Exam 4 Health and Illness II NCLEX Question Bank

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Approximately what percentage of suicides in the United Stated are associated with mental illness or alcohol and substance abuse? 1. 90 percent 2. 50 percent 3. 80 percent 4. 70 percent

1. 90 percent More than 90 percent of suicides in the United States are associated with mental illness and substance abuse

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1. Risk for suicide R/T hopelessness

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self-esteem

of all suicides; 80

of these deaths are by firearms. The other means of suicide do not account for the majority of suicides in white men

Causes vasodilation and edema: A. Bradykinin B. Substance P C. Pain Experience D. Pain Tolerance

Sensory peripheral pain nerve fiber: A. Perception B. Nociceptor C. Modulation D. Prostaglandins

The point at which a person is aware of pain: A. Perception B. Nociceptor C. Modulation D. Prostaglandins

Identify the psychological factors that can influence pain. (Select all that apply). A. Anxiety B. Age C. Coping Style D. Neurological function

A, C

A patient is admitted to a hospital with Cheyne-Stokes respirations. What would the nurse expect the assessments findings to reveal? A. A respiratory rate of less than 5 breaths per minute B. A respiratory rate of more than 30 breaths per minute C. Alternating periods of apnea and deep, rapid breathing D. Noisy and congested breathing

Which question is appropriate when assessing current loss? "When did the loss occur?" "Do you drink on a regular basis?" "Have you experienced similar losses in the past?" "Are you experiencing unresolved grief?

"When did the loss occur?" Asking when the loss occurred is appropriate when assessing current loss. The other questions are appropriate for assessing the history of loss, grief reactions, and lifestyle changes associated with grief.

Which of the following is most important when assessing a client's pain? A. The physical location of the pain B. The client's perception of the pain C. The client's vital signs D. The client appears uncomfortable

Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant & analgesics: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

Palliative care is best provided by: A- A team of nurses B- A team of social workers C- A team of physicians and pharmacists D- A team of interdisciplinary care providers

D- A team of interdisciplinary care providers

15. A 70-year-old female patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? a. Patient b. Daughter c. Doctor d. Ethics consult team

a. Patient

7. A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin

c. Endorphins

The nurse, who is caring for the spouse of a client who died of traumatic injuries, is reviewing Engel's theory on the stages of grief. For which stage of grief should the nurse plan priority care based on Engel's theory? Outcome Shock Idealization Restitution

Shock Rationale The nurse should plan priority care based on shock, which according to Engel is the first stage of grief that the spouse experiences after the client's death. Restitution, outcome, and idealization are all later stages of grief in Engel's theory.

The majority of suicides in white men are attributed to which of the following means? 1. Firearms 2. Hanging 3. Overdose 4. Drowning

1. Firearms White men complete 73

14. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

2. Empowerment of the consumer

When a client is experiencing prolonged unresolved grief and engages in detrimental activities, the nursing diagnosis will most likely be which of the following? 1. unresolved grieving 2. dysfunctional grieving 3. abnormal grieving 4. pathological grieving

2. dysfunctional grieving; Dysfunctional grieving is the state in which an individual or group experiences prolonged unresolved grief and engages in detrimental activities.

Which instruction should the nurse give a client who is prescribed lithium carbonate (lithium)? 1. Maintain stable fluid intake. 2. Exercise in hot weather. 3. Restrict fluid. 4. Restrict salt.

1. Maintain stable fluid intake. Encourage client to maintain a stable fluid intake daily to promote adequate excretion of the medication. Exercising in hot weather would cause sodium depletion, which would alter serum lithium levels. Restriction of salt may increase lithium levels in the blood. REF: Page 244 and 245

The nurse is assessing a client with rheumatoid arthritis. Which assessment data should the nurse expect in the client with chronic pain? (Select all that apply.) A. Heart rate of 80 beats per minute B. Temperature of 97 degrees C. Dilated pupils D. BP 120/80 mmHg E. Respiratory rate of 20

A, D, E

A patient with terminal cancer tells you, "I know I am going to die pretty soon, perhaps in the next month." Which of the following is your most appropriate response? A. "What are your feelings about being so sick and thinking you may die soon?" B. "None of us knows when we are going to die. Is this a particularly difficult day?" C. "Would you like for me to call your spiritual advisor so you can talk about your feelings?" D. "Perhaps you are depressed about your illness; I will speak to the doctor about getting some medications for you."

A. "What are your feelings about being so sick and thinking you may die soon?" The most appropriate response to psychosocial questions is to acknowledge the patient's feelings and explore his or her concerns. This option does both and is a helpful response that encourages further communication between the patient and nurse.

Which is a psychological response to grief? Anger Personality changes Insomnia Decreased appetite

Anger is a psychological response to grief. Insomnia and decreased appetite are biological responses to grief. Personality changes are a behavioral response to grief.

Which nursing intervention supports a client who is experiencing grief? Using one-to-one observation Staying with the client Teaching relaxation techniques Asking open-ended questions

Asking open-ended questions Asking open-ended questions is an appropriate intervention for a client who is experiencing grief. Teaching relaxation techniques, staying with the client, and using one-to-one observation are appropriate interventions for a client who is suicidal.

Which is a symptom of complicated grief? Loss of appetite Difficulty concentrating Auditory hallucinations Sleep disturbances

Auditory hallucinations Individuals with complicated grief may experience auditory hallucinations. Sleep disturbances, loss of appetite, and difficulty concentrating are symptoms of normal grief.

The nurse suspects that a client is experiencing chronic pain. Which finding caused the nurse to make this clinical determination? (Select all that apply.) A. Causes changes in vital signs B. Describes the pain as persistent C. Has been occurring for 2 months D. Says the pain varies in intensity and location E. Demonstrates depression

B, D, E

A terminally ill patient has become confused, disoriented, and restless. The patient is incoherent and has clouding of consciousness. The nurse identifies that the patient has had constipation for 3 days. What action should the nurse take next? A. Obtain a prescription for a benzodiazepine. B. Administer laxatives to treat constipation. C. Do not take any measures as this is normal during the terminal stage. D. Inform the family members that the patient is breathing the last breaths.

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI has tapped my room and are out to get me.

B. "I'm the world's most perceptive attorney."

A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis, she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common end-of-life (EOL) psychologic manifestation is she most likely demonstrating? A. Peacefulness B. Decreased socialization C. Decreased decision-making D. Anxiety about unfinished business

B. Decreased socialization Decreased socialization is a common psychosocial manifestation of approaching death.

A client on an inpatient unit is diagnosed with bipolar disorder: manic phase. During a discussion in the dayroom about weekend activities, the client raises voice, becomes irritable, and insists that plans change. What should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems

C. Assist the client to move to a calmer location.

During admission of a patient diagnosed with metastatic lung cancer, you assess for which of the following as a key indicator of clinical depression related to terminal illness? A. Frustration with pain B. Anorexia and nausea C. Feelings of hopelessness D. Inability to carry out activities of daily living

C. Feelings of hopelessness Feelings of hopelessness are likely in a patient with a terminal illness who has clinical depression. This can be attributed to lack of control over the disease process or outcome. You should assess for depression routinely when working with patients with a terminal illness.

You are visiting with the wife of a patient who is having difficulty making the transition to palliative care for her dying husband. What is the most desirable outcome for the couple? A. They express hope for a cure. B. They comply with treatment options. C. They set additional goals for the future. D. They acknowledge the symptoms and prognosis.

D. They acknowledge the symptoms and prognosis. The grief experience for the caregiver of the patient with a chronic illness often begins long before the death. This is called anticipatory grief. Acceptance of the expected loss is associated with more positive outcomes.

The nurse is comforting the adult daughter of a client who has just passed away. When planning care, the nurse should include interventions based on which type of loss? Perceived Situational Developmental Anticipatory

Developmental Rationale A developmental loss is one that is expected to occur throughout the course of life, such as the death of aging parents; the nurse should provide interventions to address this type of loss. A perceived loss is one that cannot be verified by others. An anticipatory loss is one that is experienced before the loss actually occurs. A situational loss is one that is due to an external circumstance.

A nurse caring for a grieving family is aware that complicated grief may occur. A manifestation of complicated grief is: Not seeking support after a loss due to feelings of shame, guilt, or lack of recognition of the loss Hiding grief from others as opposed to allowing support from friends and family Intense grieving for 6 months or more with little to no indication of grief resolution More pronounced feelings of anger and depression due to resentment over the unacknowledged loss

Intense grieving for 6 months or more with little to no indication of grief resolution Rationale: Complicated grief is an alteration in the grieving process defined as prolonged or intensified grief causing an individual to be unable to proceed with the grieving process. A manifestation of complicated grief is intense grieving for 6 months or more with little to no indication of grief resolution. All other manifestations are for disenfranchised grief, another alteration in the grieving process.

20. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Assess the skin under the heating pad. b. Check the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.

b. Check the respiratory rate every 2 hours. Obtaining the respiratory rate is included in NAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? a. Morphine sulfate b. Zolpidem (Ambien) c. Ondansetron (Zofran) d. Dexamethasone (Decadron)

c. Ondansetron (Zofran)* Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

When working with clients of other religions and cultures, which of the following groups of clients and their families would most likely agree to and encourage organ donation? 1. Buddhists 2. Jehovah's Witnesses 3. Muslims 4. Mormons

1. Buddhists; Organ donation is prohibited by Jehovah's Witnesses and Muslims, whereas Buddhists in America consider it an act of mercy and encourage it.

After a nurse questions a client about relationship abuse, the client responds the she is ready to leave the abusive relationship, although past attempts were not successful due to fear, lack of support, lack of confidence, and financial considerations. She asks the nurse for help. An example of perceived loss is: 1. Loss of partner 2. Loss of dreams 3. Loss of residence 4. Loss of current lifestyle

2. Loss of dreams; Perceived loss is experienced by one person but cannot be directly verified by others. Loss of partner, residence, and lifestyle can be seen and acknowledged by others, even if they are not favorable. Dreams are something of which only the client is aware. She may have dreamed of a happier relationship that she finally acknowledge was not forthcoming, or the dream may be of a different origin. Only the client knows.

While the nurse is discussing a client's likely death with family members, one of the offspring inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is: 1. "Often, there is a lucid moment during the last hour that lasts about 15 minutes. First look for relaxation followed by clearing of the eyes, looking around, focusing on faces, and clearing of the throat. Call the others in at that time." 2. "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." 3. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." 4. "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with nuchal rigidity. Don't be alarmed when you hear a death rattle in the throat. "

3. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease."; Muscles relax with decreased activity. Muscle rigidity is not a usual pattern. The gag reflex is lost, and mucus accumulates in the back of the throat. Vision is blurred. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected.

15. An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? 1. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

4 (Serotonin syndrome; possibly caused by ingestion of two different SSRIs) (Rationale: The nurse should suspect that the client is suffering from serotonin syndrome; possibly caused by ingesting two different SSRI's (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.)

A client characteristically experiences fatigue, gloom, and loss of energy during the winter months. Which diagnosis should the nurse suspect? 1. Cyclothymic disorder 2. Mild depressive disorder 3. Mood disorder 4. Seasonal affective disorder

4. Seasonal affective disorder Levels of mild to moderate depression are experienced during long winter days, especially from October to April. A cyclothymic disorder does not involve seasonal depression. Mild depression is short-lived and usually is not triggered by seasonal change. A mood disorder does not involve seasonal depression. REF: Page 242

Which of the following is a primary risk factor for suicide? 1. Economic deprivation 2. Poverty 3. Unemployment 4. Social isolation

4. Social isolation Social isolation is a primary risk factor for suicide. Other social factors associated with suicide risk include economic deprivation, unemployment, and poverty, especially among young people

Which of the following is a myth regarding suicide? 1. Many people who die by suicide have given definite warnings of their intentions 2. The suicide rate is lowest in December 3. Most suicidal people are undecided about living or dying 4. Suicidal people are fully intent on dying

4. Suicidal people are fully intent on dying A myth regarding suicide is that suicidal people are fully intent on dying. Most suicidal people are undecided about living or dying. Facts about suicide include that the suicide rate is the lowest in December and that many people who die by suicide have given definite warnings of their intentions

Which of the following terms describes a nonfatal, self-inflicted destructive act with an explicit or implicit intent to die? 1. Suicidal ideation 2. Parasuicide 3. Suicidality 4. Suicide attempt

4. Suicide attempt A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Suicidal ideation is thinking about and planning one's own death. Suicidality refers to all suicide-related behaviors and thoughts of completing or attempting suicide and suicide ideation. Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? A. Only the patient should push the button. B. Do not use the PCA until the pain is severe. C. The PCA prevents overdoses from occurring. D. Notify the nurse when the button is pushed.

While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends: A. Transitioning use of adjuvants with nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids. B. Using acetaminophen for refractory pain. C. Limiting the use of opioids because of the likelihood of side effects. D. Avoiding total sedation, regardless of how severe the pain is.

The nurse is providing home care instructions to a client with chronic pain. Which item should the nurse include in the teaching session? (Select all that apply.) A. Eating a balanced diet B. Maintaining adequate hydration C. Having resuscitation equipment ready for use, if necessary D. Administering pain medications by the intramuscular (IM) route E. Using assistive devices

A, B, E

Identify the social factors that can influence pain. (Select all that apply). A. Attention B. Culture C. Previous experience D. Ethnicity E. Family & social support F. Spiritual factors

A, C, E, F

A nurse who does not believe in God is caring for a terminally ill patient. The patient asked the nurse to arrange for a pastoral visit. What action should the nurse take? A. Arrange for a chaplain. B. Refuse to arrange for a chaplain. C. Share views about God with the patient. D. Educate the patient about atheism.

A nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further reinforcement of teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are used to prevent a relapse of MDD."

A. "Care during the continuation phase focuses on treating continued manifestations of MDD." Rationale: The focus of the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD.

A nurse working on an acute mental health unit is caring for a client who has major depressive disorder and co-morbid anxiety disorder. Which of the following is the highest priority action by the nurse? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Telling the client about medication adverse effects

A. Placing the client on one-to-one observation Rationale: The greatest risk for a client who has MDD and co-morbid anxiety is injury due to self-harm.

The nurse is determining if a client is experiencing acute pain. Which finding should the nurse identify as being consistent with this type of pain? A. Pulse rate, respiratory rate, and blood pressure are increased. B. Pulse rate and respiratory rate are decreased, and blood pressure is increased. C. The client is calm; pupils are constricted. D. Respiratory rate and blood pressure are normal.

A. Pulse rate, respiratory rate, and blood pressure are increased.

8.A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? A. Relaxation and guided imagery B. Transcutaneous electrical nerve stimulation (TENS) C. Herbal supplements with analgesic effects D. Pudendal block

A. Relaxation and guided imagery

Regarding the request for organ and tissue donation at the time of death, the nurse needs to be aware that: A. Specially educated personnel make requests. B. Requests are usually made by the nurse caring for the patient at the time of death. C. Only patients who have given prior instruction regarding donation become donors. D. Professionals need to be very selective in whom they ask for organ and tissue donation.

A. Specially educated personnel make requests. Individuals specially trained in requesting organ donations facilitate the process. They are skilled in talking compassionately to people who have suffered a tragic, sudden loss and have answers to many questions that people have regarding the donation process.

34. A hospice nurse is caring for a 22-year-old with a terminal diagnosis of leukemia. When updating this patients plan of nursing care, what should the nurse prioritize? A) Interventions aimed at maximizing quantity of life B) Providing financial advice to pay for care C) Providing realistic emotional preparation for death D) Making suggestions to maximize family social interactions after the patients death

Ans: C Feedback: Hospice care focuses on quality of life, but, by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. Financial advice and actions aimed at post-death interaction would not be appropriate priorities.

Which type of medication is typically prescribed for anxiety? Select all that apply. Antihistamines Antidepressants Sleep aids Sedatives Beta-blockers

Antidepressants beta-blockers antihistamines There are no medications specifically for grief and loss, but clients might receive medications also used for anxiety if they are experiencing acute grief reactions. Antidepressants, beta-blockers, and antihistamines are prescribed for anxiety. Sleep aids and sedatives are no longer routinely prescribed for acute anxiety because of the risk of addiction and possible overdose.

A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating? A) Peacefulness B) Decreased socialization C) Decreased decision making D) Anxiety about unfinished business

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Stool softener B. Stimulant laxative C. H 2 receptor blocker D. Proton pump inhibitor

No protective; serves no purpose. Lasts longer than 6 months & is constant or recurring with a mild-to-severe intensity: A. Acute pain B. Chronic pain C. Chronic episodic pain D. Idiopathic pain

Pain is a protective mechanism warning of tissue injury and is largely a(n): A. Objective experience B. Subjective experience C. Acute symptom of short duration D. Symptom of a severe illness or disease

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic: A. Incident pain B. End-of-dose pain C. Spontaneous pain D. Acute pain

To adequately assess the quality of a patient's pain, which question would be appropriate? A. "Is it a sharp pain or a dull pain?" B. "Tell me what your pain feels like." C. "Is your pain a crushing sensation?" D. "How long have you had this pain?"

The nurse is caring for a school-age child with appendicitis. Which manifestation of pain should the nurse recognize as being consistent with a child of this age? (Select all that apply.) A. Cries uncontrollably B. Exhibits stalling behaviors C. Attempts to be brave D. May deny pain in front of parents E. May push away painful stimuli

B, C

During a palliative care evaluation: A- Avoid giving the patient an estimate of "time left." B- Help the patient identify possible sources of support. C- Focus on discussing treatments aimed at curing the disease. D- Discuss physical symptoms, but avoid discussion of psychosocial needs.

B- Help the patient identify possible sources of support.

The nurse recognizes that metoclopramide (Reglan) is useful in treating postoperative nausea and vomiting because of what action? A. It inhibits chemoreceptor stimulation. B. It promotes motility in the small intestine. C. It improves the body's response to analgesia. D. It decreases peristalsis in the intestinal wall.

B. Metoclopramide works by increasing gastrointestinal (GI) motility in the small intestine, thus minimizing gastric distention and accompanying stimulation of the vomiting center.

The nurse is assessing a client for pain. Which question should the nurse avoid using during this assessment? A. "What is causing the pain?" B. "Are you really sure you are in pain?" C. "Does anything make the pain better?" D. "Have you been in pain before?"

B. "Are you really sure you are in pain?"

The point at which a person feels pain: A. Neuromodulators B. Serotonin C. Pain Threshold D. Pain Experience

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Theresa says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? A. You are safe here. We will make sure nothing happens to you. B. You're just lucky your roommate came home when she did. C. What exactly do you plan to do? D. I don't understand. You have so much to live for.

C Rationale During the assessment phase it is important to assess how serious the intent was, if the person has a plan, if they do have a plan if they have a means of carrying out said plan, how lethal those means are, and if the individual has attempted suicide before. Theresa already has attempted suicide so it is vital to ask the other questions about her suicidal plan.

