Exam 2

The nurse correctly describes psychosocial theories on aging as theories that:

Describe role changes in behaviors in older adults.

A 64-year-old quadriplegic patient needs an IM injection of antibiotic. What is the best site for the administration?

Vastus Lateralis

A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. What finding indicates that the child needs further assessment?

Weight of 16 pounds.

A nursing student is asked to compare major life events of young adult, middle adult, and childbearing families. Which statement by the student demonstrates understanding?

When married people both work, income is increased, but so is stress.

An adult male reports new-onset seizurelike activity. An EEG and a neurology consultants report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurses next best action would be to:

Obtain history of any recent life stressors.

The nursing student correctly explains health promotion teaching points for parents of toddlers when she states:

Setting consistent, firm limits will help the child cope with the frustration of learning self-control.

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply)

- Determine client understanding several times during the conversation. - Use lay terms if possible. - Do not interrupt the interpreter and the family as they talk.

A nurse is teaching the parents of a toddler about disclipine. Which of the following actions should the nurse suggest?

- Establish consistent boundaries for the toddler.

When providing prenatal care, what information does the nurse expect to provide? (Select all that apply.)

- Protecting against urinary infection. - Exercise patterns. - Proper diet

Which of the following are methods to reduce the risk of needlestick injury? (Select all that apply.)

- Have sharps boxes emptied when three-quarters full. - Never force a needle into the sharps disposal. - Clearly mark sharps disposal containers. - Use needleless devices whenever possible.

A nurse is talking with the guardian of a 4-year-old child who reports that the child is waking up at night with nightmares. Which of the following interventions should the nurse suggest?

- Have the child go to bed at a consistent time every day.

A nurse is reviewing salary measures with the patient with the parent of an 8-month-old infant. Which of the following statements by the parents indicates an understanding of safety for the infant?

- My baby loved to play with the crib gym, but I took it out of the crib.

What do changing norms and values about family life in the United States reveal?

Basic shifts in attitudes in our society

A nurse is talking with guardians who are concerned about several issues with their preschooler. Which of the following issues should the nurse identify as the priority?

- My child has temper tantrums every time we tell them to do something they don't want us to do.

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care on these clients?

- The same religious beliefs can influence individuals differently.

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category?

Preadolescence

The nurse and the patient have the same religious affiliation. Because of this, the nurse:

Should not impose her personal values on the patient.

Normal physical findings in a healthy newborn include:

Sporadic motor movements

A terminally ill patient is experiencing constipation secondary to pain medication. What is the best way for the nurse to improve the patients constipation problem?

Use a stimulant laxative and increase fluid intake.

The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?

Withdraw the needle and prepare the injection again.

A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include?

- Position the car seat so that the infant is rear-facing.

A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms? (Select all that apply)

- Tremors - Acute dystonia - Restlessness

A charge nurse is explaining to various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?

- Devoting time to establishing an occupation.

A nurse is reviewing a clients medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine the nurse should identify that this combination is likely to result in which of the following effects?

- Increased risk of imipramine toxicity.

The nurse is caring for a patient who is in the final stages of his terminal disease. The patient is very weak but refuses to use a bedpan, and wants to get up to use the bedside commode. What should the nurse do?

Enlist assistance from family members if possible and assist the patient to get up.

The nurse knows that the purpose of aspiration on IM injections is to:

Ensure proper placement of the needle.

The nurse can identify that which hormones are the likely causes of the abnormal vital signs?

Epinephrine and norepinephrine

In caring for the patients spiritual needs, the nurse understands that:

Establishing presence is part of the art of nursing.

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hour. The clients family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?

- Decreased muscle tone.

In discussing spiritual well-being, the nurse identifies that the vertical dimension involves:

The transcendent relationship between a person and God.

Which of these manifestations, if identified in a school-aged child during a routine assessment, should a nurse associate with a possible developmental delay or problem?

Withdrawn demeanor and verbalizes that he has no friends.

A nurse is attempting to administer medication to a child, but the child refuses to take the medication. The nurse asks for the parents cooperation by saying:

I will prepare the medication for you and observe if you would like to try to administer the medication.

