Acute Final- No Select All That Apply
After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a. "I will replace my nitroglycerin supply every 6 months." b. "I can take up to 5 tablets every 3 minutes for relief of my chest pain." c. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin. d. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."
b Rationale: Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.
The Nurse prepares a discharge teaching plan for a patient who has recently been diagnosed with coronary artery disease (CAD). Which priority risk factor should the nurse plan to focus on during the teaching session? a. Type A personality. b. Elevated serum lipids. c. Family cardiac history. d. High homocysteine levels.
b Rationale: Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.
The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination medication? 1. "I feel like my heart is racing." 2. "I feel more bloated than usual." 3. "My eyes have been watering lately." 4. "I haven't had a bowel movement in 4 days."
Answer: 1 Rationale: Albuterol/ipratropium is a combination agent—one is a β2-adrenergic agonist and the other is an anticholinergic medication, and in combination they produce an overall bronchodilation effect. Common side and adverse effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia. Therefore, option 1 is correct. Options 2, 3, and 4 are not specifically associated with this medication.
A client begins therapy with theophylline. The nurse plans to teach the client to limit the intake of which items while taking this medication? 1. Coffee, cola, and chocolate 2. Oysters, lobster, and shrimp 3. Melons, oranges, and pineapple 4. Cottage cheese, cream cheese, and dairy creamers
Answer: 1 Rationale: Theophylline is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.
A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1) It hurts more when I breathe in. 2) I have never had this pain before. 3) It hurts on the left side of my chest. 4) The pain is about a 6 on a scale of 1 to 10
Answer: 1 Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristic, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration.
The nurse and an assistive personnel (AP) are assisting the respiratory therapist to position a client for postural drainage. The AP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? 1) Lobes 2) Alveoli 3) Trachea 4) Main bronchi
Answer: 1 Rationale: Postural drainage uses specific client positions that vary depending on the affected lobe of lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect.
A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1) Pleural pain and fever 2) Decreased respiratory rate 3) Diaphoresis during the day 4) Hyperresonant breath sounds over the left thorax
Answer: 1 Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.
The postpartum nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? A. 3 days postpartum B. 7 days postpartum C. On the day of the birth D. Within 2 weeks postpartum
Answer: A Rationale: After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.
A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats per minute 4. Respirations of 18 breaths per minute
Answer: 2 Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths per minute.
A client who is experiencing respiratory difficulty asks the nurse, "why is it so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1) Air flows by gravity 2) The respiratory muscles relax 3) The respiratory muscles contract 4) Air is flowing against a pressure gradient
Answer: 2 Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.
The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? ]1) Edema 2) Dyspnea 3) Frothy sputum 4) Diminished breath sounds
Answer: 2 Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clar. Edema is not directly associated with ARDS.
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear
Answer: 2 Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? 1. Metabolic acidosis 2. myocardial hypoxia 3. Decreased catecholamine secretion 4. Increased parasympathetic nervous system stimulation
Answer: 2, Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium.
Which patient has early clinical manifestations of hypoxemia? 1. 48-yr-old patient who is intoxicated and acutely disoriented to time and place. 2. 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. 3. 72-yr-old patient who has four new premature ventricular contractions per minute. 4. 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.
Answer: 3 Rationale: Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.
The nurse determines that therapy with ipratropium is effective after noting which assessment finding? 1. Decreased respiratory rate 2. Increased respiratory rate 3. Increased peak flow readings 4. Decreased sputum production
Answer: 3 Rationale: Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates.
A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent? 1. Orthostatic hypotension 2. Headache with disorientation 3. Bleeding at the arterial puncture site 4. infiltration of the radiopaque dye in the tissue
Answer: 3 Bedrest and elevation encourages coagulation, and healing of the arterial puncture site.
A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedural teaching, what does the nurse explain to the client is the major purpose for catheterization? 1) To obtain the pressures in the heart chambers 2) To determine the existence of congenital heart disease 3) To visualize the disease process in the coronary arteries 4) To measure oxygen content in various heart chambers
Answer: 3, Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization.
An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? 1. Suppress fears 2. Deny illness 3. Maintain independence 4. Reassure the adult child
Answer: 3, Maintain independence. The client's statement is really saying, "I can manage this myself. I am capable." None of the information given leads to the conclusion that the client is suppressing fears. Nothing in the statement can be interpreted as denial; the client has stated, "I know I'm sick." Telling the adult child that self-care is possible will not be reassuring to a family member who brought the client to the hospital and who probably is more reassured by having the client hospitalized.