Identify the cultural factors that can influence pain. (Select all that apply). A. Coping style B. Spiritual factors C. Meaning of pain D. Ethnicity

C, D

Which of the following agents has a rapid anxiolytic effect and would be best for the acute management of anxiety? A) Buspirone B) Venlafaxine (SNRI) C) Lorazepam (BZ) D) Escitalopram (SSRI) E) Duloxetine (SNRI)

C- Lorazepam because it is a benzodiazepine The rest take a few weeks to start working

When planning to administer metoclopramide (Reglan), the nurse is aware that this drug must be given in regards to which fluid or food consideration? A. Give with a full glass of water in the morning. B. Take with 8 oz of orange or apple juice. C. Take 30 minutes before meals and at bedtime. D. Give with food to decrease GI upset.

C. Metoclopramide should be administered 30 minutes before meals and at bedtime. Administering the medication before meals allows time for onset to increase GI motility before food ingestion, thus decreasing stomach distention and resulting nausea and vomiting.

1. What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A. Assess the patient's body language. B. Observe cardiac monitor for increased heart rate. C. Ask the patient to rate the level of pain. D. Ask the patient to describe the effect of pain on the ability to cope.

C. Ask the patient to rate the level of pain.

For which client should the nurse consider skipping step 1 (nonopioid +/dash adjuvant) and step 2 (opiate for mild to moderate pain, +/dash nonopioid, +/dash adjuvant) of the World Health Organization's (WHO) three-step approach to administering pain relief? A. The 45-year-old female client with chronic back pain B. The 10-year-old male client with a sprained wrist C. The 30-year-old female client with several first-degree burns D. The 45-year-old male client with gout

C. The 30-year-old female client with several first-degree burns

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem solving to cope adequately after discharge.

C. The client will remain safe throughout the hospitalization.

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient' s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: A. Discontinue all ordered opioids B. Close the room door to allow the patient to recover C. Administer the remaining naloxone over 4 minutes D. Assess patient's vital signs every 15 minutes for 2 hours

An 8-year-old client is crying with pain after a tonsillectomy. Which nursing intervention is most appropriate for this client? A. Tell him he is too big to cry. B. Tell him he may have a Popsicle when he stops crying. C. Tell him you will put him in his bed if he continues to cry. D. Hold him and provide comfort.

Increase sensitivity to pain: A. Perception B. Nociceptor C. Modulation D. Prostaglandins

Level of pain a person is willing to put up with: A. Bradykinin B. Substance P C. Pain Experience D. Pain Tolerance

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? A. TENS works by causing distraction. B. TENS therapy does not require a health care provider's order. C. TENS requires an electrical source for use. D. TENS electrodes are applied near or directly on the site of pain.

The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. The nurse recognizes that the person who is responsible for making the decision about end of life measures when the patient cannot communicate his or her specific wishes is which of these? A. The patient's wife B. A notary and attorney C. The primary health care provider D. Such decisions cannot be made if the patient is unable to communicate.

Which client statement indicates the need for further teaching about antiemetic medications? A. "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." B. "I will not drive while I am taking these medications because they may cause drowsiness." C. "I should take my prescribed antiemetic before receiving my chemotherapy dose." D. "I will apply the scopolamine patch to my right or left arm and rotate sites of application."

The nurse should teach a client about which antiemetic commonly used to prevent motion sickness? A. Prochlorperazine (Compazine) B. Droperidol (Inapsine) C. Metoclopramide (Reglan) D. Scopolamine (Transderm-Scōp)

D. Scopolamine has potent effects on the vestibular nuclei, which are located in the area of the brain that controls balance. These effects make scopolamine one of the most commonly used drugs for the treatment and prevention of nausea and vomiting associated with motion sickness.

A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. The nurse knows these findings are characteristics of A. postpartum fatigue. B. postpartum psychosis. C. the letting-go phase. D. postpartum depression.

D. CORRECT: Postpartum depression in the client is characterized by tearfulness, insomnia, lack of appetite, and feeling let down.

source (Taylor 1191-1192)Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. The nurse caring for a child with pain understands that a normal sympathetic response to pain is not always present in children. Which clinical manifestation is the most reliable indicator of acute pain in a child? A. Hypotension B. Bradycardia C. Excessive sleepiness D. Compensatory posturing

D. Compensatory posturing

Arrange Elisabeth Kübler-Ross's stages of grieving in the correct sequence. Acceptance Bargaining Depression Anger Denial

Denial Anger Acceptance Bargaining Depression

A 25-year old woman has a long history of depressive symptoms accompanied by low back and sharp leg pain secondary to a motor vehicle accident 4 years ago. Physical and laboratory tests are unremarkable. Which of the following drugs might be useful in this patient? Fluoxetine (SSRI) Sertraline (SSRI) Phenelzine (MAOI) Mirtazapine (Atypical)

Duloxetine (SNRI) Duloxetine- use lower doses for chronic pain than depression

A client comes in demonstrating increased activity and agitation and gives much more importance to thoughts and ideas. This client is demonstrating ____________.

Mania

The nurse is providing care to a client who recently lost her child in a car crash. The client presents with difficulty breathing and diaphoresis. Based on these symptoms, which nursing intervention is the priority for this client? Using body language that encourages the client to talk. Staying with the client and treating the symptoms. Listening to the client's concerns. Asking the client open-ended questions.

Staying with the client and treating the symptoms. Rationale The client is experiencing an anxiety attack, and the priority intervention is to stay and treat the symptoms. The other interventions may be appropriate for a client experiencing grief, but client safety is the first concern.

A palliative care nurse understands that nurses can employ various interventions to help clients with their grief. An example of an independent intervention which can be utilized is: Requesting a referral to group therapy, bereavement groups, and grief therapists Requesting a referral to a social worker who can provide expert guidance about coping with loss Facilitating meetings between the hospital chaplain and the client Using active listening techniques to show full engagement in the interaction

Using active listening techniques to show full engagement in the interaction Rationale: An independent intervention for clients with alterations in grief include using active listening techniques to show full engagement in interaction. All other interventions are important, however, are collaborative in nature rather than independent.

13. A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? a. The nurse places the patient in a sitting position while the family visits. b. The nurse places identification tags on both the shroud and the ankle. c. The nurse removes soiled dressings and tubes. d. The nurse makes sure a death certificate is issued and signed.

a. The nurse places the patient in a sitting position while the family visits.

End-of-life care must consider the needs of the family, as well as those of the patient. A TYPICAL need of family members is a- To avoid expressing their emotions b- To find meaning in the death of the patient c- To avoid being present at the patient's deathbed d- To be shielded from information about the patient's changing condition

b- To find meaning in the death of the patient

A patient being discharged appears angry with the nurse when she attempts to review discharge instructions with the patient. The nurse can best assist the patient in this stage of the relationship with which of the following responses? a. "You should be able to regulate your feelings better by now. Why are you angry?" b. "I can sense you are angry this morning. Tell me how you feel about being discharged today." c. "Would you rather not be discharged today?" d. "We have to go over these instructions before you can go. Please try to listen."

b. "I can sense you are angry this morning. Tell me how you feel about being discharged today."

5. A nurse is visiting a male patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family and wants to live. Which response by the nurse would be most appropriate? a. "You can't be feeling this way. You know you are going to die." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll be all right; who knows how much time any of us has" d. "Tell me about your pain. Did it keep you awake last night?"

b. "It does seem unfair. Tell me more about how you are feeling."

What is the focus of the SAFE-T assessment tool? (Select all that apply.) a. Facilitate hospitalization. b. Identify level of suicidal risk. c. Development of client focused treatment. d. Introduce antidepressant medication therapy e. Stress collaboration with the client

b. Identify level of suicidal risk. c. Development of client focused treatment. e. Stress collaboration with the client The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is an assessment tool that allows the clinician to benchmark relative risk (high, moderate, low) and to develop a treatment plan, in consultation with the patient, to reduce current risk. The tool does not provide for specific interventions.

1. A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a. Pain is whatever the physician treating the pain says it is. b. Pain exists whenever the person experiencing it says it exists. c. Pain is an emotional and sensory reaction to tissue damage. d. Pain is a simple, universal, and easy-to-describe phenomenon. e.. Pain that occurs without a known cause is psychological in nature. f. Pain is classified by duration, location, source, transmission, and etiology.

b. Pain exists whenever the person experiencing it says it exists. c. Pain is an emotional and sensory reaction to tissue damage. d. Pain is a simple, universal, and easy-to-describe phenomenon. e.. Pain that occurs without a known cause is psychological in nature. f. Pain is classified by duration, location, source, transmission, and etiology.

Which of the following statements is true regarding culture and protective factors against suicide? a. Asian Americans have the highest rates of suicide. b. Religion and the importance of family are protective factors for Hispanic Americans. c. Older women have the highest risk for suicide among African Americans. d. American Indians and Pacific Islanders have the lowest rates of suicide.

b. Religion and the importance of family are protective factors for Hispanic Americans. Among Hispanic Americans, Roman Catholic religion (in which suicide is a sin) and the importance given to the extended family decrease the risk for suicide. The other options are all incorrect and are in fact the opposite of what is true.

An assessment tool that is useful to nurses in rating suicide risk is the a. AIMS scale. b. SAFE-T. c. CAGE questionnaire. d. Mini-Mental Status Examination.

b. SAFE-T. Evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. The SAFE-T is short and easy to use and is focused on the risk for self-injury. That is not the focus of the other options.

12. A nurse is caring for terminally ill patients in a hospital setting. Which example describes appropriate end-of-life care? a. To eliminate confusion, taking care not to speak too much when caring for a comatose patient b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient c. Referring to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father d. Telling a dying patient to sit back and relax and performing patient hygiene for the patient because it is easier than having the patient help

b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient

Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment? (Select all that apply.) a. How long the client has been suicidal b. Whether the plan has specific details c. Whether the method is one that could cause death d. Whether the client has the means to implement the plan e. Has the client been suicidal in the past

b. Whether the plan has specific details c. Whether the method is one that could cause death d. Whether the client has the means to implement the plan Lethality refers to how deadly a plan is. The length of time a client has been suicidal or a history suicidal thoughts have nothing to do with the lethality of the plan. While the remaining options present important about the seriousness of the plan.

8. A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to a. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. consult with the health care provider about using a different treatment protocol to control the patient's pain. c. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

b. consult with the health care provider about using a different treatment protocol to control the patient's pain. PCAs are best for controlling acute pain; this patient's history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

15. These medications are prescribed by the health care provider for a patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question? a. morphine (Roxanol) b. pentazocine (Talwin) c. celecoxib (Celebrex) d. dexamethasone (Decadron)

b. pentazocine (Talwin) Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient.

A patient has been referred to hospice and asks what it means. The nurse's response is based on what knowledge about hospice? a. Hospice is a special place of care. b. Hospice care is a life-long type of care. c. Hospice is a model of care rather than a place of care. d. Hospice is designed for patients with serious chronic illness.

The nurse is teaching a 70-year-old man about his depression. Which of the following statements by the client would indicate that teaching has been effective? a. "All old people get depressed at times." b. "I'm glad I'll feel better in 2 or 3 days." c. "I never knew depression could just happen for no specific reason." d. "When I reduce the stress in my life, the depression will go away."

c. "I never knew depression could just happen for no specific reason."

12. When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly

c. Around the clock (ATC)

The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? a. Will reclaim any prized possessions that were given away. b. Be able to name three personal strengths. c. Seek help when feeling self-destructive. d. Consistently participate in a self-help group.

c. Seek help when feeling self-destructive. Having the client cope with self-destructive impulses in a healthy way is the only appropriate short-term goal presented for Risk for self-directed violence since it focuses on client safety.

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide? a. γ-Amino-butyric acid b. Dopamine c. Serotonin d. Acetylcholine

c. Serotonin Low serotonin levels have been noted among individuals who have committed suicide. None of the other options are as directly related in the physiology of depression.

13. The nurse is caring for a diabetic patient who has chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. Which of these prescribed medications is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. aspirin (Ecotrin) b. celecoxib (Celebrex) c. amitriptyline (Elavil) d. acetaminophen (Tylenol)

c. amitriptyline (Elavil) The patient's pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain.

12. Which of these prescribed therapies should the nurse use first when caring for a patient with cancer pain that the patient describes as at "level 8 (0 to 10 scale), deep, and aching." a. fentanyl (Duragesic) patch b. ketorolac (Toradol) tablets c. hydromorphone (Dilaudid) IV d. acetaminophen (Tylenol) suppository

c. hydromorphone (Dilaudid) IV The patient's pain level indicates that a rapidly-acting medication such as an IV opioid is needed. The other medications also may be appropriate to use, but will not work as rapidly or as effectively as the IV hydromorphone.

When should pain be assessed? a- Only when the patient complains b- Only if the family tells you the patient is uncomfortable c- At each shift change d- On a regular schedule, with any complaint or appearance of pain, and after administering pain medication

d- On a regular schedule, with any complaint or appearance of pain, and after administering pain medication

7. A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"

d. "Does the pain keep you from doing things you enjoy?" The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

A patient has a history of suicidal ideation. The nurse understands that the patient is at highest risk for self-harm at which of the following times? a. Immediately after a family visit b. On the anniversary of significant life events in the patient's life c. During the first few days after admission d. Approximately 2 weeks after starting antidepressant medication

d. Approximately 2 weeks after starting antidepressant medication

The nurse initiating a therapeutic relationship with a client should explain the purpose, which is to a. Alleviate stressors in life b. Become stabilized on medications c. Establish relationships d. Facilitate a positive change

d. Facilitate a positive change

14. The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? a Inform the family that there is no need for them to wash the body since the mortician typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. c. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

4. A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain

d. Referred pain

14. A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression

d. Respiratory depression

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority? a. Hopelessness related to recent divorce b. Ineffective coping related to inadequate stress management c. Spiritual distress related to conflicting thoughts about suicide and sin d. Risk for suicide related to highly lethal plan

d. Risk for suicide related to highly lethal plan

A nurse working in an outpatient clinic is reinforcing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active.

" C. "I am aware that my PMDD causes me to have rapid mood swings." Rationale: A clinical finding of PMDD is emotional lability. The client can experience rapid changes in mood.

Several questions can be used to assess a suicidal person's intent to die, severity of suicidal ideation, and degree of planning. Which of the following questions may be used to elicit information regarding the severity of suicidal ideation? 1. Have you done anything to put the plan into action? 2. Can you dismiss thoughts of killing yourself, or do they tend to return? 3. How seriously do you want to die? 4. Have you made any plans to kill yourself?

2. Can you dismiss thoughts of killing yourself, or do they tend to return? A question to ask regarding severity of suicidal ideation may include, "Can you dismiss thoughts of killing yourself, or do they tend to return?" The other questions focus on the intent to die and the degree of planning

A terminally ill client tells the nurse that they do not want to be placed on a ventilator, have CPR, or be intubated to prolong their life. Which of the following actions would most ensure that the client's wishes are carried out? 1. the nurse writing these instructions in the client's care plan. 2. the client preparing and signing an advanced directive 3. the client preparing and signing a health-care proxy 4. the physician writing an order to this effect in the chart

2. the client preparing and signing an advanced directive; The living will provides specific instructions about what medical treatment the client chooses to omit or refuse (e.g. CPR, intubation, ventilatory support) if the client is unable to communicate those decisions. A health-care proxy, also referred to as durable power of attorney, is a written statement appointing someone to make health-care decisions if the client is unable to do so.

A client is prescribed citalopram (Celexa), 20 mg daily. Available are six 10-mg tablets. This medication will supply the client with the necessary dosage for ________ days.

3 days Rationale 3 days is the recommended maximum number of days a person with depression should be given at one time to prevent an overdose.

Which client would the nurse expect to prepare for electroconvulsive therapy (ECT)? 1. A female client with dysthymic disorder 2. A male client with major depressive disorder and history of heart disease 3. A male client with major depression and at risk for suicide 4. A female client with major depression and brain metastasis

3. A male client with major depression and at risk for suicide ECT is an appropriate intervention for major depression with risk of suicide. ECT is not used for dysthymic disorders. ECT is contraindicated in persons with heart disease. ECT is contraindicated in persons with tumors of the nervous system. REF: Page 243

Which mental health disorder is a major risk factor for suicide? 1. Mania 2. Anxiety 3. Depression 4. Schizophrenia

3. Depression Depression is a major risk factor of suicide. Anxiety, schizophrenia, and mania are not major risk factors for suicide

Protective; has identifiable cause, is of short duration, and has limited tissue damage & emotional response: A. Acute pain B. Chronic pain C. Chronic episodic pain D. Idiopathic pain

Severe cancer pain is most effectively treated with analgesics given: A. Around the clock, with extra doses available as needed B. Around the clock, in titrated doses C. As needed by the client D. Sparingly, to avoid side effects

The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? 1.Prone 2.Supine 3.Lateral 4.Trendelenburg's

3.Lateral Rationale: Dyspnea may occur during the last days of life. Nursing management of a terminally ill client experiencing dyspnea includes elevating the head and/or positioning the client on the side to improve chest expansion. The positions noted in options 1, 2, and 4 will increase the dyspnea.

Which of the following is accurate regarding women and suicide? 1. They attempt suicide less than men 2. They are more likely to choose a more lethal method than men 3. They are more likely to die from attempted suicide than men 4. They are less likely to complete suicide than men

4. They are less likely to complete suicide than men Women are less likely to complete suicide than men, partly because they are more likely to choose a less lethal method. Women are less likely to die from an attempted suicide than men, but they attempt suicide more often

Women make how many attempts for every suicide attempt by their male counterparts? 1. Four 2. Two 3. One 4. Three

4. Three Women make three attempts to every attempt by men. Women are less likely to complete a suicide, partly because they are more likely to choose less lethal methods

A health care provider writes the following order for an opioid naive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: A. Calls the health care provider, and questions the order B. Applies the patch the third postoperative day C. Applies the patch as soon as the patient reports pain D. Places the patch as close to the hip dressing as possible

Binds to receptors on peripheral nerves, increasing pain stimuli: A. Bradykinin B. Substance P C. Pain Experience D. Pain Tolerance

Which agent would be a poor choice in a 70-year old elderly female with depressive symptoms due to the drug having significant alpha-1 receptor antagonism and thus a higher risk for falls due to orthostatic hypotension? A) Lithium (Mood-stabilizer) B) Bupropion (Atypical) C) Escitalopram (SSRI) D) Imipramine (TCA) E) Sertraline (SSRI)

A and D are not good choices Lithium because not antidepressent NOT imipramine because side effect of orthostatic hypotension and anticholinergic side effects!! sertraline and escitalopram are fine best answer is D though

3.Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? A."Meditation controls pain by blocking pain impulses from coming through the gate." B. "Meditation will help me sleep through the pain because it opens the gate." C."Meditation stops the occurrence of pain stimuli." D."Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

A."Meditation controls pain by blocking pain impulses from coming through the gate."

