics will prevent Lyme disease if taken for 10 days.
B. Check for an enlarging reddened area with a clear center.
Cody is a 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months. He is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for Cody's treatment plan while in the hospital? A. Cody will return to a predrug level of functioning within 1 week. B. Cody will be medically stabilized while in the hospital. C. Cody will state within 3 days that he will totally abstain from drugs and alcohol. D. Cody will take a leave of absence from college to alleviate stress.
B. Cody will be medically stabilized while in the hospital.
The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager
B. Combination antiretroviral therapy
The patient has vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to the nurse, other patients, staff, and those outside the hospital? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions
B. Contact precautions
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? A. Apple B. Custard C. Popsicle D. Potato chips
B. Custard
A nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient uses which description of the condition? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes
B. Degeneration of articular cartilage in synovial joints
The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. The nurse knows that scar tissue results from A. Optimal functioning of the inflammatory process after an injury. B. Fibrous tissue replacing damaged tissue when injury is extensive. C. The development of chronic inflammation. D. A surgical incision.
B. Fibrous tissue replacing damaged tissue when injury is extensive. Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.
A hospital has seen a recent increase in the incidence of hospital care-associated infections (HAIs). Which measure should be prioritized in the response to this trend? A. Use of gloves during patient contact B. Frequent and thorough hand washing C. Prophylactic, broad-spectrum antibiotics D. Fitting and appropriate use of N95 masks
B. Frequent and thorough hand washing
The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer? A. Osteoarthritis B. History of colorectal polyps C. History of lactose intolerance D. Use of herbs as dietary supplements
B. History of colorectal polyps
What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? A. How to care for the wound B. How to deep breathe and cough C. The location and care of drains after surgery D. Which medications will be used during surgery
B. How to deep breathe and cough
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness
B. Intake and output
The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A. Abdominal pain and bloating B. No bowel movement for 3 days C. A decrease in appetite by 50% over 24 hours D. Muscle tremors and other signs of hypomagnesemia
B. No bowel movement for 3 days
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which finding should the nurse expect to be present on examination of the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement
B. Pain with joint movement
A patient with pneumonia has a fever of over 103° F. What should the nurse do to manage the patient's fever? A. Administer aspirin on a scheduled basis around the clock. B. Provide acetaminophen every 4 hours to maintain consistent blood levels. C. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. D. Provide drug interventions if complementary and alternative therapies have failed.
B. Provide acetaminophen every 4 hours to maintain consistent blood levels.
A patient had abdominal surgery last week. The patient calls the office and says the wound is now draining thick white material and it smells funny. How should the nurse document this drainage? A. Serous B. Purulent C. Fibrinous D. Catarrhal
B. Purulent
Sasha has been having angry outbursts with staff and peers on the unit. You are talking with Sasha on her third day of admission. You ask whether she is having any thoughts of suicide. Sasha becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" Your response is based on the knowledge that: A. Sasha is getting better because she is able to be assertive. B. Sasha may be at high risk for self-harm. C. Sasha is probably experiencing transference. D. Sasha may be angry at someone else and projecting that anger to staff.
B. Sasha may be at high risk for self-harm.
A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? A. Anxiety. B. Seasonal affective disorder. C. Medication side effects. D. Antisocial personality.
B. Seasonal affective disorder. Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.
A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? A. Primary prevention. B. Secondary prevention. C. Tertiary prevention. D. Modified prevention.
B. Secondary prevention. Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.
The patient has inflammation and is complaining of malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A. Local response B. Systemic response C. Infectious response D. Acute inflammatory response
B. Systemic response
A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? (Select all that apply): A. The patient states, "I don't think my body will recover from the drinking." B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected my family life." D. The patient states, "I am glad that I did not drag others into my drinking." E. The patient states, "I have been attending a meeting a day."