The nurse is planning to assess the effectiveness of a patient's coughing and deep breathing exercise. What assessment will provide the nurse with information on the effectiveness of the patients coughing and deep breathing? A. Auscultating the lungs B. Assess skin color C. Increase fluid intake D. Suction the airway
Answer: A Rationale: Auscultating the lungs, noting areas of decreased or absent airflow and adventitious breath sounds: crackles and wheezes. Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 1 month." 2. "I can't shop at the mall for the next 6 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy.
Answer: 4 Rationale: The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered non-contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.
1. A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition? * 1. Echocardiogram shows an ejection fraction of 38%. 2. Heart catheterization shows an ejection fraction of 65%. 3. Patient has frequent episodes of nocturnal paroxysmal dyspnea. 4. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.
Answer: 4- Option 2 is a finding expected in left-sided DIASTOLIC dysfunction heart failure because the issue is with the ability of the ventricle to FILL properly...therefore a patient usually has a normal ejection fraction. Remember a normal EF is >60% in a healthy heart (Registered Nurse RN). Strategies- Left side, expected finding?
These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the work load of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes? 1. Beta Blockers 2. Vasodilators 3. Angiotensin II receptor blockers 4. Angiotensin-converting-enzyme inhibitor
Answer: 4- This is a description of ACE inhibitors (Registered Nurse RN Strategies- first line treatment
What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath. 1. Left ventricular systolic dysfunction 2. Left ventricular right-sided dysfunction 3. Right ventricular diastolic function 4. Left ventricular diastolic dysfunction
Answer: 4- This statement describes left ventricular DIASTOLIC dysfunction. Strategies- blood is backing up into the lungs, and it is heart failure
A nurse is reviewing the onset of labor. Which sign should the nurse identify as not preceding the onset of labor? A. A decline in energy, as the body stores up for labor B. Stronger and more frequent uterine (Braxton Hicks) contractions C. A return of urinary frequency as a result of increased bladder pressure D. Persistent low backache from relaxed pelvic joints
Answer: A Rationale: "A surge of energy is a phenomenon that is common in the days preceding labor. After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress because of relaxation of the pelvic joints. Prior to the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength; bloody show may be passed"
A nurse is reviewing concepts relative to fetal circulation. Which factor should the nurse identify as not affecting fetal circulation during labor? A. Fetal position B. Uterine contractions C. Blood pressure D. Umbilical cord blood flow
Answer: A Rationale: "Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow. Uterine contractions during labor tend to decrease circulation and subsequent perfusion. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Maternal blood pressure is likely to have a significant effect on fetal circulation. Compression of the cord and reduction of umbilical blood flow do affect fetal circulation"
A nurse is taking care of a client in the third stage of labor. Which statement should the nurse identify as correct? A. The duration of the third stage may be as short as 3 to 5 minutes. B. The major risk for women during the third stage is a rapid heart rate. C. The placenta eventually detaches itself from a flaccid uterus. D. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.
Answer: A Rationale: "The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage; the risk of hemorrhage increases as the length of the third stage increases"
The nurse auscultating breath sounds of an infant with respiratory syncytial virus would immediately report the assessment of: A. "Quiet chest" from previous assessment of wheezing. B. Respiration rate decreased from 40 to 32 breaths/min. C. Heart rate decreased from 110 to 100 beats/min. D. Oxygen saturation of 90%.
Answer: A Rationale: A "quiet chest" after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? A. "I will begin abdominal exercises immediately." B. "I will notify my obstetrician if I develop a fever." C. "I will turn on my side and push up with my arms to get out of bed." D. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
Answer: A Rationale: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.
A woman is giving birth to her third child in a setting that allows her husband and children to be actively involved in the process. The nurse caring for her must also consider the husband and the two children as patients and work to meet their needs. This type of setting is termed: A. Family-centered care. B. Emergency care. C. Hospice care. D. Individual care.
Answer: A Rationale: Family-centered care is any setting where the pregnant woman and her family are treated as one unit. The nurse assumes a major role in teaching, counseling, and supporting the family. In emergency care settings, the nurse deals primarily with the patient who is having difficulty. In hospice care settings, the nurse deals with patients who have terminal illnesses. Individual care deals only with the patient and does not include the family.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? A. "You will need to bottle-feed your newborn." B. "You will need to feed your newborn by nasogastric tube feeding." C. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." D. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
Answer: A Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV will most likely be advised not to breast-feed; however, PHCPs recommendations regarding breastfeeding are always followed. There is no physiological reason why the newborn needs to be fed by a nasogastric tube.