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-IV-TR, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs due to the risk of drug interactions.

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.

4. A nurse who sits on the hospitals ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide? A) Administering a lethal dose of medication to a patient whose death is imminent B) Administering a morphine infusion without assessing for respiratory depression C) Granting a patients request not to initiate enteral feeding when the patient is unable to eat D) Neglecting to resuscitate a patient with a do not resuscitate order

Ans: A Feedback: Assisted suicide refers to providing another person the means to end his or her own life. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual. The other listed options do not fit this accepted definition of assisted suicide.

In teaching a client about his antidepressant medication, fluoxetine, which of the following would the nurse include? (Select ALL that apply) A. Don't eat chocolate while taking this medication. B. Keep taking this medication, even if you don't feel it is helping. It sometimes take a while to take effect. C. Don't take this medication with the migraine drugs "triptans". D. Go to the lab each week to have your blood drawn for therapeutic levels of this drug. E. This drug causes a high degree of sedation, so take it just before bedtime.

B, C Rationale A - chocolate is not something you would want your client to eat while taking an MAOI B - Antidepressants can take a few weeks before affects are felt. C - serotonin syndrome may occur with concomitant use of SSRI fluoxetine and "triptans" D - E - SSRI's can cause insomnia so it is important to take the dose early in the day.

The nurse is providing palliative care to a patient who is in the last stage of cancer. What does the nurse monitor in the patient as part of neurologic assessment? Select all that apply. A. Urine output B. Pupil response C. Nutritional intake D. Presence of reflexes E. Level of consciousness

B,D,E

A good practice for providing adequate end-of-life care is: A- Offer hope for a cure to the patient, regardless of prognosis. B- Ask direct questions about the patient's symptoms. C- Try all possible treatments to prolong a patient's life. D- Never address end-of-life preferences with patients

B- Ask direct questions about the patient's symptoms.

A client recovering from surgery is prescribed an opioid for analgesia. Which medication should the nurse prepare for this client? A. Ibuprofen B. Oxycodone C. Gabapentin D. Temazepam

B. Oxycodone

Teaching a child about painful procedures is best achieved by: A. Early warnings of the anticipated pain B. Storytelling about the upcoming procedure C. Relevent play directed toward procedure activities D. Avoiding explanations until the pain is experienced

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. " Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase last for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

A nurse has been working full time with terminally ill patients for 3 years. He has been experiencing irritability and mixed emotions when expressing sadness since four of his patients died on the same day. To optimize the quality of his nursing care, he should examine his own A Full-time work schedule. B) Past feelings toward death. C) Patterns for dealing with grief. D) Demands for involvement in patient care.

Arises from organs such as the gastrointestinal tract & pancreas; is sometimes subdivided: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

10.A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? A. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." B. "You should take your medication after you walk to make sure you do not fall while you are walking." C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." D "You need to take oral pain medications when you experience severe pain."

C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain."

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

Which client should the nurse assess for depression as a result of the grieving process? Adolescent client Older adult client Adult client School-age client

Older adult client The older adult client is at the greatest risk of developing depression; therefore, the nurse should assess this client for depression.

A newly diagnosed patient states, "I hate this cancer." According to Kübler-Ross, what stage of loss is being verbalized? a. anger b. bargaining c. depression d. denial

Which of the following individual is at highest for committing suicide? a. 71 year old male, alcohol user, independent-minded b. 16 year old female, diabetic, with 2 best friends c. 47 year old male, schizophrenic, unemployed d. 57 year old female, depression, active in church

a. 71 year old male, alcohol user, independent-minded

15. When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: a. A respiratory rate of 10/min with normal depth b. A sedation level of 4 c. Mild confusion d. Reported constipation

b. A sedation level of 4

9. Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication

b. Applying a moist heating pad to the area at prescribed intervals

11. A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse? a. amitriptyline (Elavil) 50 mg at bedtime b. oxycodone (OxyContin) 80 mg twice daily c. ibuprofen (Advil) 800 mg 3 times daily d. meperidine (Demerol) 25 mg every 4 hours

d. meperidine (Demerol) 25 mg every 4 hours Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management.

For the past 5 years Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? A) Adaptive grief B) Disruptive grief C) Anticipatory grief D) Prolonged grief disorder

Choose the true statement about palliative care and hospice: a- Hospice provides palliative care in the patient's home only. b- During hospice care, patients may receive treatment aimed at curing their disease. c- Because hospice provides palliative care, other healthcare providers do not need to know about palliative care. d- To qualify for hospice, a patient must have a terminal illness and a prognosis of no more than six months to live.

d- To qualify for hospice, a patient must have a terminal illness and a prognosis of no more than six months to live.

A nurse is caring for an older adult client with cognitive impairment. Which concept should the nurse keep in mind when assessing this client for pain? A. This client is more likely to express pain verbally. B. Pain assessment is impossible in this client. C. Pain assessment in this client is similar to that of a client without cognitive impairment. D. This client is less likely to express pain verbally.

D. This client is less likely to express pain verbally.

Which is not a physiological factor that influences pain? A. Age B. Culture C. Fatigue D. Genes E. Neurological Function

The nurse prepares to assess a client for pain. Which structures, as per the nurse's recollection, receive pain impulses from the site of injury? A. Tendons and ligaments B. Brain and muscles C. Muscles and spinal cord D. Spinal cord and brain

D. Spinal cord and brain

The nurse is caring for an older adult client on a medical-surgical unit who had abdominal surgery for mass removal one day ago. Which clinical manifestation of pain should the nurse expect to assess in this client? A. Guards abdomen B. Loss of appetite C. Decreased energy D. Changes in sleep patterns E. Cries inconsolably

B, C

A client is taking morphine for chronic pain. Which instruction should the nurse give the client to minimize adverse effects of this medication? A. Eat large frequent meals to increase food intake. B. Increase fiber in the diet. C. Decrease the intake of protein. D. Decrease the amount of fluid intake.

B. Increase fiber in the diet.

6. An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? a. Mechanical b. Thermal c. Chemical d. Electrical

a. Mechanical

A client is supposed to be ambulating ad lib. Instead, he refuses to get out of bed, asks for a bed bath, and makes many demands of the nurses. He also yells that they are lazy and incompetent. The client's behavior is an example of which of the following defense mechanisms? a. Introjection b. Projection c. Rationalization d. Reaction formation

b. Projection

22. These medications are ordered for an 86-year-old patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. aspirin (Bayer) 650 mg orally b. naproxen (Aleve) 200 mg orally c. oxycodone (Roxicodone) 5 mg orally d. acetaminophen (Tylenol) 650 mg orally

d. acetaminophen (Tylenol) 650 mg orally Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients.

2. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as a. somatic pain. b. referred pain. c. neuropathic pain. d.breakthrough pain.

d.breakthrough pain. Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

Pain that occurs sporadically over an extended period of time: A. Acute pain B. Chronic pain C. Chronic episodic pain D. Idiopathic pain

Which is an effective treatment that may be ordered for dyspnea and pain? A- Opioids B- TENS C- Ibuprofen D- Oxygen

A- Opioids. Opioids, like morphine, can be effective for pain and dyspnea.

Which is not an acceptable reason to communicate with a proxy decision maker? A- You don't like the patient. B- The patient is incompetent. C- The patient's culture dictates you should speak with someone else, for example, the husband of a female patient. D- The patient asks you to discuss any issues with a family member.

A- You don't like the patient.

6.The nurse anticipates administering an opioid fentanyl patch to which patient? A.A 15-year-old adolescent with a broken femur B.A 30-year-old adult with cellulitis C. A 50-year-old patient with prostate cancer D. An 80-year-old patient with a broken hip

C. A 50-year-old patient with prostate cancer

A client with an acute bowel obstruction is having ischemic abdominal pain. This type of pain is best described as: A. Visceral B. Somatic C. Intractable D. Cutaneous

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife? A) A priest B) Dying wife C) Hospice staff D) Husband of dying wife

Inhibition of the pain impulse of the nociceptive process: A. Perception B. Nociceptor C. Modulation D. Prostaglandins

Identify the ABCDE clinical approach to pain assessment and management. A. Ask about pain, Believe patient, Choose pain control options, Deliver interventions & Empower patient B. Assess, Balance, Calculate, Diagnose, Evaluate C. Ability, Balance, Circulation, Diagnostics, Exercise D. Ambulate, Balance, Care, Delayed, Empathy

Mental & physical freedom from tension or stress that provides the patient a sense of self control: A. Relaxation B. Distraction C. Music D. Cutaneous Stimulation

Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged. Usually responsive to nonopiods and or opiods. A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

A nurse is conducting a grief and loss assessment interview and understands that the current loss, the history of previous losses, and lifestyle are all a part of this assessment. What question will the nurse ask the client to assess the current loss? "Do you drink on a regular basis?" "Are you having trouble carrying on with your normal activities?" "What types of coping mechanisms have you employed to work through your grief? "Do you have an active support system?"

"Are you having trouble carrying on with your normal activities?" Rationale: A question that the nurse will ask the client to assess the current loss is: "Are you having trouble carrying on with your normal activities?" All other questions are appropriate questions to ask during the grief and loss assessment, however, are part of the lifestyle area of the assessment, not the current loss.

A client tells the nurse that he engages in prayer and laughter every day. To which stress assessment question is this information applicable? "How long have the stressors been present in your life?" "What stress are you experiencing now" "How well do your coping strategies work?" "How do you handle stress?"

"How do you handle stress?" Rationale Prayer and laughter are two examples of how a client handles stress. These actions do not address what stress the client is experiencing now, how long the stressors have been present, or how well the client's coping strategies work.

Cliff has been attending group counseling for depression and has been expressing more hopelessness in the last few days. When the nurse provides the group with a homework assignment to be completed and returned to the group the next day, Cliff responds "I don't need to bother." Which of these responses by the nurse is most appropriate? 1) "Are you having suicidal thoughts?" 2) "Trust me, it will be beneficial." 3) "Why don't you want to cooperate?" 4) "This assignment will help you combat the hopelessness."

1 Rationale Hopelessness is a risk factor for suicide, and the client's statement may be a veiled suicide threat, so it is most important to assess for suicide risk in response.

Bill is a 70-year-old man who is diagnosed with major depressive disorder. He is married and has two adult children who are alcoholics. He currently lives in a rural neighborhood and works part-time at a convenience mart. Which of these demographics is a risk factor for suicide? 1) 70-year-old male 2) Parent of alcoholic children 3) Lives in a rural neighborhood 4) Works part-time

1 Rationale Suicide is highest among persons over 50, and men are at higher risk than females.

A client has a history of major depressive disorder (MDD). Police escort the client to the ED after finding the client nude at an ATM, screaming for money to pay off credit card debt. What would make the ED psychiatrist question the client's prior diagnosis? 1) The client is experiencing symptoms of mania. 2) The client is experiencing symptoms of a severe anxiety disorder. 3) The client is experiencing symptoms of an amnestic disorder. 4) The client is experiencing symptoms of a histrionic personality disorder.

1 Rationale The DSM-5 criteria for the diagnosis of MDD rule out this diagnosis if the client has ever experienced a manic episode. The symptoms described in the question indicate that this client is experiencing a manic episode. Therefore, it would be appropriate for the ED psychiatrist to question the diagnosis of MDD.

A client being treated for depression asks the nurse what causes this illness. Which response by the nurse is the most accurate, evidence-based statement? 1) "The etiology of depression is unclear. Evidence supports there may be several different causative factors." 2) "Depression has been proven to be the result of an imbalance in certain neurotransmitters." 3) "Depression is transmitted by a specific gene for the illness." 4) "Depression has been proven to develop as a result of negative thinking patterns."

1 Rationale This is the most accurate, evidence-based statement about causative factors for depression. Although several theories have been advanced, no single cause for depression has been identified conclusively.

Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? 1. On his or her side, to prevent aspiration 2. In high Fowler's position, to prevent increased intracranial pressure 3. In Trendelenburg's position, to promote blood flow to vital organs 4. In prone position, to prevent airway blockage 2 (Social isolation R/T poor self-esteem AEB secluding self in room)

1 (On his or her side, to prevent aspiration) (Rationale: The nurse should place a client who has received ECT on his or her side, to prevent aspiration.)

A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis? 1. Thyroid-stimulating hormone (TSH) level of 25 U/mL 2. Potassium (K+) level of 4.2 mEq/L 3. Sodium (Na+) level of 140 mEq/L 4. Calcium (Ca2+) level of 9.5 mg/dL

1 (Thyroid-stimulating hormone (TSH) level of 25 U/mL) (Rationale: A diagnosis of major depressive episode may be ruled out if the client's lab results reveal a TSH level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid function. The client's high TSH value may indicate hypothyroidism, which can lead to depressive symptoms. The DSM-5 criteria for the diagnosis of major depressive episode states that this diagnosis must not be attributable to the direct physiological effects of another medical condition.)

Pain that is predictable & elicited by specific behaviors: A. Incident pain B. End-of-dose pain C. Spontaneous pain D. Acute pain

... Which of the following may be considered normal or "healthy" types of grief? Select all that apply. 1. Abbreviated grief 2. Anticipatory grief 3. Disenfranchised grief 4. Complicated grief 5. Unresolved grief 6. Inhibited grief

1, 2, & 3. Abbreviated grief, anticipatory grief, and disenfranchised grief. Abbreviated grief (normal grief that is briefly experienced), anticipatory grief (experienced before the loss/death but appropriate), and disenfranchised grief (the emotions are felt privately, just not expressed in public). Unhealthy/abnormal types of grief include complicated grief (option 4) in several different forms; unresolved grief is extended in length and severity (option 5). With inhibited grief, symptoms are suppressed, and other effects, including somatic, are experienced instead (option 6).

A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.) 1. Symptoms include verbal rages or physical aggression toward people or property. 2. Temper outbursts must be present in at least two settings (at home, at school, or with peers). 3. DMDD is characterized by severe recurrent temper outbursts. 4. The temper outbursts are manifested only behaviorally. 5. Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.

1, 2, 3 (Rationale: The APA has included a new diagnostic category in the Depressive Disorders chapter of the DSM-5. This childhood disorder is called disruptive mood dysregulation disorder. Criteria for the diagnosis include, but are not limited to, the following. Verbal rages or physical aggression toward people or property; temper outbursts must be present in at least two settings (at home, at school, or with peers). DMDD is characterized by severe recurrent temper outbursts. The temper outbursts are manifested both behaviorally and/or verbally. Symptoms of DMDD must be present for 12, not 18 or more months to meet diagnostic criteria.)

A client diagnosed with major depression is being discharged from the hospital with a prescription for fluoxetine (Prozac). The nurse's discharge teaching should include which of the following? Select all that apply. 1) "It may take a few weeks before you begin to feel better; however, continue taking Prozac as prescribed." 2) "Make sure that you follow up with scheduled outpatient psychotherapy." 3) "If significant mood elevation is noted, your psychiatrist may discontinue this medication within 6 months to a year." 4) "You should avoid foods with tyramine, including beer, beans, processed meats, and red wine." 5) "You can discontinue the Prozac when you are feeling better."

1, 2, 3 Rationale Feedback 1: The nurse should inform the client that it is important to take Prozac as prescribed and that the therapeutic effect can take up to 4 weeks to be realized. Feedback 2: Along with medication compliance, the nurse should also stress the importance of follow-up psychotherapy. Feedback 3: The nurse should advise the client to discontinue the medication only under a doctor's supervision. Although the medication may be tapered and stopped after 6 months, there is a risk for further depressive episodes. Feedback 4: Avoidance of foods with tyramine would hold true if the client were taking an MAOI, not a selective serotonin reuptake inhibitor, such as Prozac. Feedback 5: The client should be advised to not stop taking Prozac abruptly. To do so might produce withdrawal symptoms such as nausea, vertigo, insomnia, headache, malaise, and nightmares.

The nurse is conducting an assessment for Leroy, a 65-year-old man who presented at the health clinic with complaints of depression. He lists several medications he has been taking. Of the following medications on his list, which are known to produce a depressive syndrome? Select all that apply. 1) Prednisone 2) Cimetidine (Tagamet) 3) Ampicillin 4) Ibuprofen (Advil) 5) Aspirin

1, 2, 3, 4 Rationale Feedback 1: Prednisone is a steroid medication that can produce depression. Feedback 2: Cimetidine is an anti-ulcer medication that can produce depression. Feedback 3: Ampicillin is an antibacterial medication that can produce depression. Feedback 4: Ibuprofen is an analgesic/anti-inflammatory medication that can produce depression. Feedback 5: Aspirin has not been associated with producing depression.

A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) 1. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." 2. "I guess I will have to give up my glass of red wine with dinner." 3. "I'll have to be very careful about reading food and medication labels." 4. "I'm going to miss my caffeinated coffee in the morning." 5. "I'll be sure not to stop this medication abruptly."

1, 2, 3, 5 (Rationale: The nurse should evaluate that teaching has been successful when the client states that phenelzine should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is an MAOI that can have negative interaction with other medications. The client needs to tell other physicians about taking MAOIs, because of the risk of drug interactions.)

A client has been diagnosed with major depression. The psychiatrist prescribes imipramine (Tofranil). Which of the following medication information should the nurse include in discharge teaching? Select all that apply. 1) "The medication may cause dry mouth." 2) "The medication may cause urinary incontinence." 3) "The medication should not be discontinued abruptly." 4) "The medication may cause photosensitivity." 5) "The medication may cause nausea."

1, 3, 4, 5 Rationale Feedback 1: Dry mouth can occur with all antidepressants, including imipramine. Feedback 2: Urinary retention, not incontinence, may occur when taking imipramine. Feedback 3: Antidepressants such as imipramine must be tapered and not stopped abruptly. Feedback 4: Tricyclic antidepressants such as imipramine can cause photosensitivity, whereas other types of antidepressants do not. Therefore, the client must be educated specifically about this potential side effect. Feedback 5: Nausea can occur with all antidepressants, including imipramine.

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) 1. Sad mood on most days 2. Mood rating of 2 out of 10 for the past 6 months 3. Labile mood 4. Sad mood for the past 3 years after spouse's death 5. Pressured speech when communicating

1, 4 (Rationale: The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than two years. The essential feature of dysthymia is a chronically depressed mood, which can have an early or late onset.)

The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate? 1. "I'm very sorry for your loss." 2. "I'll take you in to view the body." 3. "I didn't know your father but I am sure he was a wonderful person." 4. "How long will you want to stay with your father?"

1. "I'm very sorry for your loss"; This statement acknowledges the family's grief simply. Avoid statements that may be interpreted as overly impersonal (option 2) , false support (option 3), or harsh (option 4).