Spiritual distress has been identified in a patient who has been diagnosed with AIDS. Upon evaluating the following interventions, which are appropriate for the diagnosis of Spiritual distress? (Select all that apply.)

- Develop activities to heal body, mind, and spirit. - Offer to pray with the patient. - Teach relaxation, guided imagery, and meditation.

A nurse is reviewing a clients prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply)

- A once-daily multivitamin. - A subcutaneous injection prescribed once weekly.

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the clients vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaption syndrome (GAS)?

- Alarm stage

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply)

- Allow the client to provide input in the treatment plan. - Assist the client with time management, and address the client's priorities. - Encourage the client in the expression of feelings and concerns.

A nurse is orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process?

- Another nurse should listen to the phone call.

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply)

- Apply fresh linens and place a clean gown on the body. - Remove all equimpment from the bedside. - Dim the lights in the room.

A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply)

- Assembling puzzles. - Using musical toys. - Playing with puppets. - Coloring with crayons.

A nurse is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make?

- At this age, children tend to become modest and value their privacy.

A nurse is caring for a client who has stage iV lung cancer and is 3 days postoperative following a wedge resection. The client states "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Lubber-Ross model, which stage of Grieg is the client experiencing?

- Bargaining

A nurse is planning diversionary activities for a school-aged children on an inpatient pediatric unit Which of the following activities should the nurse include? (Select all that apply)

- Building models. - Playing video games. - Reading books. - Playing board games.

A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?

- Convening a family meeting.

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply)

- Decreased height - Nail thickening - Decreased bladder capacity

A nurse knows that patient education has been effective when the patient states:

I will rotate the location where I give myself injections.

A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and not feeling well. The nurse notes warmth, edema, induration, and red streaking on the clients arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

- Discontinue the infusion.

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lbs) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

- Eat foods that are easy to eat, such as finger foods. - Invite family members to eat meals with you. - Exercise everyday to increase appetite.

A recently widowed 80-year-old male is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. The nurses best action is to assess the patient for which of the following reversible causes? (Select all that apply.)

- Electrolyte imbalance. - Hypoglycemia - Drug effects - Cerebral anoxia

A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first?

- Enlargement of the testes and scrotum.

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

- Ensure no visitors or staff enter the room for a short period of time.

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply)

- Eye examination every 1-3 years. - DXA screening for osteoporosis. - Increase intake of carbohydrates in the diet. - Screening for depressive disorders.

A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply)

- Filling and emptying containers. - Playing with blocks. - Looking at books.

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?

- Flush the tube before and after each medication.

A nurse is an outpatient clinical is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

- Get up and change positions slowly.

A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medicines? (Select all that apply)

- Have the guardians bring in a favorite toy from home. - Engage the child in pretend play with a toy medical kit.

A nurse is counseling a young adult who is describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

- I don't even know who I am yet, and now I'm supposed to know what to do.

A nurse is caring for a client receiving dextrose 5% in 0/9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to feel suspect fluid overload? (Select all that apply)

- I feel as though my heart is racing. - I feel a little short of breath. - The nurse technician told me that my blood pressure was 150/90.

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client?

- I will ask the client if they want to schedule some times to pray during the day.

A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

- I will eat two crackers with the pain pills.

A nurse is teaching an adult client wow to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

- I will gently apply pressure with my finger to the front part of my ear after putting in the drops.

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration invites understanding of the procedure?

- I will insert the needle into the clients skin at an angle of 10-30 degrees with the bevel up.

A nurse educator is teaching newly licensed nurses about safe medication administration.. Which of the following statements indicates understanding? (Select all that apply)

- I will observe for adverse effects. - I will monitor for therapeutic effects. - I will refuse to give a medication if I believe it is unsafe.

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?

- I will replace any IV catheter when I suspect contamination during insertion.

A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?

- I'll give my son about 2 tablespoons of each food at mealtime.

A nurse is an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurses priority?

- Identifying the clients medication allergies.

A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply)

- Immature liver. - Higher body water content. - Increased absorption of topical medications.

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply)

- Increase protein intake to increase muscle mass. - Increase calcium intake to prevent osteoporosis. - Limit sodum intake to precent edema. - Increase fiber intake to prevent constipation.