B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected my family life." E. The patient states, "I have been attending a meeting a day." A patient who realizes that changing his environment will decrease temptation shows that he is motivated and willing to try to change. A patient who is able to see the effect the abuse is having on his life has a key component of motivation. A patient who is attending meetings at Alcoholics Anonymous (AA) is motivated toward recovery.
A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance? A. The side-effects are unpleasant. B. The voices tell the client to stop taking it. C. The client prefers to feel "high" and energetic. D. The client feels well and denies the possibility of recurrence.
B. The voices tell the client to stop taking it.
The mother does not want her child to have any extra immunizations for diseases that no longer occur. What teaching about immunization should the nurse provide this mother? A. There is currently no need for those older vaccines. B. There is a reemergence of some of the infections, such as pertussis. C. There is no longer an immunization available for some of those diseases. D. The only way to protect your child is to have the federally required vaccines.
B. There is a reemergence of some of the infections, such as pertussis.
A patient's low hemoglobin and hematocrit have necessitated a transfusion of packed red blood cells (RBCs). Shortly after the first unit of RBCs starts to infuse, the patient develops signs and symptoms of a transfusion reaction. Which type of hypersensitivity reaction has the patient experienced? A. Type I B. Type II C. Type III D. Type IV
B. Type II
A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? A. Together they will cure HIV. B. Viral replication will be inhibited. C. They will decrease CD4+ T cell counts. D. It will prevent interaction with other drugs.
B. Viral replication will be inhibited.
A desired outcome for the maintenance phase of treatment for a manic client would be that the client will A. exhibit optimistic, energetic, playful behavior. B. adhere to follow-up medical appointments. C. take medication more than 50% of the time. D. use alcohol to moderate occasional mood "highs."
B. adhere to follow-up medical appointments.
The major reason for hospitalization for depressed patients is: A. inability to go to work. B. suicidal ideation. C. loss of appetite. D. psychomotor agitation.
B. suicidal ideation.
Erik is a 26-year-old patient who abuses heroin. He states to you, "I've been using more heroin lately. I told my provider about it and she said I need more and more heroin to feel the effect I want." You know this describes: A. intoxication. B. tolerance. C. withdrawal. D. addiction.
B. tolerance.
Sasha is a 38-year-old patient admitted with major depression. Which of the following statements Sasha makes alerts you to a common accompaniment to depression? A. "I still pray and read my Bible every day." B. "My mother wants to move in with me, but I want to independent." C. "I still feel bad about my sister dying of cancer. I should have done more for her!" D. "I've heard others say that depression is a sign of weakness."
C. "I still feel bad about my sister dying of cancer. I should have done more for her!"
Sasha is started on fluoxetine. Which statement by Sasha indicates that she understands the medication teaching you have provided? A. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." B. "I will not take any over-the-counter medication while on the fluoxetine." C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." D. "I will report increased thirst and urination to my provider."
C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away."
A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."
C. "I'm hoping that surgery will be an option for me in the future."
A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? A. "I will call your care provider. Perhaps you need a different medication." B. "Don't worry. We can try taking it at a different time of day to help it work better." C. "It usually takes a few weeks for you to notice improvement from this medication." D. "Your life is much better now. You will feel better soon."
C. "It usually takes a few weeks for you to notice improvement from this medication." Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.
A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be A. "What an offensive thing to suggest!" B. "I don't have sex with clients." C. "It's time to work on your art project." D. "Let's walk down to the seclusion room."
C. "It's time to work on your art project."
A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? A. "The person may have sleep more, have trouble completing hygiene needs, and have a poor appetite." B. "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." C. "The person may have excess energy, talk a lot, feel restless, and spend too much money." D. "The person may experience decreased energy and interest in activities beginning in the winter months."
C. "The person may have excess energy, talk a lot, feel restless, and spend too much money." Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.
A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."
C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection."