When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response? 1. "Tell me what it means to you to have this surgery." 2. "You must be very glad to be having this lesion removed." 3. "I cry when I am happy or relieved sometimes, too." 4. "Isn't it wonderful that the lesion is not cancer?"

1. "Tell me what it means to you to have this surgery"; The nurse needs to assess and explore the meaning of the client's crying. Options 2 and 4 leap to assumptions about the meaning of the tears and ignore the possibility of the client's distress. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct.

The ability of an individual to cope with death is dependent upon a number of factors. Which person likely will have the most difficulty coping with a death? 1. A parent whose 17-year-old child died in an auto accident the night before graduation 2. A child of 8 years whose grandparent dies a week before a planned visit 3. The spouse of an alcoholic who is killed in an automobile accident 4. The grandparent of a child born with Tay-Sachs disease

1. A parent whose 17-year-old child died in an auto accident the night before graduation; Many factors affect the grieving experience. These include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, social support systems, and the cause of the death. In our culture, the death of an older person is accepted more easily than that of a younger person. The death is more easily accepted if it is anticipated, and if the person who died did not contribute to the death. Usually, the closer the individual is to the person who died, the more difficult it is to cope with the death.

In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action? 1. Allows the client to make as many decisions about care as is possible. 2. Shares with the client the nurse's own views about life after death. 3. Avoids talking about dying and focuses on the present. 4. Relieves the client of as much responsibility for self-care as is possible.

1. Allows the client to make as many decisions about care as is possible; Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life. Sharing the nurse's own views about life after death (option 2) does not enhance client dignity. The nurse should not assume that avoiding talking about death and dying and emphasizing the present (option 3) is therapeutic for the client. Only if the client wishes to have someone else perform care is doing so supporting death with dignity (option 4). Otherwise is may have the opposite effect.

When assessing risk of suicide, which of the following are important assessment components? SATA 1. Degree of hopelessness 2. Previous attempt 3. Unemployment 4. Lethality of method 5. Seriousness of suicidal ideation

1. Degree of hopelessness 2. Previous attempt 4. Lethality of method 5. Seriousness of suicidal ideation Assessing for suicide risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, disorders, previous attempt, suicide planning and implementation, and availability and lethality of the suicide method

Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent takes this as proof that the family truly believes the accusation. This sets up a destructive cycle of family dysfunction. Which nursing diagnosis is most appropriate for this family? 1. Impaired family processes related to impaired adjustment 2. Impaired adjustment related to loneliness 3. Loneliness related to fear 4. Dysfunctional grieving related to loss of relationships

1. Impaired family processes related to impaired adjustment; The first part of the diagnostic statement reflects the concern at hand, while the second part is the etiology or cause. There are a number of concerns present in this scenario. Following the child's death, the whole family is impaired in processing the event, adjusting, and grieving. In addition, the parent is alienating the family with false accusations, resulting in lack of support, dysfunctional grieving, and loneliness. If the parent improved adjustment to the death, family processing would improve.

Depression in adolescence usually is related to loneliness, family strengths, self-esteem, and which of the following? 1. Parent-teen communication 2. Peer relationships 3. Academic issues 4. Teacher-teen communication

1. Parent-teen communication Teens who can discuss their concerns with understanding parents have lower rates of depression. The rest of the choices are important, but parent-teen communication is more influential with teens with regard to depression. REF: Page 238

Which of the following statements best reflect the law in Oregon regarding euthanasia, which took place in 1997? 1. Physicians can prescribe lethal medication doses to people meeting criteria. 2. It is illegal to assist any client in hastening their death under any circumstances. 3. Significant others may assist a client in hastening their own death. 4. It is illegal for a client to approach a physician about assisted suicide.

1. Physicians can prescribe lethal medication doses to people meeting criteria; After several legal challenges, an Oregon law took effect in 1997 to permit physicians to prescribe lethal doses of medications to clients who meet certain criteria and who request these lethal doses of medication.

Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is: 1. Preparing the body to look as clean and natural as possible 2. Pulling the sheet over the patient's face until the family is comfortably seated in the room 3. Humor is helpful in relieving stress. However, use humor only after family has left. 4. Calling the physician to verify the time of death before taking the body to the morgue

1. Preparing the body to look as clean and natural as possible; The body is to be handled with dignity at all times. This does not include using humor at this time. After the body is cleaned and the linen freshened, the sheet is pulled to cover the patient's shoulders. Laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly.

Which of the following is the greatest predictor of a future suicide attempt? 1. Previous attempt 2. Suicide planning 3. Degree of hopelessness 4. Seriousness of suicidal ideation

1. Previous attempt The greatest predictor of a future suicide attempt is a previous attempt, partly because that individual already has broken the "taboo" around suicidal behavior. Assessing for risk includes determining the seriousness of suicidal ideation, degree of hopelessness, and suicide planning

When working with a client who has recently experienced the loss of a family member, you find that the client talks about the loss frequently, complains of sleep disturbances, loss of appetite, and difficulty concentrating. You realize that these signs and symptoms indicate which of the following things? 1. a normal reaction 2. severe depression 3. exaggerated grief response 4. a pathological grief response

1. a normal reaction, The client is experiencing normal manifestations of grief.

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response? 1."This must be very hard for you." 2."Don't worry, things will be fine." 3."I know. It will get easier with time." 4."You need to be strong for him! Don't cry."

1."This must be very hard for you." Rationale: When a family member or caregiver is expressing the pain of loss, the nurse should not minimize their feelings. It is important to avoid general or trite assurances. Simply listening to the spouse and acknowledging how difficult this situation is, as in "This must be very hard for you" is the best example of therapeutic communication. Responses that belittle or minimize the family member's feelings, or those that place the client's feelings on hold are not therapeutic.

When teaching about the tricyclic group of antidepressant medications, which information should the nurse include? 1) Strong or aged cheese should not be eaten while the client is taking this group of medications. 2) The full therapeutic potential of tricyclics may not be reached for 4 weeks. 3) Tricyclics may cause hypomania or recent memory impairment. 4) Tricyclics should not be given with antianxiety agents.

2 Rationale A client needs to be advised that it may take several weeks for tricyclic medications to reach their full therapeutic effect.

The physician orders fluoxetine (Prozac) for a client diagnosed with depression. Which information is true about this medication? 1) Prozac is a tricyclic antidepressant. 2) The therapeutic effect of Prozac occurs 2 to 4 weeks after treatment is begun. 3) Aged cheese, yogurt, soy sauce, and bananas should not be eaten while the client is taking this drug. 4) Prozac may be administered in combination with monoamine oxidase inhibitors (MAOIs).

2 Rationale It is true that the full therapeutic effect of Prozac may not occur for 2 to 4 weeks after initiation of treatment. Prozac is a selective serotonin reuptake inhibitor

Chloe is suffering from depression and not responding to antidepressant treatment. She asks the nurse to tell her more about transcranial magnetic stimulation (TMS). Which of the following responses is accurate with regard to this treatment modality? 1) TMS uses magnetic energy to induce a seizure. 2) One study concluded that electroconvulsive therapy was more effective than TMS for short-term treatment of depression. 3) TMS is a safe and inexpensive treatment for depression. 4) TMS has been demonstrated to be more effective than any other treatment modality for depression.

2 Rationale This is an accurate, evidence-based statement. Patients often rely on nurses to provide current accurate information about new or experimental treatment modalities, so it is important for nurses to continue to evaluate current evidence in order to provide patients with the most up-to-date, accurate information.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."

2 ("A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.") (Rationale: The nurse should explain to the client that combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches, with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread.")

After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "How many packs of cigarettes do you smoke daily?" 3. "Do you drink any alcohol?" 4. "Are you taking St. John's wort?"

2 ("How many packs of cigarettes do you smoke daily?") (Rationale: Imipramine is a tricyclic antidepressant. Smoking should be avoided while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. Alcohol potentiates the effects of antidepressants. Tyramine is only an issue when MAOI medications are prescribed. Concomitant use of St. John's wort and SSRIs, not tricyclics, increases, not decreases the effects of the drug.)

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode? 1. The attention during the assessment is beneficial in decreasing social isolation. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed clients avoid addressing physical health and ignore medical problems.

2 (Depression can generate somatic symptoms that can mask actual physical disorders.) (Rationale: The nurse should determine that a client with a diagnosis of major depressive episode needs a full physical health assessment, because depression can generate somatic symptoms that can mask actual physical disorders.)

A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client? 1. Zung Depression Scale 2. Hamilton Depression Rating Scale 3. Beck Depression Inventory 4. AIMS Depression Rating Scale

2 (Hamilton Depression Rating Scale) (Rationale: A number of assessment rating scales are available for measuring severity of depressive symptoms. Some are meant to be clinician administered, whereas others may be self-administered. Examples of self-rating scales include the Zung Self-Rating Depression Scale and the Beck Depression Inventory. One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale. The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that measures involuntary movements associated with tardive dyskinesia.)

The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? 1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia) 4. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)

2 (Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)) (Rationale: The symptoms of the maternity blues include tearfulness, despondency, anxiety, and subjectively impaired concentration appearing in the early puerperium. Symptoms of postpartum depression are associated with fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and expressions of great concern about her inability to care for her baby. Both postpartum melancholia and postpartum depressive psychosis are characterized by a lack of interest in, or rejection of, the baby, or a morbid fear that the baby may be harmed. Other symptoms include depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions.)

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) 1. Gender differences in social opportunities that occur with age 2. Drastic temperature and barometric pressure changes 3. A seasonal increase in social interactions 4. Variations in serotonergic functioning 5. Inaccessibility of resources for dealing with life stressors

2, 3, 4 (Rationale: The nurse should identify drastic temperature and barometric pressure changes, a seasonal increase in social interactions, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November)

Janice is diagnosed with major depressive disorder and is beginning to participate in a cognitive therapy group. As the nurse is orienting Janice to the group, which of the following statements about cognitive therapy are accurate? Select all that apply. 1) Cognitive therapy is designed to focus on emotional dysregulation. 2) Cognitive distortions, such as negative expectations about oneself, serve as the basis for depression. 3) Cognitive therapy focuses on altering mood by changing the way one thinks. 4) Cognitive distortions arise out of a defect in cognitive development. 5) Cognitive therapy explores pent-up rage that has been turned against oneself because of identification with the loss of a loved object.

2, 3, 4 Rationale Feedback 1: In cognitive therapy the focus is on cognitive distortions. Emotional dysregulation is the central focus of dialectical behavior therapy. Feedback 2: Beck et al. (1979) postulated that negative and irrational thinking contribute to depression. These are referred to as cognitive distortions. Feedback 3: A primary assumption in cognitive therapy is that changing the way one thinks will change one's mood. Specifically, developing patterns of more rational and positive thinking will improve one's mood. Feedback 4: In cognitive theory, it is assumed that cognitive distortions arise from a defect in cognitive development, which culminates in an individual thinking that he or she is worthless, inadequate, and rejected by others. These patterns of thinking need to be corrected to promote a positive change in mood. Feedback 5: The concept of rage turned inward is based in psychoanalytical theory, not cognitive theory.

Emily has been receiving treatment for major depressive disorder over several weeks. She is taking an antidepressant and attending cognitive behavioral therapy group once a week. When the nurse evaluates her progress in treatment, which of the following are indications that the depression is improving? Select all that apply. 1) Emily is taking the antidepressant medication as ordered. 2) Emily is expressing hope that she can return to her university classes soon and continue her education. 3) Emily demonstrates ability to make decisions concerning her own self-care. 4) Emily reports that suicide ideas have subsided. 5) Emily is engaging in activities that she enjoys.

2, 3, 4, 5 Rationale Feedback 1: Adherence to the medication regime does not presume effectiveness. More relevant indications would be the patient's report of improved mood, improved sleep and rest, and increase in energy. Feedback 2: Hopelessness is a characteristic symptom in major depressive disorder, and a return to expressing hopefulness is an indicator of improvement. Feedback 3: Indecisiveness is a symptom in depression, and a return to the ability to make decisions is an indication of improvement. Feedback 4: Suicide ideas can be pervasive and troubling symptoms in depression. When they begin to abate, it may be an indication that the depression is lifting. Feedback 5: One of the symptoms in major depressive disorder is lack of interest in activities that one used to enjoy. The return of interest in activities and in social interaction are indications that the depression is abating.

Susan is being seen in the emergency department. Her sister brought her in with concern that Susan is depressed and might be suicidal. Which of the following questions are priorities for the nurse to ask when assessing for suicide risk? Select all that apply. 1) "Why are you feeling depressed and suicidal?" 2) "Are you having thoughts of hurting or killing yourself?" 3) "When you have these thoughts, do you have a plan in mind?" 4) "Do you ever feel like you want to hurt someone else?" 5) "Are you currently using any drugs or alcohol?"

2, 3, 5 Rationale Feedback 1: This question is not relevant and, in general, is nontherapeutic. It challenges the client and does not identify level of suicide risk. Feedback 2: Asking this question elicits information about whether the client is having suicide ideation and promotes further assessment of how often, how intrusive, and how intentional the person perceives these ideas to be. Feedback 3: Asking this question allows the nurse to assess whether the client's thoughts have become more specific and intentional. It also allows the nurse to assess the lethality of means, which is important information in assessing suicide risk. Additional assessment should include an assessment of whether or not the client has access to the identified means for attempting suicide. Feedback 4: This question is directed toward assessing other directed violence and/or homicidal ideation rather than suicidal ideation. Feedback 5: This is a priority question, since evidence supports that substance abuse by people with depression and suicidal ideation increases the risk for suicide.

Assessment of a client reveals severe and sudden mood swings from mania to depression. Which diagnosis should the nurse suspect? 1. Dysthymic disorder 2. Bipolar disorder 3. Major depressive disorder 4. Personality disorder

2. Bipolar disorder Persons with bipolar disorder live in a world that fluctuates between the emotional extremes of mania and depression. Dysthymic disorder does not involve mania. Major depressive disorders do not involve mania. Emotional extremes of mania and depression are not indicative of a personality disorder. REF: Page 241

13. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

2. Discontinue the fluoxetine and rethink the client's diagnosis.

A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 PM when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? 1. Gently explain the policy to the family and then implement it. 2. Inquire of the nursing supervisor how an exception to the policy could be made. 3. Call the client's primary care provider for advice. 4. Move the deceased to an empty room and assign an aide to stay with the body.

2. Inquire of the nursing supervisor how an exception to the policy could be made; When possible, modifications of policy that demonstrate respect for individual differences should be explored. The primary care provider is in no position to modify the implementation of hospital policy (option 3). Utilizing an empty room and a staff member is an inappropriate use of resources.

People who complete suicide often have extremely low levels of which neurotransmitter? 1. GABA 2. Serotonin 3. Norepinephrine 4. Acetylcholine

2. Serotonin People who complete suicide often have extremely low levels of the neurotransmitter serotonin. Impairments in the serotonergic system contribute to suicidal behavior. People who make near-lethal suicide attempts have much lower levels of the neurotransmitter dopamine and omega-3. Low levels of the other neurotransmitters have not been implicated in completed suicides

When one of your assigned clients dies, an autopsy will most likely be performed in which of the following circumstances? 1. when one of the family members requests it 2. when death occurs suddenly or within 48 hours of hospital admission 3. if the client was sick for a long period of time 4. if, prior to death, the client suspected others of causing harm

2. when death occurs suddenly or within 48 hours of hospital admission; The law requires that an autopsy be performed when death is sudden or occurs within 48 hours of admission to a hospital.

Lamont has been scheduled for electroconvulsive therapy (ECT) and asks the nurse, "Is it true what I heard, that ECT causes brain damage?" Which of these would be the most appropriate, evidence-based response by the nurse? 1) "ECT has no effect on brain function at all." 2) "ECT has only been shown to cause brain damage in the elderly population." 3) "There is no evidence that ECT causes permanent changes in brain structure or function." 4) "Current evidence suggests that brain damage after ECT treatments is related to the anesthetic agents, not the treatment itself."

3 Rationale This is the most accurate statement, based on current evidence. It is identified, however, as an area that needs continuing study.

Ursula has sought counseling for persistent depressive disorder. She identifies that she has "always had low self-esteem" and says "I just let people walk all over me." The nurse is providing psycho-educational groups on improving self-esteem. Ursula would likely benefit from education on which of the following topics? 1) Antipsychotic medications 2) Anger management 3) Assertive communication 4) Alcoholics Anonymous groups

3 Rationale Education in assertive communication is recognized as an intervention to build positive self-esteem. Ursula's statement that she lets people walk all over her is an indication that this would be beneficial education for her.

Hannah is being evaluated for postpartum depression after she reported to her family physician that she just doesn't think she can take care of her baby. She expresses fear that God will take her children from her for being a bad mother. Which of the following is the highest priority for the nurse to assess during the initial interview? 1) The number of children Hannah is currently trying to care for. 2) Availability of support systems in Hannah's family. 3) Risks for suicide and/or infanticide. 4) What time of day the symptoms occur.

3 Rationale The risks for suicide and/or infanticide should not be overlooked. Hannah's concern that she can't care for the baby and that God might take her children raises additional concern that further assessment for these risks is a priority.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? 1. According to psychoanalytic theory, depression is a result of negative perceptions. 2. According to object-loss theory, depression is a result of overprotection. 3. According to learning theory, depression is a result of repeated failures. 4. According to cognitive theory, depression is a result of anger turned inward.

3 (According to learning theory, depression is a result of repeated failures.) (Rationale: The nurse should assess that, according to learning theory, this client's depressive symptoms may have resulted from repeated failures. The learning theory is a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.)

A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement. 2. Encourage the client to share mood improvement in group. 3. Increase the level of this client's suicide precautions. 4. Request that the psychiatrist reevaluate the current medication protocol.

3 (Increase the level of this client's suicide precautions.) (Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.)

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why? 1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure. 2. Establish room restrictions, because the client's threat is an attempt to manipulate the staff. 3. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts. 4. Call an emergency treatment team meeting, because the client's threat must be addressed. 4 (The client will establish a trusting relationship with the nurse.)

3 (Place client on one-to-one suicide precautions, because specific plans likely lead to attempts.) (Rationale: The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.)

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

3 (Placing the client on one-to-one observation while continuing to monitor suicidal ideations.) (Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.)

A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent increased intracranial pressure resulting from anoxia. 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation. 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles. 4. To prevent blocked airway, resulting from seizure activity.

3 (To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.) (Rationale: The nurse administers 100 percent oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.)

The physician tells your assigned client that their chest X-ray shows they have lung cancer. Based on your understanding of the work of Kubler-Ross, which of the following reactions would you most expect from this client during the next day or two? 1. acceptance 2. anger 3. depression 4. denial

4. denial; The five phases or stages of grieving, according to Kubler-Ross, are denial, anger, bargaining, depression, and acceptance.