A client in a provider's office tells the nurse that "I fast for several days each week to help control my weight." The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity?

- Increasing the protein-binding response.

A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following examples should the charge nurse include as a developmental task for a young adult?

- Influenza - Pertussis - Tetanus

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

- It has been so stressful for me to think about having intimate relationships.

A nurse is caring for a client who tells the nurse that based on religious values and mandates a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

- Lets discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.

The mother of a 7-month-old infant tells the nurse at the pediatric clinical that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (Select all that apply)

- Lets make a list of the foods your baby is eating so we can spot any problems. - Did the changes begin after you started one particular food? - Has your baby been vomiting since starting these new foods?

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply)

- Metabolism - Gastric secretions - Glomerular filtration

A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the clients medication administration record, which of the following medications should the nurse administer?

- Morphine 2mg IV

A nurse is preparing a wellness presentation for families about health screening for adolescents Which of the following information should the nurse include? (Select all that apply)

- Obtain a periodic mental status evaluation. - Discuss prevention of sexually transmitted infections. - Regularly screen for tuberculosis. - Provide education about drug and alcohol use.

A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?

- Offer to assist the client who needs the bedpan.

To promote adherence with medication self‑administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply)

- Place pills in daily pill holders. - Ask for lucid forms if the client has difficulty swallowing pills. - Ask a relative to assist periodically.

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply)

- Pneumococcal immunization - Yearly eye examination - Periodic mental health screening - Annual fecal occult blood test

A nurse is planning a health promotion and primary prevention class for the caregivers of school-age children. Which of the following actions should the nurse plan to take? (Select all that apply)

- Provide information about the risk of childhood obesity. - Discuss the danger os substance use disorders. - Promote discussion about sexual issues. - Reinforces stranger awareness.

What are the most common life events that occur during young adulthood? (Select all that apply.)

- Refining self-perception and ability for intimacy. - Achievement and mastery of the surrounding world. - Examination of life goals and relationships.

When evaluating a patients risk for spiritual crises, which of the following are part of the evaluation process? (Select all that apply.)

- Review the patients self-perception regarding spiritual health. - Review the patients view of his/her purpose in life. - Discuss with family and associates the patients connectedness. - Ask whether the patients expectations are being met.

A nurse is caring for a client who. has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem?

- Role conflict

A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply)

- Rolls from front to back. - Bears weight on legs. - Sits unsupported.

A nurse is reviewing a clients health record notes a new prescription for lisinopril 10 mg PO once everyday. The nurse should identify this as which of the following types of prescription?

- Routine

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take?

- Select a site on the client's abdomen.

The nurse should instruct the parents of an adolescent about which of the following health concerns? (Select all that apply.)

- Signs of substance abuse - Suicide prevention - Safe sex practices - Pregnancy

A nurse is assessing a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect?

- Sleeps 14-16 hours each day. - Hands remain in a closed position. - Current weight same as birth weight.

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply)

- Spend time focusing on improving job performance. - Welcome opportunities to be creative and productive. - Become involved with community issues and activities.

A nurse is giving a prescription about accident prevention to a group parents to toddlers. Which of the following accident prevention strategies should the nurse include? (Select all that apply)

- Store toxic agents in locked cabinets. - Turn pot handles towards the back of the stove. - Place safety gates across stairways.

A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply)

- Suggest that the guardians bring in video games to play. - Provide a television and watch movies for the adolescent to watch. - Involve the adolescent in treatment decisions when possible. - Allow the adolescent to perform morning self-care.

A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk?

- Take each dose right after breastfeeding.

A nurse is teaching a client who has a new prescription for oxybutynin about managing the medications anticholingeric effect. Which of the following instructions should the nurse include? (Select all that apply)

- Take sips of water frequency. - Wear sunglasses when outdoors in sunlight. - Urinate prior to taking the medication.

A nurse is caring for a client who has terminal lung cancer. The nurse observes the clients family assisting with all ADL's. Which of the following rationales for self-care should the nurse communicate with the family?

- The clients sense of loss can be lessened through retaining control of some aspects in life.

Nurses need to provide competent care to young and middle adult patients. Why must nurses be knowledgeable about developmental theories to care for this group? (Select all that apply.)