The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist, and that discharge was present. What is the most appropriate nursing instruction for this mother? A. Bring the infant to the clinic. B. This is a normal occurrence, and no further action is needed. C. Increase the number of times that the cord is cleaned per day. D. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
Answer: A Rationale: Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify the primary health care provider (PHCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are not the most appropriate nursing interventions for an umbilical cord infection as described in the question.
What are the symptoms of viral pneumonia that do not happen in bacterial pneumonia? A. Non-productive or productive cough of small amounts of whitish sputum. B. Productive cough of purulent yellow sputum
Answer: A Rationale:Viral pneumonia is non-productive or productive cough and produces a small amount of whitish sputum. Viral pneumonia does not produce purulent yellow sputum. It gets better without treatment within 1 to 3 weeks. In some cases may require hospital admission it depends on the severity.
A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? A. Frequent movement of the client B. Tightly secured cable connections C. Leads applied over hairy areas D. Leads applied to the limbs
Answer: B Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.
A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation
Answer: B · Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).
A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead, there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole
Answer: B · Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
A nurse is reviewing the concept of normal labor. Which statement should the nurse indicate as being incorrect? A. A regular progression of contractions, effacement, dilation, and descent occurs. B. It is completed within 8 hours. C. A single fetus presents by vertex. D. No complications are involved.
Answer: B Rational: "Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours. In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor, which usually occurs with no complications"
The maternity nurse is reviewing the concept of primary and secondary powers. Which statement should the nurse identify as correct? A. Effacement generally is well ahead of dilation in women giving birth for the first time; they are more together in subsequent pregnancies. B. Primary powers are responsible for effacement and dilation of the cervix. C. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. D. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.
Answer: B Rational: "The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement is generally well ahead of dilation in first timers; the two are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so"
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? A. Length of 19 inches B. Abnormal palmar creases C. Birth weight of 6 lb, 14 oz (3120 g) D. Head circumference appropriate for gestational age.
Answer: B Rationale: Fetal alcohol syndrome, a diagnostic category of fetal alcohol syndrome disorders (FASDs), is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? A. Feed the newborn less frequently. B. Continue to breast-feed every 2 to 4 hours. C. Switch to bottle-feeding the infant for 2 weeks. D. Stop breast-feeding and switch to bottle-feeding permanently.
Answer: B Rationale: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? A. Initiate strict enteric precautions. B. Move the infant to a private room. C. Leave the infant in the present room, because RSV is not contagious. D. Inform the staff that using standard precautions is all that is necessary when caring for the child.
Answer: B Rationale: RSV is a highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. Use of contact, droplet, and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves, gown, and a mask should be done to prevent transmission. An infant with RSV should be placed in a private room to prevent transmission. Enteric precautions are unnecessary.
A nurse is working with a postpartum client about resumption of menstrual activity following childbirth. Which of the following statements indicate that the client has a correct understanding? A. "My first menstrual cycle will be heavier than normal and then will be light for several months after." B. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." C. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." D. "I will not have a menstrual cycle for 6 months after childbirth."
Answer: B Rationale: This is an accurate statement and indicates her understanding of her expected menstrual activity. The woman can expect her first menstrual cycle, which occurs by 3 months after childbirth, to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
A Muslim couple has given birth to a baby girl. After the baby is assessed the nurse goes to talk with the father. The nurse puts his hand on his shoulder and states, "come over and look at your new baby girl." The father immediately pulls away from the nurse and refuses to go with her. The nurse understands that this action is due to the father being A. Upset that the baby is a girl B. Offended by being touched by the female nurse C. Addressed by anyone other than the physician D. Concerned about the well being of his wife
Answer: B Rationale: in some cultures, touching by other women other than the wife is offensive to men.
A nurse is caring for a client in labor. Which observation should the nurse indicate as being an accurate assessment? A. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. B. Having the woman point her toes reduces leg cramps. C. The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. D. The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions.
Answer: C Rational: "In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second-stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself"
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description should a nurse indicate as being accurate with regard to the phases of the first stage of labor? A. Lull: no contractions; dilation stable; duration of 20 to 60 minutes B. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours C. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours D. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours
Answer: C Rationale: "The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes"
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? A. Document the findings. B. Elevate the client's legs. C. Massage the fundus until it is firm. D. Push on the uterus to assist in expressing clots.