At which age does a child begin to accept that he or she will someday die? 1. Less than 5 years old 2. 5-9 years old 3. 9-12 years old 4. 12-18 years old

3. 9-12 years old; Until children are about 5 years old, they believe death is reversible. Between ages 5 and 9, the child knows death is irreversible but believes it can be avoided (option 2). Between 9 and 12 years of age, the child recognizes that he or she, too, will someday die (option 3). At 12 to 18 years old, the child builds on previous beliefs and may fear death, but often pretends not to care about is (option 4).

A family with five children experiences a stillbirth. While intervening with the family, one member expresses a view that causes special concern for the nurse. This person is: 1. A 3-year-old who wonders if the baby will come home after it gets better 2. A 5-year-old who cries, believing the death occurred because the child drew with magic markers on one of the baby blankets 3. A 13-year-old who assumes blame as punishment for shoplifting 4. A 15-year-old who says, "I still can't believe it is true."

3. A 13-year-old who assumes blame as punishment for shoplifting; A child of 3 does not understand the concept of death, or its permanence. A child of 5 may associate death with unrelated actions. A 15-year-old is expected to follow similar stages of grief, including denial.

The nurse working in a long-term care facility is assigned to a client who is in a persistent vegetative state and who has a nasogastric feeding tube. The family asks to have the tube removed. What is the nurse's best course of action? 1. Remove the nasogastric feeding tube. 2. See if the physician objects to the removal of the tube. 3. Check facility policy and laws regarding this situation. 4. Get a doctor's order for tube removal

3. Check facility policy and laws regarding this situation; Legal issues related to death are prescribed by the laws of the region and the policies of the health-care institution. In some states this nasogastric tube can be removed at the request of the family and/or the physician; in other states it can be removed only if the client has an advanced directive.

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

Which of the following individuals is more likely to experience depression? 1. Older adult with pet 2. Male older adult 3. Medically ill older adult 4. Older adult living alone

3. Medically ill older adult High rates of depression occur in older medically ill adults. The highest rates of depression in older adulthood occur in elderly women, medically ill persons, and individuals in long-term care facilities. Higher rates of depression occur in elderly women. Older adults living alone are not associated with higher rates of depression. REF: Page 238 and 239

A depressed client has been prescribed a selective serotonin reuptake inhibitor. Which medication may have been prescribed? 1. Amitriptyline (Elavil) 2. Clonazepam (Klonopin) 3. Sertraline (Zoloft) 4. Lorazepam (Ativan)

3. Sertraline (Zoloft) Selective serotonin reuptake inhibitors are more often prescribed for the treatment of depression because of their low incidence of side effects. Amitriptyline (Elavil) is a tricyclic antidepressant. Clonazepam (Klonopin) is a mood-stabilizing medication. Lorazepam (Ativan) is a benzodiazepine. REF: Page 244

The client has been close to death for some time and the family asks how the nurse will know when the client has actually died. Which of the following would be the most accurate response from the nurse? 1. When the blood pressure can no longer be 2. When the gag reflex is no longer present. 3. When there is no apical pulse. 4. When the extremities are cool and dark in color.

3. When there is no apical pulse; If there is no heartbeat, the client has died. Before death, the blood pressure may not be able to be heard on auscultation because it is very low (option 1). Loss of the gag reflex (option 2) occurs with loss of muscle tone but can exist in many circumstances unrelated to dying. Vasodialation and pooling of fluids at the end of life may cause cool and darkened extremities, but these are not reliable signs of death (option 4).

1.Assessing lung sounds 2.Monitoring temperature 3.Administering intravenous (IV) fluids 4.Performing range-of-motion exercises to the extremities

3.Administering intravenous (IV) fluids Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated with medications to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse should prepare to infuse IV fluids as prescribed and continue to monitor urine output. Options 1, 2, and 4 will not maintain viability of the kidneys.

A postoperative patient is currently asleep. Therefore the nurse knows that: A. The sedative administered may have helped him sleep, but assessment of pain is still needed. B. The intravenous (IV) pain medication is effectively relieving his pain. C. Pain assessment is not necessary. D. The patient can be switched

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's 'sweet 16' birthday party, I'll be ready to die." Which phase of coping is this client experiencing? 1.Anger 2.Denial 3.Bargaining 4.Depression

3.Bargaining Rationale: Denial, bargaining, anger, depression, and acceptance are recognized stages that a client facing a life-threatening illness experiences. Bargaining identifies a behavior in which the individual is willing to do anything to avoid loss or change the prognosis or fate. Anger also may be a first response to upsetting news, and the predominant theme is "Why me?" or the blaming of others. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn.

Tara experienced the death of a parent 2 years ago. She has not been able to work since the death, cannot look at any of the parent's belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes Tara's problem? 1) Post-trauma syndrome R/T parent's death. 2) Anxiety R/T parent's death. 3) Coping, ineffective, R/T parent's death. 4) Grieving, complicated, R/T parent's death.

4 Rationale The excessive reactions that the individual continues to exhibit, such as daily crying, inability to return to work, and inability to look at the parent's belongings after a 2-year period, are indicative of dysfunctional or complicated grieving. This individual's grieving response has arrested in the anger stage of grief and is manifested by exaggerated grieving behaviors.

Shelly is a patient on the inpatient psychiatric unit and was diagnosed with major depressive disorder. She is staying in her room and sleeping most of the day. Which of the following approaches by the nurse would best facilitate getting Shelly involved in the occupational therapy group on the unit? 1) "Would you like to go to occupational therapy? It is starting right now." 2) "Let me know what activities you want to be involved in and I'll give you a schedule." 3) "If you don't go to occupational therapy today, you will have to stay in your room for the entire evening." 4) "Occupational therapy is starting in 30 minutes; I'll help you get ready."

4 Rationale This response by the nurse uses an active approach (stating the expected behavior rather than encouraging the patient to decide), provides time to prepare, and offers assistance in the process. This approach would most likely facilitate Shelly's participation in the occupational therapy activities.

A client is being treated with sertraline (Zoloft) for major depression. The client tells the nurse, "I've been taking this drug for only a week, but I'm sleeping better and my appetite has improved." Which is the most appropriate response by the nurse? 1) "It will take a minimum of 3 to 4 weeks for therapeutic effects to occur." 2) "Sleep disturbances and appetite problems are not affected by Zoloft." 3) "A change in your environment and activity is the reason for this improvement." 4) "The initiation of Zoloft therapy can improve insomnia and appetite within 1 week."

4 Rationale Zoloft is known to improve middle and terminal insomnia, appetite disturbances, and anxiety as early as 1 week after initiation of treatment.

A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis? 1. The client is disheveled and malodorous. 2. The client refuses to interact with others and isolates self in room. 3. The client is unable to feel any pleasure. 4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

4 (Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.)

A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives? 1. "It's all my fault for trusting him." 2. "I don't play games. I never win." 3. "She never visits because she thinks I don't care." 4. "I don't have a green thumb. Any old fool can grow a rose."

4 ("I don't have a green thumb. Any old fool can grow a rose.") (Rationale: Examples of automatic thoughts in depression include: Personalizing: "I'm the only one who failed." All or nothing: "I'm a complete failure." Mind reading: "He thinks I'm foolish." Discounting positives: "The other questions were so easy. Any dummy could have gotten them right.")

12. A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Fluoxetine (Prozac)

4 (Fluoxetine (Prozac) (Rationale: Fluoxetine (Prozac) has been approved by the FDA to treat depression in children and adolescents, and escitalopram was approved in 2009 for treatment of depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.)

A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal. 2. Conducting 15-minute checks to ensure safety. 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations. 4. Encouraging client to express feelings related to suicide.

4 (The client has maxed-out charge cards and exhibits promiscuous behaviors.) (Rationale: The nurse's priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.)

A 22-year-old client with recent paraplegia lashes out and curses at the nurse about the breakfast meal. The nurse's best response is: 1. "I know you are angry, but I cannot let you make me become the object of your anger. I will send up the dietician." 2. "This is not about breakfast. Tell me what you are really angry about." 3. "I understand you are angry. I'll shut the door and let you cool off." 4. "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"

4. "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"; Acknowledging the client's anger and helping the client understand the source of the anger is helpful. Do not take the anger personally. Allow choices and control when possible.

An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss? 1. "I told the doctor I would stop driving, but I am not going to yet." 2. "I always knew this day would come, but I hoped it wouldn't be now." 3. "What does he know? I'm a better driver than he will ever be." 4. "Well, at least I have friends and family who can take me places."

4. "Well, at least I have friends and family who can take me places"; Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss. Although the other options are responses the client might likely give and feel, and are not pathologic, they do not demonstrate movement toward a goal of adaptation nor problem solving.

A client on artificial life support meets the criteria for death when the electroencephalogram (EEG) has been flat for which of the following periods of time? 1. one hour 2. four hours 3. eight hours 4. 24 hours

4. 24 hours; When a client on artificial life support has an electroencephalogram that has had a flat reading for at least 24 hours, the person can be considered dead.

Which of the following theoretical models focuses on depression as a group of learned responses? 1. Interpersonal model 2. Psychoanalytical model 3. Social model 4. Behavioral model

4. Behavioral model According to the behavioral model, all behavior is learned, and depression results from learned responses. According to the interpersonal model, behavior is motivated by avoidance of anxiety and attainment of satisfaction. According to the psychoanalytical model, mood disorders result from anger turned inward. According to the social model, depression results from faulty social interactions. REF: Page 237

The nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life-threatening conditions. Which of the following is the most important assessment data for the nurse to gather at this time? 1. Availability of insurance coverage for rebuilding the house. 2. Family members' understanding of the extent of their physical injuries. 3. Psychological support resources available from friends or other sources. 4. Family members' grief responses and coping behaviors.

4. Family members' grief responses and coping behaviors; To plan with and assist the family, the nurse needs more data regarding the family's reactions to their loss. Information on issues such as insurance coverage (option 1) can wait until later and may be more appropriately the responsibility of social services rather than the nurse. It is important for the nurse to determine their understanding of their injuries but they are stated as minor (option 2). Once the nurse as assessed the family's responses, it will be important to determine the availability of outside resources to assist them (option 3).

When the body of a deceased client is prepared prior to removal by the undertaker, it is most important that the nursing staff in a health-care facility do which of the following? 1. Wash the body. 2. Remove any dentures, hearing aides, and glass eyes. 3. Say the last rites. 4. Have two correct identification tags on the body.

4. Have two correct identification tags on the body; If the body is inappropriately identified and prepared incorrectly for burial or funeral, legal problems may result. In the hospital, the wrist identification tag is left on and another tag is tied to the ankle in case one of the tags becomes detached. In other facilities, which do not have a wrist tag system, two tags need to be on in case one is lost.

A middle-aged man has lost all sources of income. He is unable to function, cares about nothing, and feels powerless. His feelings of worthlessness and despair have lasted 3 weeks. He is suffering from which of the following? 1. Dysthymia 2. Mild depression 3. Moderate depression 4. Major depressive episode

4. Major depressive episode When depression is severe and lasts longer than 2 weeks, it is a major depressive episode. Dysthymia, or moderate depression, persists over time, and feelings of depression begin to seriously interfere with daily living. Mild depression is short-lived and usually is triggered by life events or situations outside the individual. Dysthymia, or moderate depression, persists over time, and feelings of depression begin to seriously interfere with daily living. REF: Page 240

While talking to adult children of a dying client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that the client was a parent who often showed love but followed it with criticism, anger, damaging accusations, and emotional abuse. The nurse suggests an intervention that may be helpful to the client and other family members. The most likely intervention to be helpful is: 1. Listening to relaxation tapes before visiting each other. If negative feelings arise, listen to the tapes together. 2. Having a nurse present in the room at all times when one of them visits the client. The nurse will intervene with conflict resolution if problems arise. 3. Assuring the client and children that the past no longer matters. The only time that matters is the present and the future. 4. Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together.

4. Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together; Relaxation tapes help with stress reduction, but do not help resolve problems experienced by the client and children. Staffing needs do not permit a nurse to be with one client continually, and families require privacy as well. Assurance that the past no longer matters is an assurance lacking concrete properties.

A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? 1.The client demonstrates having adequate financial resources to pay for health care for many more years. 2. The client spends the majority of his or her time in spiritual reflection. 3. The client has no signs or symptoms of preventive complications of the illness. 4. The client verbalizes satisfaction with current relationships with other persons.

4. The client verbalizes satisfaction with current relationships with other persons; Quality of life is determined by the client and expressed in terms of his and her satisfaction with a variety of aspect of life. Although being able to pay for care (option 1), having apparent spiritual peace (option 2), and absence of physiological complications (option 3) may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal.

A client questions the nurse about the difference between a living will and power of attorney. The nurse's best response is: 1. A lawyer carries a living will, while a designated family member or friend carries 2. In a living will, the client specifies medical treatments to be carried out when incapable of making decisions, while durable power of attorney allows the client to include both treatments to be carried out and treatments to be omitted in the event of terminal illness. 3. The living will indicates when a client wishes life support to be discontinued, while durable power of attorney give that power to another in the event of terminal illness. 4. The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client.

4. The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client; A living will is a legal document that expresses an individual's decision on the use of artificial life support systems. Power of attorney is a written instrument which authorizes one person to act as another's agent or attorney.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the *emotional* needs of the client and spouse? 1.Allow family members to name the infant. 2.Encourage the client to talk about the dead fetus. 3.Allow the client and the spouse to hold the infant. 4.Assess the client's and the spouse's perception of the event.

4.Assess the client's and the spouse's perception of the event. Rationale: The initial intervention in planning to meet the emotional needs of the client and her spouse is to assess their perception of the event. Although options 1, 2, and 3 are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event.

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurseʻs priority? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects

A substance that can cause analgesia when it attaches to opiate receptors in the brain is: A. Endorphin B. Bradykinin C. Substance P D. Prostaglandin

The goal of cognitive therapy with depressed clients is to: A. Identify and change dysfunctional patterns of thinking. B. Resolve the symptoms and initiate or restore adaptive family functioning. C. Alter the neurotransmitters that are creating the depressed mood. D. Provide feedback from peers who are having similar experiences.

A Rationale Cognitive therapy focuses on identifying and changing dysfunctional patterns of thinking. Resolving symptoms and initiating or restoring adaptive family functioning is the goal of Family Therapy. Altering the neurotransmitters that are creating the depressed mood is the goal with psychopharmacology. Providing feedback from peers who are having similar experiences happens with Self-Help Groups.

The nurse identifies the primary nursing diagnosis for Theresa as Risk for Suicide related to feelings of hopelessness from loss of relationship. Which is the outcome criterion that would most accurately measure achievement of this diagnosis? A. The client has experienced no physical harm to herself. B. The client sets realistic goals for herself. C. the client expresses some optimism and hope for the future. D. The client has reached a stage of acceptance in the loss of the relationship with her boyfriend.

A Rationale The immediate risk for this client is suicide. It is important to make sure this client is free from harm before addressing long term goals.

Some Biological factors may be associated with the predisposition to suicide. Which of the following biological factors have been implicated? A. genetics and decreased levels of serotonin B. Hereditary and increased levels of norepinephrine C. Temporal lobe atrophy and decreased levels of acetylcholine D. Structural alterations of the brain and increased levels of dopamine.

A Rationale Twin studies have resulted in a possible genetic predisposition. Deficiency of serotonin and changes in the noradrenergic system have been found in suicidal patients and victims.

A client with depression has just been prescribed the antidepressant phenelizine (Nardil). She says to the nurse, " The doctor says I will need to watch my diet while I'm on this medication. What foods should I avoid?" Which of the following is the correct response by the nurse? A. blue cheese, red wine, raisins B. black beans, garlic, pears C. pork, shellfish, egg yolks D mild, peanuts, tomatoes

A Rationale phenelizine is an MAOI. MAOI is known to have serious adverse effects with the possibility of developing hypertensive crisis with the consumption of foods that contain tyramine. Tyramine is found in blue cheese, red wine, and raisins.

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) A. Apply ice using firm pressure over skin. B. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. C. Apply ice until numbness occurs and discontinue application. D. Apply ice for no longer than 10 minutes.

A, B

The nurse is teaching a client about prevention methods for pain. Which item should the nurse include in the teaching session? (Select all that apply.) A. Avoiding risky behaviors B. Eating a balanced diet C. Exercising daily D. Ignoring symptoms E. Taking medications as prescribed

A, B, C

Which of the following interventions are appropriate for a client of suicide precautions? (Select ALL that apply). A. Remove all sharp objects, belts, and other potentially dangerous articles from the client's environment. B. Accompany the client to off-unit activities C obtain a promise from the client that she will not do anything to harm herself for the next 12 hours. D. Put all of the client's possessions in storage and explain to her that she may have them back when she is off suicide precautions.

A, B, C Rationale Appropriate interventions include accompany the client, obtain a no harm contract that is short term, and remove any dangerous objects. Removing all of the client's possessions may further increase a client's risk due to feelings of isolation.

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She is currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (SATA) A. Age B. Gender C. History of chronic asthma D. Smoking E. Being married

A, B, C, D

A client with a life-threatening illness has been treated with repeated doses of opioids over a period of several weeks. Which symptom obtained in the assessment should indicate to the nurse that the client is experiencing side effects related to medication administration? (Select all that apply.) A. Pruritus B. Vomiting C. Constipation D. Sweating E. Sedation

A, B, C, E

A client has just been admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which of the following behavioral manifestations might the nurse expect to assess? (Select ALL that apply) A. Slumped posture B. Delusional thinking C. Feelings of despair D. Feels best early in the morning and worse as the day progresses E. Anorexia

A, B, C, E Rationale Behavioral symptoms of severe depression include slumped posture, walking slowly, virtually nonexistent communication, delusional thinking, no personal hygiene. Affective symptoms of depression include: feelings of total despair, hopelessness, and worthlessness, flat unchanging affect, sadness, and inability to feel pleasure. Physiological symptoms of severe depression include: constipation, urinary retention, anorexia, weight loss, difficulty falling asleep and awakening very early in the morning. D is incorrect because -- people with severe depression feel worse early in the morning and somewhat better as the day progresses. * Individuals with Moderate depression experience feeling better early in the morning and worse as the day progresses.

In developing a plan of care for a client receiving an antihistamine antiemetic drug, which nursing diagnosis would be the highest priority? A. Deficient fluid volume related to nausea and vomiting B. Impaired physical mobility related to adverse effects of drugs C. Deficient knowledge regarding medication administration D. Risk for injury related to adverse effects of medication

A. Although all of the options are appropriate nursing diagnoses, fluid volume deficit is the highest priority because it has the highest associated mortality rate. Although a fall or injury could also prove fatal, this diagnosis is a risk; actual nursing diagnoses have priority over potential diagnoses.