- These theories provide nurses with a basis for understanding the life events and developmental tasks of young and middle adults. - Patients present challenges to nurses, who themselves are often young or middle adults coping with the demands of their respective developmental period. - Nurses need to recognize the needs of their patients even if they are not experiencing the same challenges and events.

A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the mother tries to help them get dressed. The nurse should recognize the toddle is manifesting which of the following stages of development?

- Trying to increase her independence.

A nurse is reviewing the CDC's immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply)

- Varicella - Human papilloma virus - Seasonal influenza

A nurse is reviewing the Centers for Disease Control and Prevention immunization recommendations with the aurdians of preschooler's. Which of the following vaccines should the nurse include in the discussion? (Select all that apply)

- Varicella - Polio - Seasonal influenza

A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?

- We just don't understand why our child can't just keep up with the one other kids in simple activities like running or jumping.

A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child Which of the following statements should indicate to the nurse an understanding of the teaching?

- We reward school achievements with a point system instead of pizza or ice cream.

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply)

- Wear a helmet while skiing. - Install a carbon monoxide detector. - Secure firearms in a safe location.

A nurse is consoling the partner of a client who just died after a long term battle with liver cancer. The grieving partner states "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply)

- Would you like me to contact the chaplain to come and speak with you? - You know, it is quite normal to feel anger toward your loved one at this time. - Tell me more about how you are feeling.

A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states "How could you possibly understand what I am going through?" Which of the following responses should the nurse make?

- You are right. I cannot really understand. Perhaps you can tell me more about how you are feeling.

A nurse in an outpatient clinic is teaching a client who is in the first trimester of pregnancy. Which of the following statements should the nurse make?

- Your provider can prescribe medication for nausea if you need it.

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

-I keep forgetting which medications I have taken during the day.

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply)

-The temperature around the IV site is cooler. - The IV dressing is damp. - The tissue around the venipuncture site is swollen.

A patient has an order to receive 20 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse draw up in the syringe and administer?

0.4 mL

The patient is to receive phenytoin (Dilantin) at 0900. The nurse knows that the ideal time to draw a trough level is:

0830

The nurse is planning to administer a tuberculin test with a 27-gauge, 3/8-inch needle. The nurse should insert the needle at an angle of _____ degrees:

15

A physician orders 1000 mL of normal saline to infuse at a rate of 50 mL/hr. The nurse plans on hanging a new bag at what time?

20 Hours

A patient has an order to receive 10 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse draw up in the syringe and administer?

20 Units

The nurse is preparing to administer a 0.5-mL rabies vaccine into the deltoid muscle of a patient. Which needle size is best for the procedure?

25 gauge 5/8 inch

Which patient using an inhaler would benefit most from using a spacer?

25-year-old with multiple sclerosis

A patient who is being discharged today is going home with an inhaler. The patient is to administer 2 puffs of his inhaler twice daily. The inhaler contains 200 puffs. When should the nurse appropriately advise the patient to refill his medication?

6 weeks from the start of using the inhaler

Aspirin is an analgesic, antipyretic, antiplatelet, and anti-inflammatory agent. A physician writes for aspirin 650 mg every 4 to 6 hours prn: febrile. For which patient would this order be appropriate?

62 year old female with pneumonia.

The nurse realizes which patient is at greatest risk for an unintended synergistic effect?

72-year-old who is seeing four different specialists

A dying patient with liver and renal failure requires pain medication. The nurse anticipates that the medication dose will be:

A decreased dose from milligrams per kilogram levels.

During infant/child development, play is best recognized as:

A means to interact with the environment and relate to others.

A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. When discussing health care services and possible long-term living arrangements with the patients only son, what should the nurse suggest?

A nursing center because home care is no longer safe

A nurse encounters a family that experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their childs death. The nurse spends time with them discussing their childs life and death. The nurses action best demonstrates which nursing principle?

Facilitating normal mourning

The nurse knows that an idiosyncratic event with the stimulant pseudoephedrine (Sudafed) is occurring when the patient:

Falls asleep during daily activities.

An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture?

Family members stay with the body until burial the next day.

In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. This plan of care would include:

Female health care workers care for the body after death has occurred.