Answer: C Rationale: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires the following isolation: A. Reverse isolation B. Airborne isolation C. Contact precautions D. Standard precautions
Answer: C Rationale: RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.
Veronica's parents were told that their daughter needs ribavirin (Virazole). This drug is used to treat which of the following? A. Cystic fibrosis B. Otitis media C. Respiratory syncytial virus (RSV) D. Bronchitis
Answer: C Rationale: Ribavirin is an antiviral medication used for treating RSV infection and for children with RSV who are compromised (such as children with bronchopulmonary dysplasia or heart disease).
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? A. Apply gentle pressure. B. Reinforce the dressing. C. Document the findings. D. Contact the primary health care provider (PHCP).
Answer: C Rationale: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the PHCP. Because the findings identified in the question are normal, the nurse would document the assessment findings.
When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth. B. Exhibit a reduced attention span, limiting readiness to learn. C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D. Have re-established her role as a spouse/partner.
Answer: C Rationale: Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long as 4-5 weeks after birth. The woman starts to initiate actions on her own and makes decisions without relying on others. Allow the woman to settle in gradually into her new role while still at the hospital or healthcare facility because decisions about the child's welfare are a difficult part of motherhood.
Michael Harrison is a 65-year-old man with type 2 diabetes. He has presented to the emergency department complaining of headache, fatigue, muscle aches, and fever. Mr. Harrison's symptoms resemble the flu. Which form of pneumonia does Mr. Harrison's nurse suspect he has? A. Walking pneumonia B. Primary atypical pneumonia C. Viral pneumonia D. Aspiration pneumonia
Answer: C. Viral pneumonia Rationale: Because Mr. Harrison is an older adult and has diabetes, he could have viral pneumonia, which affects older adults and those with chronic illnesses. His flu-like symptoms of headache, fatigue, muscle aches, and fever are all symptoms of viral pneumonia. Mr. Harrison does not show symptoms of aspiration pneumonia, whose symptoms include pulmonary edema and respiratory failure. Although fever and headache are symptoms of primary atypical pneumonia, it is unlikely that Mr. Harrison has this disease. Primary atypical pneumonia affects young adults, and Mr. Harrison is an older adult. Walking pneumonia is simply another name for primary atypical pneumonia, which Mr. Harrison is unlikely to have.
A nurse is caring for a patient in labor. Which observation by the nurse would indicate that the second stage of labor, the descent phase, has begun? A. The presenting part is below the ischial spines. B. The amniotic membranes rupture. C. The woman experiences a strong urge to bear down. D. The cervix cannot be felt during a vaginal examination.
Answer: D Rational: "The second stage of labor begins with full cervical dilation. During the active pushing phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as at 5 cm dilation"
A nurse is working with a client in the second stage of labor. Which position would the nurse suggest if the pelvic outlet needs to be increased? A. Semi recumbent B. Side-lying C. Sitting D. Squatting
Answer: D Rationale: "Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. Sitting may assist with fetal descent, but like a semi recumbent or side-lying position, it does not increase the size of the pelvic outlet"
The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? A. "I should increase my sodium intake during pregnancy." B. "I should lower my blood volume by limiting my fluids." C. "I should maintain a low-calorie diet to prevent any weight gain." D. "I should drink adequate fluids and increase any intake of high-fiber foods."
Answer: D Rationale: Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A. Protects the newborn's eyes from possible infections acquired while hospitalized. B. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. C. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. D. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
Answer: D Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options a, b, and c are not the purposes for administering this medication to a newborn infant.
The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention with the plan of care? A. Allow the newborn to establish its own sleep-rest pattern. B. Maintain the newborn in a brightly lighted area of the nursery. C. Encourage the frequent handling of the newborn by staff and parents. D. Monitor the newborn's response to feedings and weight gain pattern.
Answer: D Rationale: Fetal alcohol syndrome, a diagnostic category of fetal alcohol syndrome disorders (FASDs), is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after birth. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options a, b, and c and inappropriate interventions
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? A. Initiate an intravenous line. B. Assess the client's blood pressure. C. Prepare to administer morphine sulfate. D. Administer oxygen, 8 to 10 L/minute, by face mask.
Answer: D Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? A. Document the finding. B. Encourage the client to ambulate. C. Encourage the client to increase fluid intake. D. Contact the physician (OB) and inform them of this finding.