The nurse plans to administer 50 mg of diphenhydramine (Benadryl) intravenously. How will the nurse administer this medication? A. Undiluted over 2 minutes B. Diluted in 50 mL normal saline over 30 minutes C. Undiluted over 1 minute D. Diluted in 100 mL D5W over 20 minutes

A. Diphenhydramine should be administered undiluted at a rate of 25 mg/min.

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client? (Select all that apply.) A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes E. Being married

A. Age of 35 years old B. Female gender C. Currently smokes Rationale: Depressive disorders are more prevalent in adults between the ages of 15 and 40, twice as common in females than males, and are more common in clients who have a chronic medical illness. Depressive disorder are more common in unmarried rather than married clients.

A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The nurse recognizes that which of the following findings are suggestive of postpartum depression? (Select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Crying

A. CORRECT: Fatigue is a finding suggestive of postpartum depression. B. CORRECT: Insomnia is a finding suggestive of postpartum depression. C. INCORRECT: Euphoria is not associated with postpartum depression. D. CORRECT: A flat affect is a finding suggestive of postpartum depression. E. CORRECT: Crying is a finding suggestive of postpartum depression.

A nurse is caring for a client who has postpartum depression. Which of the following are expected findings? (Select all that apply.) A. Disappointment in the characteristics of the infant B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Postpartum physical discomfort and/or pain

A. INCORRECT: Disappointment in the characteristics of the infant would be an indication of impaired mother-infant bonding. B. CORRECT: Feelings of financial inadequacy to provide for family is a finding associated with postpartum depression. C. CORRECT: A client's anxiety about assuming a new role as a mother is a finding associated with postpartum depression. D. CORRECT: The rapid decline in estrogen and progesterone is a finding associated with postpartum depression. E. CORRECT: Physical discomfort and/or pain is a finding associated with postpartum depression

Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient? A. Older adults have usually sustained many losses in life, which influence the current loss. B. Older adults with a poor memory experience grief less intensely. C. Older adults generally handle loss better because they have more experience with it. D. Social support is less important because an older adult's circle of friends has become smaller.

A. Older adults have usually sustained many losses in life, which influence the current loss. Older adults have usually sustained more losses because they have lived longer. For people at any age, each loss influences the way one responds to subsequent losses. The loss of a social network makes it more important to find resources and sources of social support for grieving older adults. Sometimes many losses overpower a person's coping resources instead of making him or her stronger.

The nurse is planning care for a client experiencing acute pain. Which should the nurse include in the health history portion of the nursing assessment? A. Using a developmentally appropriate tool B. Assessing facial expressions C. Inspecting injuries D. Monitoring vital signs

A. Using a developmentally appropriate tool

The nurse plans to assess a client for pain. Which self-reporting tool should the nurse consider using for this assessment? A. Visual analog scale B. Glasgow coma scale C. Braden scale D. Cage assessment

A. Visual analog scale

14. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client's safety upon discharge? 1. Provide a 6-month supply of Elavil to ensure long-term compliance. 2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments. 3. Provide pill dispenser as a memory aid. 4. Provide education regarding the avoidance of foods containing tyramine.

ANS: 2 Rationale: The health-care provider should provide no more than a 1-week supply of amitriptyline, with refills contingent on follow-up appointments, as an appropriate intervention to maintain the client's safety. Antidepressants, which are central nervous system depressants, can be used to commit suicide. Also these medications can precipitate suicidal thoughts during the initial use period. Limiting the amount of medication and monitoring the client weekly would be appropriate interventions to address the client's risk for suicide. Cognitive Level: Application Integrated Process: Implementation

13. A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam? 1. To rule out bipolar disorder 2. To rule out schizophrenia 3. To rule out neurocognitive disorder 4. To rule out personality disorder

ANS: 3 Rationale: A mini-mental status exam should be performed to rule out neurocognitive disorder. The client may be experiencing reversible dementia, which can occur as a result of depression. Cognitive Level: Application Integrated Process: Evaluation

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an excessively religiously based household maybe at risk for experiencing guilt to the point of accepting liability in situations for which one is not responsible. The client may view himself or herself as evil and deserving of punishment leading to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicating

ANS: A, D The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than 2 years. The essential feature of dysthymia is a chronically depressed mood which can have an early or late onset.

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Depressed clients do not care enough about themselves to participate in grooming and hygiene.

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."

ANS: B When a client diagnosed with depression expresses physical complaints, the client is experiencing somatic symptoms. Somatic symptoms occur with depression because of a general slowdown of the entire body reflected in sluggish digestion, constipation, impotence, anorexia, difficulty falling asleep, and a wide variety of other symptoms.

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

The use of patient disctraction in pain control is based on the principle that: A. Small C fibers transmit impulses via the spinothalamic tract B. The reticular formation can send inhibitory signals to gating mechanisms C. Large A fibers compete with pain impulses to close gates to painful stimuli D. Transmission of pain impulses from the spinal cord to the cerebral cortex can be inhibited

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out senile dementia D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.

ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.

A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving monoamine oxidase inhibitor (MAOI) who consume foods or drugs high in tyramine content.

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

A client is diagnosed with dysthymic disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

13. A medical nurse is providing end-of-life care for a patient with metastatic bone cancer. The nurse notes that the patient has been receiving oral analgesics for her pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do? A) Request the physician to order analgesics by an alternative route. B) Crush the medication in order to aid swallowing and absorption. C) Administer the patients medication with the meal tray. D) Administer the medication rectally.

Ans: A Feedback: A change in medication route is indicated and must be made by a physicians order. Many pain medications cannot be crushed and given to a patient. Giving the medication with a meal is not going to make it any easier to swallow. Rectal administration may or may not be an option.

12. One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category? A) Uplifting memories B) Ignoring negative outcomes C) Envisioning one specific outcome D) Avoiding an actual or potential threat

Ans: A Feedback: Hope is a multidimensional construct that provides comfort as a person endures life threats and personal challenges. Uplifting memories are noted as a hope-fostering category, whereas the other listed options are not identified as such.

7. An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A) The patient and family should be viewed as a single unit of care. B) Persistent symptoms of terminal illness should not be treated. C) Each member of the interdisciplinary team should develop an individual plan of care. D) Terminally ill patients should die in the hospital whenever possible. Ans:

Ans: A Feedback: Hospice care requires that the patient and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care.

19. The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority? A) Allowing the patient to express her feelings without judging her B) Helping the patient to understand the phases of the grieving process C) Reassuring the patient that the childs death is not her fault D) Arranging for genetic counseling to inform the patient of her chances of having another child with the disease

Ans: A Feedback: Listening to the patient express her feelings openly without judging her is the highest priority. The nurse should not impose his or her own values on the patient. The nurse should also help the patient to understand the grieving process and use all the support systems that are available to assist her in coping with this situation. Genetic counseling may be appropriate at a later time.

17. The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying? A) Depression B) Denial C) Anger D) Resignation

Ans: A Feedback: Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life.

16. A patient on the medical unit is dying and the nurse has determined that the familys psychosocial needs during the dying process need to be addressed. What is a cause of many patient care dilemmas at the end of life? A) Poor communication between the family and the care team B) Denial of imminent death on the part of the family or the patient C) Limited visitation opportunities for friends and family D) Conflict between family members

Ans: A Feedback: Many dilemmas in patient care at the end of life are related to poor communication between team members and the patient and family, as well as to failure of team members to communicate with each other effectively. Regardless of the care setting, the nurse can ensure a proactive approach to the psychosocial care of the patient and family. Denial of death may be a response to the situation, but it is not classified as a need. Visitation should accommodate wishes of the family member as long as patient care is not compromised.

40. A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patients level of consciousness has declined and she is now unresponsive. How should the patients pain control regimen be affected? A) The patients pain control regimen should be continued. B) The pain control regimen should be placed on hold until the patients level of consciousness improves. C) IV analgesics should be withheld and replaced with transdermal analgesics. D) The patients analgesic dosages should be reduced by approximately one half.

Ans: A Feedback: Pain should be aggressively treated, even if dying patients become unable to verbally report their pain. There is no need to forego the IV route. There is no specific need to discontinue the pain control regiment or to reduce it.

3. The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patients strategy? A) The patient may be trying to protect loved ones from the emotional effects of the illness. B) The patient is being noncompliant in order to assert power over caregivers. C) The patient may be skeptical of the benefits of the Western biomedical model of health. D) The patient thinks that treatment does not provide him comfort.

Ans: A Feedback: Patients who are characterized as being in denial may be using this strategy to preserve important interpersonal relationships, to protect others from the emotional effects of their illness, and to protect themselves because of fears of abandonment. Each of the other listed options is plausible, but less likely.

Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95 percent B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10

6. After contributing to the care of several patients who died in the hospital, the nurse has identified some lapses in the care that many of these patients received toward the end of their lives. What have research studies identified as a potential deficiency in the care of the dying in hospital settings? A) Families needs for information and support often go unmet. B) Patients are too sedated to achieve adequate pain control. C) Patients are not given opportunities to communicate with caregivers. D) Patients are ignored by the care team toward the end of life.

Ans: A Feedback: Studies have demonstrated that the health care system continues to be challenged when meeting seriously ill patients needs for pain and symptom management and their families needs for information and support. Oversedation, lack of communication, and lack of care are not noted to be deficiencies to the same degree.

5. A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurses care? A) To improve the patients and familys quality of life B) To support aggressive and innovative treatments for cure C) To provide physical support for the patient D) To help the patient develop a separate plan with each discipline of the health care team

Ans: A Feedback: The goal of palliative care is to improve the patients and the familys quality of life. The support should include the patients physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the patient and family. The goal of palliative care is not aggressive support for curing the patient. Providing physical support for the patient is also not the goal of palliative care. Palliative care does not strive to achieve separate plans of care developed by the patient with each discipline of the health care team.

18. You are caring for a 50-year-old man diagnosed with multiple myeloma, he has just been told by the care team that his prognosis is poor. He is tearful and trying to express his feelings, but he is having difficulty. What should you do first? A) Ask if he would like you to sit with him while he collects his thoughts. B) Tell him that you will leave for now but will be back shortly. C) Offer to call pastoral care or a member of his chosen clergy. D) Reassure him that you can understand how he is feeling.

Ans: A Feedback: The most important intervention the nurse can provide is listening empathetically. Seriously ill patients and their families need time and support to cope with the changes brought about by serious illness and the prospect of impending death. The nurse who is able to listen without judging and without trying to solve the patients and familys problems provides an invaluable intervention. The patient needs to feel that people are concerned with his situation. Leaving him does not show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients, but should be done after you have spent time with the patient. Telling the patient that you understand how he is feeling is inappropriate because it does not help him express his feelings.

15. The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patients death is imminent? A) Mottling of the lower limbs B) Slow, steady pulse C) Bowel incontinence D) Increased swallowing

Ans: A Feedback: The time of death is generally preceded by a period of gradual diminishment of bodily functions in which increasing intervals between respirations, weakened and irregular pulse, and skin color changes or mottling may be observed. The patient will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and, possibly, the administration of a transdermal anticholinergic drug. Bowel incontinence may or may not occur.

25. A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. A) Financial pressures on health care providers B) Patient reluctance to accept this type of care C) Strong association of hospice care with prolonging death D) Advances in curative treatment in late-stage illness E) Ease of making a terminal diagnosis

Ans: A, B, D Feedback: Physicians are reluctant to refer patients to hospice, and patients are reluctant to accept this form of care. Reasons include the difficulties in making a terminal prognosis (especially for those patients with noncancer diagnoses), the strong association of hospice with death, advances in curative treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible patients.

27. Patients who are enrolled in hospice care through Medicare are often felt to suffer unnecessarily because they do not receive adequate attention for their symptoms of the underlying illness. What factor most contributes to this phenomenon? A) Unwillingness to overmedicate the dying patient B) Rules concerning completion of all cure-focused medical treatment C) Unwillingness of patients and families to acknowledge the patient is terminal D) Lack of knowledge of patients and families regarding availability of care

Ans: B Feedback: Because of Medicare rules concerning completion of all cure-focused medical treatment before the Medicare hospice benefit may be accessed, many patients delay enrollment in hospice programs until very close to the end of life. Hospice care does not include an unwillingness to medicate the patient to keep him or her from suffering. Patients must accept that they are terminal before being admitted to hospice care. Lack of knowledge is common, however, this is not why some Medicare patients do not receive adequate attention for the symptoms of their underlying illness.

9. The nurse is part of the health care team at an oncology center. A patient has been diagnosed with leukemia and the prognosis is poor, but the patient is not yet aware of the prognosis. How can the bad news best be conveyed to the patient? A) Family should be given the prognosis first. B) The prognosis should be delivered with the patient at eye level. C) The physician should deliver the news to the patient alone. D) The appointment should be scheduled at the end of the day.

Ans: B Feedback: Communicating about a life-threatening diagnosis should be done in a team setting at eye level with the patient. The family cannot be notified first because that would breech patient confidentiality. The family may be present at the patients request. The appointment should be scheduled when principles can all be in attendance and unrushed.

13. When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced sensation of pain. b. Inadequate or inconsistent relief of pain is widespread. c. Reliable assessment tools are currently unavailable. d. Narcotic analgesic use should be avoided.

b. Inadequate or inconsistent relief of pain is widespread.

20. You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment? A) Is she able to tell her family of negative test results? B) Does she have a sense of peace of mind and a purpose to her life? C) Can she let go of her husband so he can make a new life? D) Does she need time and space to bargain with God for a cure?

Ans: B Feedback: In addition to assessment of the role of religious faith and practices, important religious rituals, and connection to a religious community, you should further explore the presence or absence of a sense of peace of mind and purpose in life, other sources of meaning, hope, and comfort, and spiritual or religious beliefs about illness, medical treatment, and care of the sick. Telling her family and letting her husband go are not parts of a spiritual assessment. Bargaining is a stage of death and dying, not part of a spiritual assessment.

36. As a staff member in a local hospice, a nurse deals with death and dying on a frequent basis. Where would be the safe venue for the nurse to express her feelings of frustration and grief about a patient who has recently died? A) In the cafeteria B) At a staff meeting C) At a social gathering D) At a memorial service

Ans: B Feedback: In hospice settings, where death, grief, and loss are expected outcomes of patient care, interdisciplinary colleagues rely on each other for support, using meeting time to express frustration, sadness, anger, and other emotions, to learn coping skills from each other, and to speak about how they were affected by the lives of those patients who have died since the last meeting. Public settings are inappropriate places to express frustration about the death of a patient.

21. A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim? A) To prioritize emotional needs B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope

Ans: B Feedback: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care goes beyond simple prioritization of emotional needs, these are always considered and addressed. Palliative care is considered a bridge, but it is not limited to just hospice care. Hope is something patients and families have even while the patient is actively dying.

39. You are caring for a patient who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the patient asks you to stay with him for a while. The patient becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response for you to make at this time? A) Can I give you some advice? B) Do you need more time to think about this? C) Is there anything you want to say? D) I have cared for lots of patients in your position. It will get easier.

Ans: B Feedback: Prompt gently: Do you need more time to think about this? Giving advice is inappropriate and it is obvious from the scenario that the patient has something to say. Referring to other patients negates the patients feelings at this time.

23. As the American population ages, nurses expect see more patients admitted to long-term care facilities in need of palliative care. Regulations now in place that govern how the care in these facilities is both organized and reimbursed emphasize what aspect of care? A) Ongoing acute care B) Restorative measures C) Mobility and socialization D) Incentives to palliative care

Ans: B Feedback: Regulations that govern how care in these facilities is organized and reimbursed tend to emphasize restorative measures and serve as a disincentive to palliative care. Long-term care facilities do not normally provide acute care for their patients. Regulations for long-term care facilities do not primarily emphasize mobility and socialization.

33. A patients daughter has asked the nurse about helping him end his terrible suffering. The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. What does the Position Statement further stress? A) Educating families about the moral implications of assisted suicide B) Identifying patient and family concerns and fears C) Identifying resources that meet the patients desire to die D) Supporting effective means to honor the patients desire to die

Ans: B Feedback: The ANA Position Statement further stresses the important role of the nurse in supporting effective symptom management, contributing to the creation of environments for care that honor the patients and familys wishes, as well as identifying their concerns and fears. Discussion of moral implications would normally be beyond the purview of the nurse.

30. A patient has just died following urosepsis that progressed to septic shock. The patients spouse says, I knew this was coming, but I feel so numb and hollow inside. The nurse should know that these statements are characteristic of what? A) Complicated grief and mourning B) Uncomplicated grief and mourning C) Depression stage of dying D) Acceptance stage of dying

Ans: B Feedback: Uncomplicated grief and mourning are characterized by emotional feelings of sadness, anger, guilt, and numbness, physical sensations, such as hollowness in the stomach and tightness in the chest, weakness, and lack of energy, cognitions that include preoccupation with the loss and a sense of the deceased as still present, and behaviors such as crying, visiting places that are reminders of the deceased, social withdrawal, and restless overactivity. Complicated grief and mourning occur at a prolonged time after the death. The spouses statement does not clearly suggest depression or acceptance.

1. In the past three to four decades, nursing has moved into the forefront in providing care for the dying. Which phenomenon has most contributed to this increased focus of care of the dying? A) Increased incidence of infections and acute illnesses B) Increased focus of health care providers on disease prevention C) Larger numbers of people dying in hospital settings D) Demographic changes in the population

Ans: D Feedback: The focus on care of the dying has been motivated by the aging of the population, the prevalence of, and publicity surrounding, life-threatening illnesses (e.g., cancer and AIDS), and the increasing likelihood of a prolonged period of chronic illness prior to death. The salience of acute infections, prevention measures, and death in hospital settings are not noted to have had a major influence on this phenomenon.

31. A 67-year-old woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply. A) Reiterating her anger at her husbands care team B) Reinvesting in new relationships at the appropriate time C) Reminiscing about the relationship she had with her husband D) Relinquishing old attachments to her husband at the appropriate time E) Renewing her lifelong commitment to her husband

Ans: B, C, D Feedback: Six key processes of mourning allow people to accommodate to the loss in a healthy way: 1.) Recognition of the loss 2.) Reaction to the separation, and experiencing and expressing the pain of the loss 3.) Recollection and re-experiencing the deceased, the relationship, and the associated feelings 4.) Relinquishing old attachments to the deceased 5.) Readjustment to adapt to the new world without forgetting the old 6.) Reinvestment Reiterating her anger and renewing her lifelong commitment may be counterproductive to the mourning process.