The nurse knows that a subcutaneous injection takes longer to absorb because:

Fewer blood vessels are found under the subcutaneous level.

When describing relevant family psychosocial factors in middle adulthood that cause stress, the nurse would not include:

Financial security and certainty.

A patients states that she would prefer not to take her daily allergy pill this morning because it makes her too drowsy throughout the day. The nurse responds therapeutically by saying:

Lets change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping.

Validation of a dying persons life would be demonstrated by which nursing action?

Listening to family stories about the person

When communicating with a newly admitted teenaged patient, the nurse should:

Observe for congruency between the patients facial expressions and verbal responses.

A young adults chief complaint is seizure fits. A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young mans pseudo-seizures most likely are an example of which unconscious coping mechanism?

Conversion

When comparing developmental tasks of middle-aged persons versus older adults, what should the nurse infer?

All older adults will need nursing assistance to deal with loss.

The patient is in the intensive care unit (ICU), which has strict posted visiting hours and limits the number of visitors to two per patient at any one time. The patient is asking to see his wife and two daughters. The nurse should:

Allow the wife and daughters to visit at the patients request.

During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kbler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying?

Anger

A correctional facility nurse is called to the scene of a deceased inmate. The correction officer wants to quickly move the body to the funeral home because he is not comfortable with death. The inmates body will need to be transported where?

Coroners office for an autopsy

A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patients peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurses initial action?

Apply a cool compress to the site.

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements:

Are reasonable

A trauma survivor is requesting sleep medication because of bad dreams. Concerned about posttraumatic stress disorder, the nurse asks

Are you reliving your trauma?

Which teaching strategy is best to utilize with older adult patients?

Ask patients to recall past experiences that correspond with their interests.

During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. What is the nurses best action in response to this finding?

Assess the patient as thoroughly as possible.

The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, I just dont feel like going to work. I have no energy, and I cant eat or sleep. The patient shows no interest in taking part in his care. The nurse should:

Assess the potential for suicide and make appropriate referrals.

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to

Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

The nursing instructor will need to provide further instruction to the student who states, development proceeds:

At a slow rate during the embryonic stage.

The nurse is administering an intravenous medication that is to be administered over 10 minutes. Which method should the nurse choose to efficiently administer the medication?

Attach separate tubing and set the medication syringe in a mini-infusion pump

The word spirituality derives from the Latin word spiritus, which refers to breath or wind. Today, spirituality is:

Awareness of ones inner self and a sense of connection to a higher being.

The nurse is caring for a hospitalized young adult male who is uninsured even though he works as a dishwasher at a local restaurant. He states that he would like to get a better job, but he has no education. How can the nurse best assist this patient psychosocially?

By providing information and referrals.

The patient is in severe pain and is requesting a prn medication before the prn time interval has elapsed. The nurses priority is to:

Call the prescriber and request a stat order.

An order is written for (phenytoin) Dilantin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the prescriber meant to write for hydromorphone (Dilaudid). What should the nurse do?

Call the provider to clarify and justify the order.

An assessment finding example for caregiver strain would be which of the following?

Caregiver has not received medical care when ill.

A patient who has been receiving intermittent chemotherapy through a peripheral IV site is ordered to receive a high dose of vancomycin through the same vein. Why does this concern the nurse?

Chemotherapy is irritating to the vascular system and may cause the vein to infiltrate.

A patient is to receive medication through a nasogastric tube. What is the most important nursing action to ensure effective absorption?

Clamp suction for 30-60 minutes after medication administration.

A woman is called into her supervisors office regarding her deteriorating work performance since the loss of her husband 2 years ago. The woman begins sobbing and saying that she is falling apart at home as well. The woman is escorted to the nurses office, where the nurse recognizes the womans symptoms as which of the following?

Complicated grief

Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention?

Confusion

The nurse knows that the young adult patient understands the health risks that affect his/her age group when the patient states:

Controlling the amount of stress in my life may decrease the risk of illness.

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism?

Denial

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating No way, Im not crazy. The best response the nurse can give is which of the following?

Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness

During assessment of an older adults skin integrity, expected findings include which of the following?

Decreased elasticity.

A patient who is receiving IV fluids notifies the nurse that his arm feels tight. Upon assessment, the nurse notes that the arm is swollen and cool to the touch. What should the nurses first action be?