Answer: D Rationale: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.
The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? A. "Your newborn needs the medicine to develop immunity." B. "The medicine will protect your newborn from being jaundiced." C. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." D. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
Answer: D Rationale: Phytonadione is necessary for the body to synthesize coagulation factors. It is administered to the newborn to prevent bleeding disorders. It also promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary to synthesize fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
The nurse is providing a 68-year-old client with health promotion activities. Which vaccine will the nurse recommend for the prevention of bacterial pneumonia? A. Meningococcal vaccine B. Flu vaccine C. Tetanus, diphtheria, and pertussis vaccine (TDAP) D. Pneumococcal vaccine
Answer: D Rationale: Pneumococcal vaccine is for all adults 65+ years old and with certain medical conditions
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? a. iron b. iodine c. aspirin d. penicillin
Answer: b Rationale: The provider will usually use an iodine-based contrast to perform this procedure. Therefore, it is imperative to know whether the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.
A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is most clearly indicative of a myocardial infarction (MI). a. CK-MB b. Troponin c. Myoglobin d. c-reactive protein
Answer: b Rationale: Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1.Report of frequent insomnia 2.Development of expiratory wheezes 3.A baseline blood pressure of 150/80 Hg followed by a blood pressure of 138/72 Hg after 2 doses of the medication 4. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after 2 doses of the medication
Answer:2 Strategy: Focus on the subject, a potential adverse complication. Eliminate options indicating a decrease in blood pressure and a decrease in heart rate first, because these are expected effects from the medication. Next, focusing on the subject will direct you to the correct option.
IV heparin therapy is prescribed for a client with A-Fib. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1.Vitamin 2.Protamine sulfate 3.Potassium chloride 4.Aminocaproic acid
Answer:2 Strategy: Focus on the subject, the antidote for heparin. Knowledge regarding the various antidotes is needed to answer this question. Remember that the antidote to heparin is protamine sulfate.
A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1.Monitor for kidney failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4, Have heparin sodium available.
Answer:3 Strategy: Note the strategic word priority. Remember that bleeding is a priority for thrombolytic medications.
The nurse provides discharge instructions to a client with A-Fib who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1. "I will avoid alcohol consumption." 2. "I will take my pills every day at the same time." 3. "I have already called my family to pick up a Medic Alert bracelet." 4. "I will take coated aspirin for my headaches because it will coat my stomach."
Answer:4 Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that warfarin is an anticoagulant and that coated aspirin is an aspirin-containing product will direct you to the correct option.
What type of pain is short and self-limiting and dissipates after the injury heals? A. Acute B. Persistent C. Chronic D. Breakthrough
Correct Answer : A. Acute Rationale: Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after the injury heals. Chronic pain lasts 6 months or longer; the pain persists after the predicted trajectory. Persistent pain is another term for chronic pain. Breakthrough pain starts again or escalates before the next scheduled analgesic dose.
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? A. Addressing the pain B. Reversing feelings of hopelessness C. Promoting mobility in the residual limb D. Acknowledging the grieving for the loss of limb
Correct Answer: A. Addressing the pain Rationale: Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There is no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There is no data indicating that the client is grieving.
Nociceptors are: A. Free nerve endings that convert chemical and physical stimuli into action potentials that must travel to the brain, via the spinal cord, to be activated. B. Pressure sensitive receptors found in the vessel walls of nearly all large arteries in the head and neck. C. Sensory receptors that receive stimuli from the body in response to position and movement. D. Sensory receptors that monitor changes in blood levels of carbon dioxide and oxygen.
Correct Answer: A. Free nerve endings that convert chemical and physical stimuli into action potentials that must travel to the brain, via the spinal cord, to be activated. Rationale: Answer choice B describes baroreceptors. Answer choice C describes proprioceptors. Answer choice D describes chemoreceptors.
Fast traveling sensory fibers are: A. Myelinated B. Proprioceptors C. Unmyelinated D. Nociceptors
Correct Answer: A. Myelinated. Rationale: Myelination makes for the faster transmission of impulses.
According to the gate control theory of pain: A. Only one sensation at a time is allowed to pass through to the brain. B. Noxious stimuli travel along small diameter nerve fibers only. C. The brain is unable to collect and integrate sensory input from multiple sources D. The stimulus cell determines which impulses continue up or down the spinal cord.