The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count
C. A sharp decrease in the patient's CD4+ count
The patient developed gout while hospitalized for a heart attack. When doing discharge teaching for this patient who takes aspirin for its antiplatelet effect, what should the nurse include about preventing future attacks of gout? A. Limit fluid intake. B. Administration of probenecid (Benemid) C. Administration of allopurinol (Zyloprim) D. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)
C. Administration of allopurinol (Zyloprim)
The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation? A. Notify the health care provider. B. Document the fistula formation. C. Assess the patient and vaginal drainage. D. Have the UAP apply a dressing to the vagina.
C. Assess the patient and vaginal drainage.
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance
C. Assessment of the patient's circulation distal to the location of the dressing
Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease? (Select all that apply.) A. Restricted to rectum B. Strictures are common C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine
C. Bloody, diarrhea stools D. Cramping abdominal pain Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.
Which of the following is true regarding substance addiction and medical comorbidity? A. Most substance abusers do not have medical comorbidities. B. There has been little research done regarding substance addiction disorders and medical comorbidity. C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities.
The nurse is reviewing the erythrocyte sedimentation rate (ESR) for one of her patients. An elevated ESR A. Determines specific causes of inflammation. B. Identifies the location of inflammation within the body. C. Confirms the nonspecific presence of inflammation. D. Indicates a diagnosis of systemic lupus.
C. Confirms the nonspecific presence of inflammation. An elevated ESR is indicative of the presence of inflammation in the body. Proteins produced during the inflammatory process adhere to red blood cells, causing them to be heavier and settle out of blood samples at a faster rate than normal. The ESR does not identify specific causes of inflammation and does not determine a specific location of inflammation. The ESR is a nonspecific indicator of inflammation.
An older patient is transferred from the nursing home with a black wound on her heel. What should the nurse expect to be the first treatment of this wound? A. Dress it with an absorbent dressing for exudate. B. Handle the wound gently and let it dry out to heal. C. Debride the nonviable, eschar tissue to allow healing. D. Use negative-pressure wound (vacuum) therapy to facilitate healing.
C. Debride the nonviable, eschar tissue to allow healing.
The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do what? A. Use a wheelchair to avoid walking as much as possible. B. Sit in chairs that cause the hips to be lower than the knees. C. Eat a well-balanced diet to maintain a healthy body weight. D. Use a walker for ambulation to relieve the pressure on the hips.
C. Eat a well-balanced diet to maintain a healthy body weight.
The nurse determines that the patient may be suffering from an acute bacterial infection based upon which laboratory test result? A. Increased platelet count B. Increased blood urea nitrogen C. Increased number of band neutrophils D. Increased number of segmented myelocytes
C. Increased number of band neutrophils
The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? A. It will gather platelets for use later when needed. B. It will cause anemia because it removes whole blood and RBCs are damaged. C. It will remove the IgG autoantibodies and antigen complexes from the plasma. D. It will remove the peripheral stem cells in order to cure the autoimmune disease.
C. It will remove the IgG autoantibodies and antigen complexes from the plasma.
A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? A. Dyspnea B. Dilated pupils C. Itching and edema D. Wheal-and-flare reaction
C. Itching and edema
A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? A. Monitor the patient's fluid balance. B. Assess the patient's need for analgesia. C. Monitor for signs and symptoms of an adverse reaction. D. Assess the patient for changes in level of consciousness.
C. Monitor for signs and symptoms of an adverse reaction.
A nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which activity pattern? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C. Regular exercise program of walking D. Frequent rest periods with minimal exercise
C. Regular exercise program of walking
Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? A. Notify the physician. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one.
C. Reposition the tube and check for placement.
The patient is admitted with this pressure ulcer. How should the nurse document it? A. Stage I B. Stage II C. Stage III D. Stage IV
C. Stage III
After the surgeon tells the patient that his wound will be allowed to heal by secondary intention, the patient asks the nurse what that is. How should the nurse explain this to the patient? A. The wound will be stapled together until it heals. B. The healing will contract the area to close the wound. C. The wound will be left open and heal from the edges inward. D. The wound will be sutured after the current infection is controlled.