Discontinue the IV site, and apply a warm compress.

The nurse is admitting a patient who is a member of the Seventh Day Adventist religion. The physician has written an order for specific tests to be done the next day, which is Saturday. The nurse should:

Discuss the patients beliefs about the Sabbath.

The physician orders 4 mg of oxycodone to be delivered every 6 hours. After 4 hours, the patient is complaining that she is in more pain. The nurse advises the physician to make which medication adjustment?

Divide the dose in half and administer 2 mg every 3 hours.

Which nursing action is the number one priority for ensuring that medication stays in the target therapeutic range?

Drawing the peak and trough levels at the same time each day

A confused patient refuses his medication. What is the nurses first response?

Educates the patient about the importance of the medication

To promote parent child attachment with a healthy newborn, what should the nurse do?

Encourage close physical contact as soon as possible after birth.

A patient needs assistance excreting a gaseous medication. What is the correct nursing action?

Encourage the patient to cough and deep-breathe.

During middle adulthood, the 50-year-old patient is likely to adapt favorably to a changing body image if he or she:

Engages in good hygiene practices.

The palliative teams primary obligation to a patient in severe pain includes which of the following?

Enhancing the patients quality of life

A cancer patient asks the nurse what the criteria are for hospice care. What should the nurse answer?

Expected to live less than 6 to 12 more months

What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center?

Explain that it is probably best for the family to visit the center and inspect it personally.

An older adult patient in no acute distress reports being less able to taste and smell. What is the nurses best response to this information?

Explain to the patient that diminished senses are normal findings.

As the aging population in the United States increases, the nurse knows that the:

Extension of the average life span has also increased.

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be

Give her this list of university and community resources.

A patient is at risk for aspiration. What nursing action is most appropriate?

Have the patient self-administer the medication.

A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept?

Hope

A patient is in need of immediate pain relief for a severe headache. The nurse knows that which medication will be absorbed the quickest?

Hydromorphone 4 mg IV

A nurse is talking with an adolescent who is having difficultly dealing with several issues. Which of the following issues should the nurse identify as the priority?

I am so fat, I skip meals to try to lose weight.

The nurse knows that the mother of a newborn understands associated health risks to her baby when she states:

I need to remind anyone who wants to hold the baby to wash their hands.

The nurse knows that patient education about a buccal medication has been effective when the patient states:

I should let the medication dissolve completely.

Which of these patient statements is the most reliable indicator that an older adult has the correct understanding of health promotion activities?

I still keep my dentist appointments even though I have partials now.

A provider has ordered a STAT medication to be administered. The nurse knows that the best route of administration is:

IV

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to

Identify limits and scope of work responsibilities.

An outcome for an older adult patient living alone is to be free from falls. Which of these statements by a patient indicates that teaching on safety concerns has been effective?

Ill take my time getting up from the bed or chair.

A patient cancels a scheduled appointment because she will be attending a Shiva for a family member. Recognizing the importance of this cultural ritual, the nurses best comment would be which of the following?

Im so sorry for your loss.

The nurse is caring for a patient who claims that he does not believe in God, nor does he believe in an ultimate reality. The nurse realizes that this patient:

Is an atheist/agnostic.

A nurse is instructing a young adult client about the health promotion and illness prevention. Which of the following statements indicates understanding?

It is important to schedule routine health care visits even if I feeling well.

After the anticipated demise of a chronically ill patient, the unit nurse is found crying in the staff lounge. The best response to her crying colleague would be:

It is normal to feel this way. Give yourself some time to mourn.

A mother expresses concern because her 5-year-old child frequently talks about friends who dont exist. What is the nurses best response to this mothers concern?

Its very normal for a 5-year-old child to have imaginary playmates.

A nurse discusses the risks of repeated sun exposure with a young adult patient. Which of these patient responses would be most expected from this patient?

Ive had this mole my whole life. So what if it changed color? My skin is fine.

Immediate intervention is needed when the newborn exhibits:

Lack of reflexes

A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. What should the nurse tell the patient?

Lamaze classes can prepare pregnant women and their partners for what is coming.