Correct Answer: A. Only one sensation at a time is allowed to pass through to the brain. Rationale: When a large volume of non-painful stimuli are competing for the gate, pain impulses may be blocked. A high volume of pain, however, may override other stimuli and pass through the gate, causing the individual to perceive the pain.
A patient with colorectal cancer has continuous, poorly localized abdominal pain at an intensity of 5 on a scale of 0 to 10. How does the nurse teach the patient to use pain medications? A. On an around-the-clock schedule B. As often as necessary to keep the pain controlled C. By alternating two different types of drugs to prevent tolerance D. When the pain cannot be controlled with distraction or relaxation
Correct answer: A. On an around-the-clock schedule Rationale: Analgesics should be scheduled around the clock for patients with constant pain to prevent pain from escalating and becoming difficult to relieve. If pain control is not adequate, the analgesic dose may be increased or an adjunctive drug may be added to the treatment plan.
Neuropathic pain implies an abnormal? A. Processing of the pain message B. Degree of pain interpretation C. Modulation of pain signals D. Transmission of pain signals
Correct answer: A. Processing of the pain message Rationale: Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? A. Document the findings. B. Attempt to arouse the client. C. Contact the primary health care provider (PHCP) immediately. D. Check the medication administration history on the PCA pump.
Correct Answer: B. Attempt to arouse the client. Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused, because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should contact the PHCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.
The gate control theory concludes that pain transmission is controlled by a gate mechanism in the: A. Autonomic nervous system (ANS). B. Central nervous system (CNS). C. Sympathetic nervous system (SNS). D. Parasympathetic nervous system (PNS).
Correct Answer: B. Central Nervous System Rationale: The gate control theory (GCT) explains that a balance of impulses conducted to the spinal cord, where cells in the substantia gelatinosa function as a spinal gate, regulates pain transmission to higher centers in the CNS.
How can a nurse best soothe a hospitalized infant who appears to be in pain? A. Feeding the infant B. Holding the infant C. Playing soft music in the room D. Providing a quiet environment
Correct Answer: B. Holding the infant Rationale: Physical contact provides security for a distressed infant. Feeding to provide comfort is not always an option because the infant may have been fed recently, may be anorexic, or may be on nothing-by-mouth status. Music or a quiet environment may not always have a calming influence; often infants are not aware of the environment.
The posterior nerve roots (dorsal roots) of the spinal cord are where: A. Interneurons synapse with neurotransmitters to initiate action potentials B. Most afferent sensory pain fibers enter the spinal cord. C. Prostaglandins sensitize nociceptors with repeated stimulation, so that small sensory stimuli will cause a big pain response. D. All of the above
Correct Answer: B. Most afferent sensory pain fibers enter the spinal cord at the posterior nerve roots. Rationale: Choices A & C are red herrings designed to feel as if they could be correct. Choice D plays on the red herring effect by encouraging the test taker to emotionally select all of the answers that feel correct.
Which client assessment finding should the nurse document as subjective data? A. A. Blood pressure 120/82 beats/min B. B. Pain rating of 5 C. C. Potassium 4.0 mEq D. D. Pulse oximetry reading of 96%
Correct Answer: B. Pain rating of 5 Rationale: Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.
Neuropathic pain implies an abnormal: A. Degree of pain interpretation. B. Processing of the pain message. C. Transmission of pain signals. D. Modulation of pain signals.
Correct Answer: B. Processing of the pain message. Rationale: Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient's heel. During care of the ulcer, what is the nurse's understanding of the patient's perception of pain? A. The patient will have a behavioral response if pain is perceived. B. The area should be treated as a painful lesion, using gentle cleansing and dressing. C. The area can be thoroughly scrubbed because the patient is not able to perceive pain. D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain
Correct Answer: B. The area should be treated as a painful lesion, using gentle cleansing and dressing. Rationale: It is known that the brain is necessary for pain perception but because it is not clearly understood where in the brain pain is perceived, pain may be perceived even in a comatose patient who may not respond behaviorally to noxious stimuli. Any noxious stimulus should be treated as potentially painful.
A client with dementia is admitted with a fractured hip after a fall at home. The client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. What does the nurse conclude? A. The client has the need to go to the bathroom B. The client may be in pain and unable to respond appropriately C. The family member may be trying to keep the client overmedicated D. The family member feels guilty about the fall and wants to keep the client pain free
Correct Answer: B. The client may be in pain and unable to respond appropriately Rationale: The client's dementia indicates that the client has problems with thought processes and may not be able to interpret or communicate the presence of pain. An increased blood pressure, caused by central nervous system stimulation, and pulling on the bedclothes suggest that the client is in pain. The client may have a need to go to the bathroom, but is more likely that the client has pain that he or she is unable to communicate. There is not evidence that the family member wants the client overmedicated or has feelings of guilt.