C. The wound will be left open and heal from the edges inward.
The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis? (Select all that apply.) A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.
C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.
When assessing a patient who is receiving cefazolin (Ancef) for the treatment of a bacterial infection, which data suggest that treatment has been effective? A. White blood cell (WBC) count 8000/μL, temperature 101° F B. White blood cell (WBC) count 4000/μL, temperature 100° F C. White blood cell (WBC) count 8500/μL, temperature 98.4° F D. White blood cell (WBC) count 16,500/μL, temperature 98.8° F
C. White blood cell (WBC) count 8500/μL, temperature 98.4° F
The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop A. major histoincompatibility. B. primary immunodeficiency. C. secondary immunodeficiency. D. acute hypersensitivity reaction.
C. secondary immunodeficiency. Secondary immunodeficiency is most commonly caused by immunosuppressive drugs, such as corticosteroids. It can also be caused by diabetes mellitus, severe infection, malnutrition, and chronic stress, all of which are present in this patient. The other options are not possible for this patient. Histoincompatibility occurs when the human leukocyte antigen (HLA) system of the donor is not compatible with the recipient's HLA genes. Primary immunodeficiency is rare and includes phagocytic defects, B cell deficiency, T cell deficiency, or a combination of B cell and T cell deficiency. Acute hypersensitivity reaction is an anaphylactic-type allergic reaction to an antigen.
Cody is preparing for discharge. He tells you, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A. "It helps your mood so that you don't feel the need to do drugs." B. "It will keep you from experiencing flashbacks." C. "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D. "It helps prevent relapse by reducing drug cravings."
D. "It helps prevent relapse by reducing drug cravings."
Which patient statement most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning, and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse all the time, and nothing seems to help."
D. "My lower back pain seems to be getting worse all the time, and nothing seems to help."
Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? A. "My drug dosages will be lower because the medications enhance each other." B. "Taking more than one medication will put me at risk for developing allergies." C. "I will be more prone to malignancies because I will be taking more than one drug." D. "The lower doses of my medications can prevent rejection and minimize the side effects."
D. "The lower doses of my medications can prevent rejection and minimize the side effects."
A patient comes to a clinic with a chief complaint of, "My left arm is red and swollen. It hurts badly enough that I couldn't go to work today." The physician orders computer-assisted tomography (CT) scanning of the left upper extremity. The nurse knows the patient understands the reason for the procedure when he states A. "I need to have this done because my arm is broken." B. "The doctor wants me to have this so that the pain will stop." C. "This will tell you what I did to my elbow because I really don't know what happened." D. "This test will help to better determine where the injury actually is and how severe it is."
D. "This test will help to better determine where the injury actually is and how severe it is."
The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate? A. "This will prevent air from accumulating in the stomach, causing gas pains." B. "This will prevent the heartburn that occurs as a side effect of general anesthesia." C. "The stress of surgery is likely to cause stomach bleeding if you do not receive it." D. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."
D. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."
Which of the following patients is at higher risk for inflammatory reactions? A. 2-year-old girl with a healthy diet. B. 38-year-old man who is obese. C. 54-year-old woman in menopause. D. 79-year-old man with diabetes.
D. 79-year-old man with diabetes. The 79-year-old man is at highest risk for inflammatory reactions among these patients for two reasons, his age and having diabetes. The risk would be high during the first year of life, but this 2-year-old girl has gotten beyond this risk period and she also has the positive factor of a healthy diet. The 38-year-old man is not in a high-risk category because of age but is because of obesity. Although a 54-year-old woman is getting older, being in menopause does not increase the risk for inflammatory reactions.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? A. The patient is experiencing a type I allergic reaction. B. An atopic reaction is causing the patient's symptoms. C. The patient is experiencing rejection of the bone marrow. D. Cells in the transplanted bone marrow are attacking the host tissue.