The patient is admitted with chronic back pain. The nurse who is caring for this patient should:

Look at how pain influences the patients ability to function.

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following?

Maturational and sociocultural factors

When choosing an appropriate topic for a young adult health fair, the nurse ranks which topic as least relevant?

Menopause and climacteric factors

A patient with gradual, progressive cognitive impairment (dementia) is admitted to the nursing unit after hip replacement surgery. Which of the following is a nursing care principle for care of cognitively impaired older adults?

Mental physical health.

Which of the following statements by a new graduate nurse should be corrected by an experienced nurse?

Most older patients are ill and disabled. Thats why we care for so many of them in the hospital.

Which of the following statements by a new graduate nurse should be corrected by an experienced nurse? Most older patients are ill and disabled. Thats why we care for so many of them in the hospital.

Most older patients are ill and disabled. Thats why we care for so many of them in the hospital.

The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of a infants developmental needs when he states:

My child will probably enjoy playing peek-a-boo.

As a patient ages, the nursing plan of care:

Needs to be individualized to the patients unique needs.

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory?

Neuman systems model

The mother of a recently murdered child keeps the childs room intact. Family members are encouraging her to redecorate and move forward in life. The visiting nurse recognizes this behavior as _____ grief.

Normal

The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurses priority?

Notify the physician that the prescribed dose is below the therapeutic range.

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

Nurse

A 61-year-old obese patient is diagnosed with type 2 diabetes and high blood pressure. The patient states that he is upset about the diet restrictions imposed by the treatment regimen. What is the nurses best approach?

Offer counseling on nutrition and exercise.

An 80-year-old male is brought to the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD). He states that he quit smoking 30 years ago, so it cant be COPD. He argues, Its just these colds Ive been getting. Theyre just getting worse and worse. The nurse understands that:

Older adults do not have to alter physical activity because of physical changes.

To promote physical well-being and socialization in an older adult, what should the nurse realize?

Older adults may have a functional purpose in social arenas.

The priority assessment immediately after birth is too:

Open the airway

A drug requires a low pH to be metabolized. Knowing this, the nurse anticipates that the medication will be administered by which route?

Oral

A patient informs the nurse that his urine is starting to look discolored. How should the nurse respond?

Other than the discoloration, has anything changed with your urination?

What is the nurses priority action to protect a patient from medication error?

Requesting that the prescriber write out an order, rather than giving a verbal order.

One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks associated with medication usage is to:

Periodically review the patients list of medications.

Which of the following demonstrates proper oral medication administration?

Placing all of the patients medications in the same cup, except medications with assessments

Which statement by the nurse best explains the importance of play during the toddler stage of development?

Play can enhance cognitive and psychosocial development.

The nursing student is preparing a teaching project for parents of school-aged children. Which statement correctly identifies health risks in this age group?

Poor nutrition and lack of immunizations continue to be health concerns for children of the poor.

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem?

Posttraumatic stress disorder

Identify a sociocultural factor that can lead to developmental problems.

Prolonged poverty

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual?

Protect against feelings of worthlessness and anxiety.

During hospitalization, the nurse should encourage the parents of an 8-month-old infant to:

Provide as much care as possible.

The nurse is caring for a patient who is terminally ill with very little time left to live. The patient states, I always believed that there was life after death. Now, Im not so sure. Do you think there is? The nurse states, I believe there is. The nurse has attempted to:

Provide hope.

An older patient has fallen and broken his hip. As a consequence, the patients family is concerned about his ability to care for himself, especially during his convalescence. What should the nurse do?

Provide information and answer questions as family members make choices among care options.

When performing a thorough psychosocial assessment on a young adult, what must the nurse realize?

Psychosocial health is often related to job and family stress.

A 2-year-old child is ordered to have ear irrigation performed daily. The nurse correctly performs the procedure by:

Pulling the auricle down and back to straighten the ear canal.

A 25-year-old patient is brought to the hospital by police after crashing his car in a high-speed chase when trying to avoid arrest for spousal abuse. What should the nurse do?

Question the patient about drug use.

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will:

Reassess patients stress-related symptoms and compare with expected outcomes.

Enuresis is reported in a previously toilet trained toddler. While gathering a health history from the grandparent, the nurse asks about which factor as the most likely cause?