The nurse is caring for a 56 year old female with persistent nociceptive pain. Which intervention will be most effective during the perception phase of pain? A. Ask the physician if opioid medications could be prescribed when the pain becomes severe. B. Determine what the patient's signs of pain are and if she is expressing pain. C. Engage in conversation about the patient's family, hobbies, and plans once she is discharged from the hospital. D. No intervention is required at this stage of the pain process.
Correct Answer: C. Engage in conversation about the patient's family, hobbies, and plans once she is discharged from the hospital. Rationale: During the perception phase, distractions are effective for relieving pain without the use of medications. Pain tolerance is affected by environment and other modifiable factors.
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? A. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." B. "I know that I should follow up after giving medication to make sure it is effective." C. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." D. "I know that pain in the older client might manifest as sleep disturbances or depression."
Correct Answer: C. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by clients in other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population.
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? A. Bed rest B. Ibuprofen C. Bending or lifting D. Application of heat
Correct Answer: C. Bending or lifting Rationale: Low back pain that radiates down 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.
Important chemical mediators involved in the transduction of pain are: A. Calcium and Magnesium B. Iron and Sodium C. Histamine and Substance P D. None of the above
Correct Answer: C. Histamine and Substance P Rationale: Of the answer choices, only histamine and substance P are involved in the chemical transduction of pain. The other choices do not even make sense.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? A. Infection under the cast B The anxiety of the client C. Impaired tissue perfusion D. The recent occurrence of the fracture
Correct Answer: C. Impaired tissue perfusion Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the primary health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.
The nurse explains the difference between pain threshold and pain tolerance. Which statement about pain tolerance is true? A. Pain tolerance is the point where the first sensation of pain is perceived. B. Pain tolerance is similar from one individual to another. C. Pain tolerance is the point where pharmacological intervention is required. D. Pain tolerance is the point where an individual will seek relief from pain.
Correct Answer: D. Pain tolerance is the point where an individual will seek relief from pain. Rationale: Pharmacological intervention is one way to seek relief from pain but it is not required. There are many therapeutic ways to seek relief from pain. The other options are true of pain threshold.
BM is a sixty-five-year-old male presenting with a burning pain in his lower back. BM does not recall any specific event where he might have caused an injury to his lower back. BM states that the pain occurs whenever he moves, and that on a scale of 0-10 his pain is a 9. What type of sensory fibers are involved in the transmission of pain signals to BM's brain? A. Efferent unmyelinated C fibers B. Afferent myelinated Aδ fibers C. Efferent myelinated C fibers D. Afferent unmyelinated C fibers
Correct Answer: D. Afferent unmyelinated C fibers. Rationale: All C fibers are unmyelinated. C fibers are responsible for the majority of pain transmission and result in a dull, burning, or aching sensation.
The nurse is caring for a client with terminal cancer. The nurse should consider which factor when planning pain relief? A. Not all pain is real. B. Opioid analgesics are highly addictive. C. Opioid analgesics can cause tachycardia D. Around-the-clock dosing gives better pain relief than as-needed dosing.
Correct Answer: D. Around-the-clock dosing gives better pain relief than as-needed dosing. Rationale: Pain is what the client describes it as, and any indication of pain should be perceived as real for the client. Opioid analgesics may be addictive, but this is not a concern for a client with terminal cancer. Not all opioid analgesics cause tachycardia. Remember to focus on what the question is asking.
After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be? A. Notify the primary healthcare provider B. Use distraction techniques C. Medicate the client as prescribed D. Perform a complete pain assessment
Correct Answer: D. Perform a complete pain assessment Rationale: A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be caused by neurovascular trauma to the affected leg, and the intervention for each is different. Notifying the primary healthcare provider, using distraction techniques, and medicating the client as prescribed may be done after a complete assessment reveals that this is the appropriate intervention; assessment is the priority.
Which of the following is the most reliable indicator for chronic pain? A. Blood drug levels B. Patient self-report C. Magnetic resonance imaging (MRI) results D. Tissue enzyme levels
Correct answer: B. Patient self-report Rationale: The most important and reliable indicator for chronic pain is the patient's self-report. Chronic pain is transmitted on a cellular level, and current technology such as MRI, tissue enzyme levels, or blood drug levels cannot reliably detect this process.