D. Cells in the transplanted bone marrow are attacking the host tissue.
The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? A. Write an incident report about this untoward event. B. Attempt to have the family convince the patient to take the ordered dose. C. Withhold the medication at this time and try to administer it later in the day. D. Chart the dose as not given on the medical record and explain in the nursing progress notes.
D. Chart the dose as not given on the medical record and explain in the nursing progress notes.
The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? A. Ask family members whether they have discussed the surgical procedure with the physician. B. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. C. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. D. Delay the patient's signature on the consent and notify the physician about the conversation with the patient.
D. Delay the patient's signature on the consent and notify the physician about the conversation with the patient.
When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? A. White bread, cheese, and green beans B. Fresh tomatoes, pears, and corn flakes C. Oranges, baked potatoes, and raw carrots D. Dried beans, All Bran (100%) cereal, and raspberries
D. Dried beans, All Bran (100%) cereal, and raspberries
The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The nurse needs to be aware that the patient has A. Primary immunodeficiency. B. Secondary immunodeficiency. C. Optimal immune response. D. Exaggerated immune response.
D. Exaggerated immune response.
The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? A. Adhesion B. Contractions C. Keloid formation D. Excess granulation tissue
D. Excess granulation tissue
The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction
D. High-pitched and hyperactive above the area of obstruction
The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A. Increases bulk in the stool B. Lubricates the intestinal tract to soften feces C. Increases fluid retention in the intestinal tract D. Increases peristalsis by stimulating nerves in the colon wall
D. Increases peristalsis by stimulating nerves in the colon wall
The nurse would question the use of which cathartic agent in a patient with renal insufficiency? A. Bisacodyl (Dulcolax) B. Lubiprostone (Amitiza) C. Cascara sagrada (Senekot) D. Magnesium hydroxide (Milk of Magnesia)
D. Magnesium hydroxide (Milk of Magnesia)
The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? A. Administer IV diphenhydramine (Benadryl). B. Administer nitroprusside as soon as possible. C. Anticipate tracheostomy with laryngeal edema. D. Place the patient recumbent and elevate the legs.
D. Place the patient recumbent and elevate the legs.
What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A. Take a dose of mineral oil at the same time. B. Add extra salt to food on at least one meal tray. C. Ensure dietary intake of 10 g of fiber each day. D. Take each dose with a full glass of water or other liquid.
D. Take each dose with a full glass of water or other liquid.
A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? (Select all that apply.) A. Take the antibiotic until the wound feels better. B. Take the analgesic every day to promote adequate rest for healing. C. Be sure to wash hands after changing the dressing to avoid infection. D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E. Notify the health care provider of redness, swelling, and increased drainage.
D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E. Notify the health care provider of redness, swelling, and increased drainage.
Sasha's roommate Kate was admitted with major depression and suicidal ideation with a plan to overdose. Kate is preparing for discharge and asks you, "Why did Dr. Travis give me a prescription for only 7 days of amitriptyline?" Your response is based on the knowledge that: A. amitriptyline (Elavil) is very expensive, so the patient may have to buy fewer at a time. B. Dr. Travis is going to see how Kate responds to the first week of medication to evaluate its effectiveness. C. Dr. Travis wants to see whether any minor side effects occur within the first week of administration. D. amitriptyline (Elavil) is lethal in overdose.
D. amitriptyline (Elavil) is lethal in overdose.
When the wife of a manic client asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on the knowledge that A. no research exists to suggest genetic transmission. B. much depends on the socioeconomic class of the individuals. C. highly creative people tend toward development of the disorder. D. the rate of bipolar disorder is higher in relatives of people with bipolar disorder.
D. the rate of bipolar disorder is higher in relatives of people with bipolar disorder.
When the nurse changes the dressing and documents that there is serosanguineous drainage, which type of drainage did she see on the dressing? (Images from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.) A. B. C. D.
Semi clear liquid drainage