Recent parental death

The nurse knows to assess for signs of medication toxicity within older adults because of which physiological change?

Reduced glomerular filtration

A nurse has withdrawn a narcotic from the medication dispenser. Upon checking the drug against the medication administration record, the nurse notices that the narcotic order has expired. What should be the nurses first action?

Return the medication to the medication dispenser according to protocol.

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which of the following actions should the nurse complete first?

Return to the room to check and assess the patient.

The nurse knows that caring for two patients with the same last name can lead to a medication error involving which right of medication administration?

Right patient

Encouraging children to play a game of kickball would be best suited for which age group?

School-aged

When comparing physical growth patterns between school-aged children and adolescents, the nurse notes that:

Secondary sex characteristics usually develop during the adolescent years.

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery:

Sensory peaceful words

After comparing appropriate play activities for infants and preschool children, the nurse should appropriately offer which of the following activities to an infant?

Set of plastic stacking rings.

The nurse is observing his 2-year-old hospitalized patient in the playroom. The nurse is most likely to observe the child:

Sitting beside another child while playing with blocks.

A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss?

Situational loss

Which symptom is an expected cognitive change in the older adult patient?

Slower reaction time.

A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which of the following psychosocial changes does the nurse focus on as a priority?

Social isolation

In assessing the spiritual health of her patients, the nurse understands that:

Spiritual beliefs change as patients grow and develop.

The nurse creates a referral to pastoral care when he/she realizes that the patient is in need of:

Spiritual care.

A complex concept that is unique to each individual; is dependent upon a persons culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples lives is called:

Spirituality

Which of the following statement about religion and spirituality is true?

Spirituality is unique to the individual.

An older adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patients vital signs are normal. What should the nurse do?

Take into account age-related changes in body systems that affect pharmacokinetic activity.

The nurse has had three patients die during the past 2 days. Which approach is most appropriate to manage the nurses sadness?

Talking with a colleague or writing in a journal

The father has recently begun to attend his childrens school functions since the death of his wife. This would best be described as which task in the Worden Grief Tasks Model?

Task III

A male older adult patient expresses his concern and anxiety about decreased penile firmness during erection. What is the nurses best response?

Tell the patient that this change is expected in aging adults.

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention?

Tertiary

Which of the following is characteristic of the cognitive changes in a preschooler?

The ability to classify objects by size or color.

A patient asks the nurse what the term polypharmacy means. The nurse defines this term as:

The concurrent use of many medications.

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce childrens stress regarding homework assignments?

Time management skills.

Which statement by the patient is an indication to use the Z-track method?

The last shot like that turned my skin colors.

When caring for a terminally ill patient, the nurse should focus on the fact that:

The nurses relationship with the patient allows for an understanding of patient priorities.

Which of these findings, if identified in a patient on a gerontological unit, would be most surprising to a culturally sensitive nurse?

The older person not being functionally independent.

A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. What should the nurse explain?

The patients age and symptoms point toward normal menopause.

The nursing instructor will need to provide further instruction to the student who uses which of these statements when describing the differences between cognitive and psychosocial development in children?

The school-aged child still requires total assistance in all activities for safety.

A family is grieving after learning of a family members accidental death. The transplant coordinator requests to talk with the family about possible organ and tissue donation. The nurse recognizes that:

The transplant coordinator is working in accordance with federal law.

A couple is informed that their fetus condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following?

Time and careful explanations

The patient is having a difficult time dealing with his AIDS diagnosis. He states, Its not fair. Im totally isolated from my family because of this. Even my father hates me for this. He wont even speak to me. The nurse needs to:

Use therapeutic communication to establish trust and caring.

According to some developmental theorists, intellectual development and moral development differ between men and women. What did Gilligan propose?

Women struggle with issues of care and responsibility.

Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family members unexpected death, the surviving family members begin to cry and scream in despair. The nurse recognizes this as the Bowlby Attachment Theory stage of:

Yearning and searching

The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which statement by the nurse accurately describes these changes?

You and your partner may experience feelings of uncertainty about assuming the roles of parents.

What should the nurse recognize when comparing the physical changes in young and middle adulthood?

Young adults are quite active but are at risk for illness in later years.