A patient with multiple injuries resulting from an automobile accident tells the nurse that he has "bad" pain but that he can "tough it out" and does not require pain medication. To gain the patient's participation in pain management, what should the nurse explain to the patient? A. Patients have a responsibility to keep the nurse informed about their pain. B. Unrelieved pain has many harmful effects on the body that can impair recovery. C. Using pain medications rarely leads to addiction when they are used for actual pain. D. Nonpharmacologic therapies can be used to relieve his pain if he is afraid to use pain medications.
Correct answer: B. Unrelieved pain has many harmful effects on the body that can impair recovery. Rationale: When a patient wants to be stoic about pain, it is important that he or she understands that pain itself can have harmful physiologic effects and that failure to report pain and participate in its control can result in severe unrelieved pain. No evidence indicates fear of taking the medication is present in this situation.
On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse's action have on the patient? A. Protects the patient from addiction and toxic effects of the drug B. Prevents hastening or causing a patient's death from respiratory dysfunction C. Contributes to unnecessary suffering and physical and psychosocial dysfunction D. Indicates that the nurse understands the adage of "start low and go slow" in administering analgesics
Correct answer: C. Contributes to unnecessary suffering and physical and psychosocial dysfunction Rationale: Administering the smallest prescribed analgesic dose when given a choice is not consistent with current pain management guidelines and leads to undertreatment of pain and inadequate pain control. Without reassessing the pain within 30 minutes of the IV analgesic the nurse is unsure how well the previous dose of medication worked for the patient to determine the current dose needed. Unnecessary suffering, impaired recovery from acute illness, increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, and other physical dysfunction can occur.
Which assessment is of highest priority for the nurse to complete before administration of morphine? A. Pain rating B. Blood pressure C. Respiratory rate D. Level of consciousness
Correct answer: C. Respiratory rate Rationale: A decreased respiratory rate below 12/min is a sign of opioid toxicity.
Pain signals are carried to the central nervous system by way of A. Perception B. Modulation C. Referred pain D. Afferent pain
Correct answer: D. Afferent pain. Rationale: Nociceptors carry the pain signal to the CNS by two primary sensory (or afferent) fibers. Perception indicates the conscious awareness of painful sensations. Modulation inhibits the pain message producing an analgesic effect. Referred pain is pain felt at a particular site that originates from another location.
What is the source of deep somatic pain? A. Pancreas B. Intestine C. Skin and subcutaneous tissues D. Bones and joints
Correct answer: D. Bones and joints Rationale: Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas and intestines.
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia? A. Aspiration pneumonia B. Ventilator acquired pneumonia C. Hospital-acquired pneumonia D. Community-acquired pneumonia
The answer is C. The key words to let you know this is hospital-acquired pneumonia and NOT community-acquired is that the patient was admitted with a gunshot wound AND has been hospitalized for 48 hours. If the patient presents with signs and symptoms of pneumonia 48-72 hours after admission it is classified as hospital-acquired. This is not a ventilator acquired because the patient is not on mechanical ventilation and there is nothing in the scenario that leads us to think it is aspiration pneumonia.
You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device? A. Encourage the patient to use it twice a day. B. The patient exhales into the device rapidly and then coughs. C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales. D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
The answer is C. The patient will inhale slowly from the device until no longer able, and then hold breath for 6 seconds and exhale. The patient should use the device at least 10 times every 1-2 hours while awake. The other options are incorrect ways to use the device.
Which person would the nurse identify as having the highest risk for coronary artery disease (CAD)? a. A 60-yr-old man with low homocysteine levels b. A 45-yr-old man with a high-stress job who is depressed c. A 54-yr-old woman vegetarian with increased high-density lipoprotein (HDL) levels A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2
b Rationale: The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.
In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? a. "What precipitated the pain?" b. "Has the pain changed this time?" c. "In what areas did you feel this pain?" d. "What is your pain level on a scale from 0-10?"
c Rationale: Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.
A female patient with type 1 diabetes has chronic stable angina controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. What goal should the nurse use in planning care to prevent cardiovascular disease progression? a. Exercise almost every day. b. Avoid saturated fat intake. c. Limit calories to daily limit. d. Keep Hgb A1C less than 7%.
d Rationale: If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.