26. A nurse is caring for an 87-year-old Mexican-American female patient who is in end-stage renal disease. The physician has just been in to see the patient and her family to tell them that nothing more can be done for the patient and that death is not far. The physician offers to discharge the patient home to hospice care, but the patient and family refuse. After the physician leaves, the patients daughter approaches you and asks what hospice care is. What would this lack of knowledge about hospice care be perceived as? A) Lack of an American education of the patient and her family B) A language barrier to hospice care for this patient C) A barrier to hospice care for this patient D) Inability to grasp American concepts of health care

Ans: C Feedback: Historical mistrust of the health care system and unequal access to even basic medical care may underlie the beliefs and attitudes among ethnically diverse populations. In addition, lack of education or knowledge about end-of-life care treatment options and language barriers influence decisions among many socioeconomically disadvantaged groups. The scenario does not indicate whether the patients family has an American education, whether they are unable to grasp American concepts of health care, or whether they can speak or understand English.

11. The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond? A) Privately ask the son to allow the patient to make his own health care decisions. B) Explain to the patient that he is responsible for his own decisions. C) Work with the team to negotiate informed consent. D) Avoid divulging information to the eldest son.

Ans: C Feedback: In this case of a patient who wishes to defer decisions to his son, the nurse can work with the team to negotiate informed consent, respecting the patients right not to participate in decision making and honoring his familys cultural practices.

22. The organization of a patients care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice? A) It is based on the participation of clinicians without a team leader. B) It is based on clinicians of varied backgrounds integrating their separate plans of care. C) It is based on communication and cooperation between disciplines. D) It is based on medical expertise and patient preference with the support of nursing.

Ans: C Feedback: Interdisciplinary collaboration, which is different from multidisciplinary practice, is based on communication and cooperation among the various disciplines, each member of the team contributing to a single integrated care plan that addresses the needs of the patient and family. Multidisciplinary care refers to participation of clinicians with varied backgrounds and skill sets, but without coordination and integration. Interdisciplinary collaboration is not based on patient preference and should not prioritize medical expertise over other disciplines.

24. A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based? A) Meaningful living during terminal illness requires technologic interventions. B) Meaningful living during terminal illness is best supported in designated facilities. C) Meaningful living during terminal illness is best supported in the home. D) Meaningful living during terminal illness is best achieved by prolonging physiologic dying.

Ans: C Feedback: The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness and that it is best supported in the home, free from technologic interventions to prolong physiologic dying.

10. A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response? A) I know how you are feeling. B) You have lived a long life. C) This must be very difficult for you. D) Life can be so unfair.

Ans: C Feedback: The most important intervention the nurse can provide is listening empathetically. To communicate effectively, the nurse should ask open-ended questions and acknowledge the patients fears. Deflecting the statement or providing false sympathy must be avoided.

37. A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome? A) Inefficiency in the provision of care B) Excessive weight gain C) Emotional exhaustion D) Social withdrawal

Ans: C Feedback: Well before the nurse exhibits symptoms of stress or burnout, he or she should acknowledge the difficulty of coping with others pain on a daily basis and put healthy practices in place that guard against emotional exhaustion. Emotional exhaustion is more likely to have deleterious effects than inefficiency, social withdrawal, or weight gain, though these may signal emotional exhaustion.

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? A. The drug B. The time interval C. The dose D. The route

28. One of the functions of nursing care of the terminally ill is to support the patient and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support patients and their families during this process? Select all that apply. A) Describe their personal experiences in dealing with end-of-life issues. B) Encourage the patient and family to keep fighting as a cure may come. C) Try to appreciate and understand the illness from the patients perspective. D) Assist patients with performing a life review. E) Provide interventions that facilitate end-of-life closure.

Ans: C, D, E Feedback: Nurses are responsible for educating patients about their illness and for supporting them as they adapt to life with the illness. Nurses can assist patients and families with life review, values clarification, treatment decision making, and end-of-life closure. The only way to do this effectively is to try to appreciate and understand the illness from the patients perspective. The nurses personal experiences should not normally be included and a cure is often not a realistic hope.

32. A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group? A) Providing a framework for incorporating the old life into the new life B) Normalizing adaptation to a continuation of the old life C) Aiding in adjusting to using old, familiar social skills D) Normalization of feelings and experiences

Ans: D Feedback: Although many people complete the work of mourning with the informal support of families and friends, many find that talking with others who have had a similar experience, such as in formal support groups, normalizes the feelings and experiences and provides a framework for learning new skills to cope with the loss and create a new life. The other listed options are incorrect because they indicate the need to hold onto the old life and not move on.

14. A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patients liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing? A) Administer a bolus of normal saline, as ordered. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators and corticosteroids, as ordered.

Ans: D Feedback: Bronchodilators and corticosteroids help to improve lung function as well as low doses of opioids. Low- flow oxygen often provides psychological comfort to the patient and family. A fluid bolus is unlikely to be of benefit.

35. A pediatric nurse is emotionally distraught by the death of a 9-year-old girl who received care on the unit over the course of many admissions spanning several years. What action is the most appropriate response to the nurses own grief? A) Take time off from work to mourn the death. B) Post mementos of the patient on the unit. C) Solicit emotional support from the patients family. D) Attend the patients memorial service.

Ans: D Feedback: In many settings, staff members organize or attend memorial services to support families and other caregivers who find comfort in joining each other to remember and celebrate the lives of patients. Taking time off should not be necessary and posting mementos would be inappropriate. It would be highly inappropriate to solicit emotional support from the patients family during their time of loss.

29. The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? A) Aggressively continuing to fight the disease process B) Moving the patient to a long-term care facility when it becomes necessary C) Including the children in planning their fathers care D) Supporting the patients and family's values and choices

Ans: D Feedback: Nurses need to develop skill and comfort in assessing patients and families responses to serious illness and planning interventions that support their values and choices throughout the continuum of care. To be admitted to hospice care, the patient must have come to terms with the fact that he is dying. The scenario states that the patient wants to be cared for at home, not in a long-term setting. The children may be able to participate in their fathers care, but they should not be assigned responsibility for planning it.

38. The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify? A) Helping the family to understand why the patient needs to be sedated B) Making arrangements to promptly move the patient to an acute-care facility C) Explaining to the family that death is near and the patient needs around-the-clock nursing care D) Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition

Ans: D Feedback: Nursing interventions should be aimed at accommodating the change in the patients status and maintaining her safety. The scenario does not indicate the need either to sedate the patient or to move her to an acute-care facility. If the family has the resources, there is no need to bring in nurses to be with the patient around-the-clock, and the scenario does not indicate that death is imminent.

2. A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? A) The increase in cultural diversity in the United States B) Staffing shortages in health care and questions concerning quality of care C) Increased costs of health care coupled with inequalities in access D) Ability of technology to prolong life beyond meaningful quality of life

Ans: D Feedback: The application of technology to prolong life has raised several ethical issues. The major question is, Because we can prolong life through increasingly sophisticated technology, does it necessarily follow that we must do so? The increase in cultural diversity has not raised ethical issues in health care. Similarly, costs and staffing issues are relevant, but not central to the most common ethical issues surrounding palliative care.

In determining degree of suicidal risk with a suicidal client, the nurse assess the following behavioral manifestations: severely depressed, withdrawn, statements of worthlessness, difficulty accomplishing activities of daily living, no close support systems. The nurse identifies the client's risk for suicide as: A. low B. moderate C. high D unable to determine

C Rationale severe depression, withdrawn statements, difficulty with ADL's, and no support system indicate a high risk of suicide. Refer to Table 17-2 Assessing the Degree of Suicidal Risk on page 279

8. A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this? A) The patient is not listening effectively. B) The patient is noncompliant with the plan of care. C) The patient may have a low intelligence quotient or a cognitive deficit. D) The patient has not achieved the desired learning outcomes.

Ans: D Feedback: The nurse should be sensitive to patients ongoing needs and may need to repeat previously provided information or simply be present while the patient and family react emotionally. Telling a patient something is not teaching. If a patient continues to ask the same questions, teaching needs to be reinforced. The patients response is not necessarily suggestive of noncompliance, cognitive deficits, or not listening.

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate? A. No action is required by the nurse because the order is appropriate. B. Request to have the ordered changed to ATC (around the clock) for the first 48 hours. C. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. D. Begin the Vicodin when the patient shows nonverbal symptoms of pain.

Comes from bone, joint, muscle, skin or connective tissue; is usually aching or throbbing in quality & well localized: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (0-10 point scale). In prioritizing activities for the visit, what should the nurse do first? A) Auscultate for breath sounds. B) Administer PRN pain medication. C) Check pressure points for skin breakdown. D) Ask family about patient's food and fluid intake.

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. B. The patient's report of pain is the best method for assessing the pain. C. The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. D. The nurse is the most experienced at assessing pain.

Success of long-term psychotherapy with Theresa (who attempted suicide following a breakup with her boyfriend) could be measured by which of the following behaviors? A. Theresa has a new boyfriend. B. Theresa has an increased sense of self-worth C. Theresa does not take antidepressants anymore D. Theresa told her old boyfriend how angry she was with him for breaking up with her.

B Rationale A long term goal would be that the client has increased sense of self-worth. Other long term goals include: -Develop and maintain a more positive self-concept. -Learn more effective ways to express feelings to others -Achieve successful interpersonal relationships - Feel accepted by others and achieve a sense of belonging.

Theresa, who has been hospitalized following a suicide attempt, is placed on suicide precautions on the psychiatric unit. She admits that she is still feeling suicidal. Which of the following interventions is the most appropriate in this instance? A. Obtain an order from the physician to place Theresa in restraints to prevent any attempts to harm herself. B. Check on Theresa every 15 minutes or assign a staff person to stay with her on a one-to-one basis. C. Obtain an order from the physician to give Theresa a sedative to calm her and reduce suicide ideas. D. Do not allow Theresa to participate in any unit activities while she is on suicide precautions.

B Rationale It is important to maintain close observation of the client. Depending on level of suicide precaution, provide one-to-one contact, constant visual observation, or every 15 minute checks. Place the client in a room close to the nurse's station; do not assign to a private room. Accompany to off-unit activities if attendance is indicated. May need to accompany to bathroom.

A newly admitted depressed client isolates herself in her room and just sits and stares into space. How best might the nurse begin an initial therapeutic relationship with this client? A. Say, "Come with me. I will go with you to group therapy. B. Make frequent short visits to her room and sit with her. C. Offer to introduce her to the other clients. D. help her to identify stressors in her life that precipitate crises.

B Rationale It is important to begin establishing a trusting relationship with the client so just taking the time to sit quietly with the client will show them that you care and have an interest in their wellbeing.

The physician orders sertraline (Zoloft) 50 mg PO bid for Margaret, a 68 year old women with major depressive disorder. After 3 days of taking the medication, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." What is the most appropriate response by the nurse? A. Cheer up, Margaret. You have so much to be happy about. B. Sometimes it take a few weeks for the medicine to bring about an improvement in symptoms. C. I'll report that to the physician, Margaret. Maybe he will order something different. D. Try not to dwell on your symptoms. Why don't you join the others down in the dayroom?

B Rationale To answer this question it is important to understand the action of Zoloft and the amount of time it takes to be in the body before it becomes effective. It can take up to a few weeks before there is an improvement in symptoms.

Which of the following individuals is at the highest risk for suicide? A. Nancy, age 22, Asian American, Catholic, middle socioeconomic group, alcoholic B. John, age 72, white, Methodist, low socioeconomic group, diagnosis of metastatic cancer of the pancreas C. Carol, age 15, African American, Baptist, high socioeconomic group, no physical or mental health problems D. Mike, age 55, Jewish, middle socioeconomic group, suffered myocardial infarction a year ago

B Rationale John is an older white male and even though he is involved with a church his low socioeconomic status and diagnosis of a terminal illness increases his risk for suicide.

Before administering the anticholinergic drug scopolamine (Transderm-Scōp), the nurse should carefully assess the client for a history of which condition? A. Hyperthyroidism B. Glaucoma C. Gastroenteritis D. Rheumatoid arthritis

B. Anticholinergic drugs are contraindicated in clients with glaucoma. These drugs can cause pupillary dilation, which can obstruct the flow of aqueous humor and increase intraocular pressure.

A client receiving an anticholinergic drug to treat nausea and vomiting should be taught to expect which adverse effect? A. Lacrimation B. Dry mouth C. Diarrhea D. Bradycardia

B. Anticholinergic drugs block the parasympathetic nervous system, which causes the body to "rest and digest." Blocking of these effects leads to constipation, urinary retention, and decreased secretions (dry mouth).

4. A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? A Older patients often have difficulty determining what is causing their pain." B. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." C. "As adults age, their ability to perceive pain decreases." D. "Patients who have dementia probably experience pain, and their pain is not always well controlled."

B. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflect a helpful understanding of patient self-care at the end of life? A. "Learning to accept that you can't perform some activities anymore will bring you more acceptance and peace." B. "Which activities are most important to you, and how can you continue to do them?" C. "People in your life want to help you with things; allow them to do what they want for you." D. "Spending more of your time resting or reading will conserve your energy."

B. "Which activities are most important to you, and how can you continue to do them?" Even seriously ill people want to carry on with life, doing what they can to maintain their identity and purpose. They know best how to regulate their energy and wishes for how to spend their time.

A family member of a recently deceased patient talks casually with the nurse at the time of the patient ' s death and expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to this family member? A. Denial B. Anticipatory grief C. Dysfunctional grief D. Yearning and searching

B. Anticipatory grief If a person has been anticipating a loss for some time, he or she may have already experienced many of the emotions (sadness, shock) commonly associated with death.

Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care? A. Practice honesty with everyone, telling patients about their illness, even if the news is not good. B. Ask family members if they prefer to help with the care of the body after death. C. Provide postmortem care at the time of death to relieve family members of this difficult job. D. Value patient self-determination, understanding that each person makes his or her own decisions.

B. Ask family members if they prefer to help with the care of the body after death. Giving people options in caregiving allows them to honor their cultural beliefs. Although western health care practices place a high value on honesty, people from some cultural backgrounds regard being told the "truth" as harmful.

The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not believe the treatments will make any difference, does not ask about her progress, and missed two chemotherapy sessions. Based on the above assessment data, the nurse gathers more information to consider making which of the following nursing diagnoses? A. Anxiety B. Hopelessness C. Spiritual distress D. Complicated grieving

B. Hopelessness The patient exhibits signs and symptoms of hopelessness. Manifestations of hopelessness include withdrawing, not following through with recommended treatment, and losing confidence that anything she does will be of help.

A nurse is providing postmortem care. Which action is the priority? A. Locating the patient's clothing B. Providing culturally and religiously sensitive care in body preparation C. Transporting the body to the morgue as soon as possible to prevent body decomposition D. Providing all postmortem care to protect the family of the deceased from having to see the body

B. Providing culturally and religiously sensitive care in body preparation At the end of life religious and cultural expectations are important for the lasting memories held by the family about the way their loved one's death occurred. Sensitive care contributes to feelings of closure, appropriateness of the death rituals, and fulfilled family obligations.

The nurse plans outcomes with a client recovering from knee replacement surgery. Which outcome should the nurse identify as appropriate for this client? A. The nurse will utilize a pain scale assessment. B. The client will report pain of 1 on a scale of 1-10 C. The nurse will administer analgesia when requested. D. The client will have impaired physical mobility.

B. The client will report pain of 1 on a scale of 1-10

The nurse is teaching a course on grieving to new staff members at a local hospital. Which manifestation should the nurse include in the presentation as expected alterations or manifestations of grief? Select all that apply. Having difficulty concentrating Selling the family home Experiencing auditory hallucinations Moving in with a friend or family member

Becoming distrustful of others Having difficulty concentrating Selling the family home Moving in with a friend or family member Rationale Selling the family home, moving in with a friend or family member, and having difficulty concentrating are expected alterations or manifestations of grief. Becoming distrustful of others or experiencing auditory hallucinations are manifestations of complicated grief and require immediate intervention by the health care team.

A client fell down some stairs and broke the humerus. Upon admission, the client is experiencing limited range of motion and severe pain. Which kind of pain should the nurse recognize this client is experiencing? A. Chronic pain B. Idiopathic pain C. Acute pain D. Visceral pain

C. Acute pain

A client tells the nurse that since he lost his job, he cannot sleep at night and has no energy to get out of bed. Which type of grief response should the nurse educate this client about based on the symptoms exhibited? Biological Biophysical Behavioral Psychological

Biological Rationale Biological responses are physical manifestations a client may develop in response to grief and loss; they may include sleep problems, decreased energy, lack of appetite, or weight loss. Psychological responses to grief or loss affect the emotions of the client (e.g., anger, tearfulness, depression). Behavioral responses to grief and loss are identified in clients who change their normal patterns of behavior; these changes can include such personality changes as a lack of social interactions with other individuals. There are no biophysical responses to grief and loss.

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when Iʻm menstruating." B. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

Following surgery, a client has great difficulty getting out of bed, walking, and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client? A. "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication, you will get weaker, not stronger." B. "I noticed you don't use much pain medication. If you don't push that button, I will. You need that medicine. Don't worry about getting addicted. It won't happen." C. "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant." D. "I can understand why you are reluctant to use pain medication. Many people feel the same way. Yet without pain relief, you can get atelectasis, pneumonia, and blood clots, and maybe even develop an ileus."

Pain that is unpredictable and not associated with any activity or event: A. Incident pain B. End-of-dose pain C. Spontaneous pain D. Acute pain

Patient-controlled analgesia (PCA) effectiveness is evaluated by: A. The number of minutes on the lockout interval B. How large a loading dose is required to relieve pain C. The client's indicating that pain is a 1 on a scale of 1 to 10 D. When the client is sleeping

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding

Treats acute or chronic pain, stress, anxiety & depression: A. Relaxation B. Distraction C. Music D. Cutaneous Stimulation

While waiting to perform x-rays on an injured right hand according to nonpharmacological pain management practice, pain can be modulated or reduced if the nurse: A. Performs frequent pain assessment B. Administers a placebo C. Applies ice to the right elbow D. Turns off the light and shuts the door

Theresa, age 27, was admitted to the psychiatric unit from the medial intensive care unit where she was treaded for taking a deliberate overdose of her antidepressant medication, trazodone (desyrel). She says to the nurse, "My boyfriend broke up with me. We had been together for 6 years. I love him so much. I know I'll never get over him." Which is the best response by the nurse? A. You'll get over him in time, Theresa. B. Forget him. There are other fish in the sea. C. You must be feeling very sad about your loss. D Why do you think he broke up with you, Theresa?

C Rationale It is important to accept the client's feelings in a nonjudgmental attitude. It is also important to discuss the current crisis situation in the client's life.

A client whose husband died 6 months ago is diagnosed with major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way. " What is an appropriate response by the nurse? A. Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer. " B. I can understand how you must feel. C. Those feelings are a normal part of the grief response. D. Just think bout the good times that you had while he was alive.

C Rationale Teaching the normal states of grief and behaviors associated with each stage should be implemented as a nursing intervention for someone undergoing complicated grieving . Helping the client understand that feelings such as guilt and anger toward the lost concept are appropriate and acceptable during the grief process and should be expressed rather than held inside.

Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A) PPD symptoms are consistently severe. B) This syndrome affects only new mothers. C) PPD can easily go undetected. D) Only mental health professionals should teach new parents about this condition.

C) PPD can easily go undetected. Rationale: PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.

When making a visit to the home of a postpartum woman 1 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) Shifts 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 reestablished her role as a spouse/partner.

C) Shifts 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. Rationale: One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth. Reviewing events and behavior during labor/birth and exhibiting reduced attention span/limited readiness to learn are characteristic of the taking-in stage, which lasts for the first few days after birth. Re-establishing role as spouse/partner reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Which agent is best used in the emergency room setting for patients who are believed to have received too much of a benzodiazepine drug or taken an overdose of benzodiazepines? A) Diazepam B) Ramelteon C) Flumazenil D) Doxepin E) Naloxone

C- Flumazenil is the reversal of benzodiazepines Naloxone is for narcotics

When planning administration of antiemetic medications to a client, the nurse is aware that combination therapy is preferred because of which drug effect? A. It is easier to achieve the desired level of sedation. B. There are faster drug absorption and distribution. C. Different vomiting pathways are blocked. D. The risk of constipation is decreased.

C. Combining antiemetic drugs from various categories allows the blocking of the vomiting center and chemoreceptor trigger zone (CTZ) through different pathways, thus enhancing the antiemetic effect.

Which drug works by blocking serotonin receptors in the GI tract, vomiting center, and CTZ? A. Meclizine (Antivert) B. Metoclopramide (Reglan) C. Ondansetron (Zofran) D. Droperidol (Inapsine)

C. Ondansetron is a serotonin blocker. Metoclopramide is a prokinetic drug, meclizine is an antihistamine, and droperidol is an antidopaminergic drug.

9.Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? A. "This is the only pain medication I will need to be on." B. "I can administer the pain medication as frequently as I need to" C. "I feel less anxiety about the possibility of overdosing." D. "I will need the nurse to notify me when it is time for another dose."

C. "I feel less anxiety about the possibility of overdosing."

The nurse is instructing a client on various medications that may be prescribed for pain. Which statement indicates that the client requires additional teaching? A. "I should not take over-the-counter nonopioids for a long period of time." B. "Nonopioids can be an effective treatment for severe pain." C. "I should not take an opioid with a nonopioid." D. "Over-the-counter nonopioids have serious side effects."

C. "I should not take an opioid with a nonopioid."

You have identified three nursing diagnoses for a patient who is having anxiety and hopelessness as a result of a loss. Which general approach do you take to prioritize the nursing diagnoses? (Select all that apply.) A. Use family members and physician orders as primary resources for prioritizing your actions. B. Address the nursing diagnosis that most affects the medical diagnosis. C. Ask the patient to identify the most distressing D. symptom and first address that diagnosis. D. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses.

C. Ask the patient to identify the most distressing D. symptom and first address that diagnosis. D. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses. When you are prioritizing nursing diagnoses, first get the patient's sense of the most important issue. Some patients do not fully understand the physiology or relationship among diagnoses. For example, one patient does not understand that pain contributes to a decreased appetite or depression. Your nursing knowledge along with the patient's perceptions help you determine the diagnosis with the highest priority.

7.What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? A Keeping the reversal agent in a syringe in the patient's bedside table B. Applying a gauze dressing to the epidural catheter insertion site C. Labeling the tubing that leads to the epidural catheter D. Asking the nursing assistive personnel to check on the patient at least once every 2 hours

C. Labeling the tubing that leads to the epidural catheter

Which approach to helping grieving people is most consistent with postmodern grief theories? A. Help the patient identify the tasks to be accomplished during his or her grief. B. Encourage people to recognize stages of grieving in anticipation of what is to come. C. Listen carefully to a person's story of how his or her grief experience is unfolding. D. Offer general grief timelines to help the person know when a phase will pass.

C. Listen carefully to a person's story of how his or her grief experience is unfolding. Postmodern grief interventions focus on the uniqueness of the patient's story that unfolds and "writes" itself as the person lives through the experience of loss.

A self-care goal you set when caring for dying and grieving patients includes: A. Learning not to take losses so seriously. B. Limiting involvement with patients who are grieving. C. Maintaining life balance and reflecting on the meaning of your work. D. Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to care for these patients.

C. Maintaining life balance and reflecting on the meaning of your work. Maintaining life balance is very important for emotional, spiritual, and physical well-being. Withdrawing or not seeing one's work with grieving people as serious does not help maintain balance but rather may contribute to numbing feelings.

5. The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? A. Neurological factors B.Competency of the surgeon C.Meaning of pain D. Postoperative support personnel

C. Meaning of pain

A nurse is interviewing a 25-year-old who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of five or more clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self-esteem

C. Presence of manifestations for at least 2 years Rationale: The manifestations of dysthymic disorder last for at least 2 years in adults.

A client who is extremely distraught after losing her spouse of 45 years is sobbing with her head in her hands. The client says, open double quote"I don't want to go sit with a bunch of other old widows; I want to sit with Harold.close double quote" Based on this client's assessment findings, which collaborative therapy should the nurse recommend? A group hobby session Cognitive-behavioral therapy Church attendance on Wednesdays and Sundays Placement in a long-term care facility

Cognitive-behavioral therapy Rationale The client experiencing grief over the loss of a spouse may need to attend a form of psychotherapy called cognitive-behavioral therapy, which helps the client move through each step of the grief process. Placement in a long-term care facility is not a realistic or appropriate option. A group hobby or church attendance does not address the client's needs based on the assessment findings.

The nurse is preparing to assess a client who is experiencing grief and loss. When the nurse enters the room, the client is on his knees at the end of the bed and sobbing "Why, God, why?" What should the nurse include in the assessment? Select all that apply. Community assessment Family assessment Financial assessment Spiritual assessment Client assessment

Community assessment Family assessment Client assessment Rationale The nurse should conduct an assessment to determine available coping resources for the client. This usually includes a client assessment, a family assessment, and a community assessment. The client who is sobbing as he cries out to God may need a spiritual assessment, but a spiritual assessment is a part of the community assessment. A financial assessment is not a routine part of an assessment to determine a client's coping resources.

While assessing a 76-year-old female client who fell off a stepstool in her kitchen, the nurse learns that the client is recently widowed. Which area should the nurse investigate to provide holistic health care for this client? Select all that apply. Physical therapy resources Community resources Family resources Spiritual resources Dietary resources

Community resources Family resources Spiritual resources Dietary resources Rationale A client experiencing a loss will have to address many lifestyle changes in the days, months, and years to come. A client who has been married for many years and recently widowed should be assessed for resources available to help in the daily living routine. These include family, community, spiritual, and dietary resources. While physical therapy may be necessary, this is not something the nurse would address at this time.

A client learns of the death of a family member. Which manifestation of grief should the nurse expect in this client? Agitation Palpitations Restlessness Crying

Crying Rationale Crying is an expected manifestation of grief. Agitation is an emotional response to stress. Restlessness and palpitations are physical manifestations of stress.

A nurse is treating a patient in acute pain. What is an outcome appropriate for this patient? A. Able to self medicate B. Use of alternative therapies C. Able to tolerate high levels of pain D. Reports pain of 3 or less on a scale of 0 to 10

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: A. Call the patient's health care provider. B. Administer pain medication as ordered. C. Check the patient's vital signs. D. Assess the characteristics of the pain.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependence.

A postoperative client is prescribed acetaminophen (Tylenol) with codeine at discharge. When performing discharge teaching, the nurse: A. Warns of signs of addiction B. Recommends that the client decrease the number of tablets taken each day C. Warns that some clients experience temporary stress incontinence D. Recommends that the client take milk of magnesia at bedtime

A variety of meds that enhance analgesics or have analgesic properties: A. Acetaminophen B. Herbals C. Opioids D. Adjuvants

Both clients and nurses have misconceptions about pain. Which statement reflects a misconception? A. People can adapt to severe pain. B. Minor injuries can cause intense pain. C. The client is the authority about pain. D. Regular administration of analgesics leads to addiction.

Pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition: A. Acute pain B. Chronic pain C. Chronic episodic pain D. Idiopathic pain

Stimulation of skin helps relieve pain: A. Relaxation B. Distraction C. Music D. Cutaneous Stimulation

When asked about pain, a client complains of having severe discomfort from arthritis. Vital signs are unchanged, and the client is calmly watching television. Which of the following nursing diagnoses is most appropriate? A. Acute pain B. Altered sensory perception C. Impaired mobility D. Chronic pain

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Freudian psychoanalytic theory would explain Theresa's suicide attempt in which of the following ways? A. She feels hopeless about her future without her boyfriend. B. Without her boyfriend, she feels like an outsider with her peers. C. She is feeling intense guilt because her boyfriend broke up with her. D. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself.

D Rationale Freud believed that suicide was a response to intense self-hatred that an individual possessed. The anger had originated toward a love object but was ultimately turned inward against the self.

Education for the client who is taking MAOI's should include which of the following? A. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity. B. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks. C. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug at the end of treatment. D. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification.

D Rationale Tyramine can cause episodes of hypertensive crisis. Foods that contain tyramine include:aged cheeses, raisins, fava beans, red wines, smoked and processed meats, chicken of beef liver, soy sauce, meat tenderizer, chocolate. There is a lot of medication interactions that occur with MAOI's so it is important to consult your physician before taking any OTC meds.

Which of the following is correct regarding benzodiazepines? A) They directly open chloride channels B) Benzodiazepines have analgesic effects C) Clinical improvement in anxiety requires 2 - 4 weeks of treatment D) All have some sedative effects E) Benzodiazepines readily produce general anesthesia

D is correct-They put the brakes on your CNS, slow your brain down, so all have sedative effects A isn't because it is an indirect process, not direct B isn't because it isn't true, not used for pain but for muscle relaxing C isn't because it is immediate E isn't because they have a ceiling on their effect, not something that will make you stop breathing, stop effect at a certain point

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A) Tell the woman she can rest after she feeds her baby. B) Recognize this as a behavior of the taking-hold stage. C) Record the behavior as ineffective maternal-newborn attachment. D) Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

D)Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. Rationale: The woman should not be told what to do and needs to care for her own well-being. The taking-hold stage occurs about 1 week after birth. Because the woman needs to rest does not indicate ineffective maternal-newborn attachment. The behavior described is typical of this stage and not a reflection of ineffective attachment unless it persists. Mothers need to reestablish their own well-being to effectively care for their baby.

55 year-old teacher began to experiences changes in mood. He was losing interest in his work and lacked the desire to play daily tennis as normal. He was preoccupied with feelings of guilt, worthlessness, and hopelessness. In addition to the psychiatric symptoms, he complained of muscle aches throughout the body. Physical and laboratory tests were unremarkable. After 6 weeks of therapy with fluoxetine, his symptoms resolved completely. However, he began complaining of sexual dysfunction. Which of the following drugs might be useful? Fluvoxamine (SSRI) Sertraline (SSRI) Citalopram (SSRI) Bupropion (Atypical) Lithium (Mood-stabilizer)

D- Bupropion No sexual side effects!! If you add to SSRI you can sometimes reverse the side effects A-C are all SSRIs so will not help

John is a client at the mental health clinic. He is depressed, has been expressing suicidal ideations, and has been seeing the psychiatric nurse every 3 days. He has been taking 100 mg of sertraline daily for about a month, receiving small amounts of the medication from his nurse at each visit. Today he comes to the clinic in a cheerful mood, much different than he seemed just 3 days ago. How might the nurse assess this behavioral change? A. The sertraline is finally taking effect. B. He is no longer in need of antidepressant medications. C. He has completed the grief response over loss of his wife. D. He may have decided to carry out his suicide plan.

D. Rationale Some clients after beginning antidepressants finally have enough energy to follow through with their suicidal thoughts/plans. It is important to monitor for mood changes especially as sudden unexpected elevation in mood for this may be an indication of a decision to carry out their suicidal ideations/plans.

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? A. "Your vitals do not show that you are having pain; can you describe your pain?" B."You do not look like you are in pain." C. "OK, I will go get you some narcotic pain relievers immediately." D. "What would you like to try to alleviate your pain?"

D. "What would you like to try to alleviate your pain?"

A family member asks a home care nurse what he should do if the patient's serious chronic illness worsens even with increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life? A. Encourage the family member to think more positively about the patient's new therapy B. Avoid the discussion because it has to do with medical, not nursing, diagnoses C. Initiate a discussion about advance directives with the patient, family, and health care team D. Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present

D. Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present If you ask the patient first what he or she believes is best, you know how to discuss that option in more detail and give realistic ways of reaching that desired goal. Discussing other possible options after the patient's preference helps family members know and understand the patient's wishes.

A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing? A. Delayed B. Anticipated C. Exaggerated D. Disenfranchised

D. Disenfranchised This woman's friends are not fully acknowledging the value of her pregnancy because of the short length of time the woman was pregnant or because, by comparison, the loss seems less than losing a child after birth. The loss does not seem "legitimate." Thus the woman does not experience sympathy from others and feels disenfranchised.

The nurse suggests that a patient receive a palliative care consultation for symptom management related to anxiety and increasing pain. A family member asks the nurse if this means that the patient is dying and is now "in hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) A. Hospice and palliative care are the same thing. B. Palliative care is for any patient, any time, any disease, in any setting. C. Palliative care strategies are primarily designed to treat the patient's illness. D. Palliative care interventions relieve the symptoms of illness and treatment. B. Palliative care is for any patient, any time, any disease, in any setting.

D. Palliative care interventions relieve the symptoms of illness and treatment. Palliative care is not reserved for people who are at the end of life. The goal of palliative care is to help relieve the burdens of illness at any time along the continuum of that illness.

A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic communication with this patient? A. Younger patients are usually less talkative about their diagnosis. B. All patients benefit by talking about their feelings with another person. C. Avoid discussing illness-related topics with quiet patients. D. Remain alert for signals that the patient wants to discuss his illness.

D. Remain alert for signals that the patient wants to discuss his illness. Make no presumptions about this patient other than the fact that he is not yet ready to talk about his situation. However, stay alert for a time when he might want to talk to you. Some people do not work through their problems by talking to others.

The nurse is assessing a client who just lost her spouse as the result of cancer. Which question allows the nurse to determine whether socioeconomic factors may cause an alteration in the grieving process? Do you have any family close by that I can call? Do you have children? Are there any special requests you have regarding after-death care? Do you have any financial concerns?

Do you have any financial concerns? Rationale Asking about any financial concerns helps the nurse determine whether socioeconomic factors will impact the grieving process. The other questions help determine whether the client will experience alterations in grieving but do not address socioeconomic factors.

The nurse is planning care for a client who is experiencing overwhelming grief and loss after the death of a parent. Which intervention by the nurse helps reduce this client's anxiety? Teaching family members to encourage the client's expressions of grief. Teaching about safe administration and side effects of medications. Encouraging the client to resume normal activities when ready, to promote physical and psychological health. Helping the client gain insight into maladaptive behaviors.

Helping the client gain insight into maladaptive behaviors. Rationale Helping the client gain insight into maladaptive behaviors helps reduce the client's anxiety. Teaching about medications and side effects is appropriate only when the client is prescribed antianxiety or other medications to treat stress. Teaching family members to encourage the client's expressions of grief and encouraging the client to resume activities when ready are appropriate interventions to facilitate the client's grief work.

The nurse is providing care to a pediatric client whose mother is terminally ill. Which intervention by the nurse allows the pediatric client to express grief? Administering medication to the client. Allowing the client to talk about the loss. Telling the client that the parent will be in a better place. Implementing imaginary games with the client.

Implementing imaginary games with the client. Rationale Imaginary games allow the pediatric client to express grief. Administering medication and allowing the client to talk about the loss are appropriate interventions for adults who are experiencing grief. Telling the client that the parent will be in a better place is not an appropriate intervention.

(Rationale: The nurse's first priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's first priority. Outcomes should be client-centered, specific, realistic, measureable, and must also include a time frame.)

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? 1. The client will not physically harm self. 2. The client will express hope for the future by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during hospital stay.

The nurse is providing care to a client who lost a child in a car crash 7 months ago. The client states that she has been feeling better over the last month, but that all of a sudden for the past week she has felt like the death just occurred. Which question allows the nurse to assess the reason for this resurgence of grief? How many hours of sleep are you getting each night? Did you recently sell your home? Have you been experiencing anger? Is this time of year significant for any reason?

Is this time of year significant for any reason? Rationale It is not uncommon for a resurgence of grief to occur on holidays, birthdays, and other days of significance; asking the client whether this time of year has any special meaning helps the nurse determine whether this is what the client is experiencing. The other questions allow the nurse to assess expected alterations and manifestations of grief.

List Elizabeth Kubler-Ross's Stages of Grieving:

Kubler-Ross defined 5 stages of grieving including: denial, anger, bargaining, depression, and acceptance.

A nurse is caring for a client who is grieving the loss of a spouse. The nurse understands that grief is a combination of various factors including all except: Moral Psychological Biological Behavioral

Moral Grief is the combination of various psychological, biological, and behavioral responses to a loss. Morality is not a factor in grief.

Which anti-depressant drug is most sedating? Fluoxetine (SSRI) Duloxetine (SNRI) Nortriptyline (TCA) Citalopram (SSRI) Venlafaxine (SNRI)

Nortriptyline- main side effect is drowsiness!! not the number one agent for depression anymore because of this side effect

The nurse is providing care to an older adult client who is experiencing new symptoms of grief. Which item in the client's history might be the cause of these symptoms? The recent move to an assisted living facility Being diagnosed with type 1 diabetes mellitus as a child The loss of a pregnancy 20 years ago The loss of a spouse 5 years ago

The recent move to an assisted living facility Rationale While the loss of a pregnancy and of a spouse years ago may influence symptoms of grief, the recent move to an assisted living facility and the loss of independence associated with this move is the likely cause of the client's new symptoms of grief. The diagnosis of type 1 diabetes mellitus in childhood is not a factor in this client's grief.

A nurse is caring for the family of a client who died. The nurse observes the family celebrating with music and dancing. The appropriate response from the nurse is: Observe the practice but do not intervene unless asked by the family. Observe the practice but notify the family that the practice is inappropriate. Observe the practice and suggest a different coping mechanism for the family. Observe the practice and participate once it appears appropriate.

Observe the practice but do not intervene unless asked by the family. Rationale: Accurate assessment of the grieving process requires awareness of an individual's cultural influences. Certain cultures see death as a beginning rather than an end and choose to celebrate the individual's life on earth and the movement to the next life. The nurse should observe the practice but do not intervene unless asked by the family. A nurse who suggests a different coping mechanism or tells the family the practice is inappropriate, is not culturally aware of the variety of mourning practices. The nurse should not participate in the celebration unless asked by the family.

A palliative care nurse is caring for a terminally ill client and his family. The nurse understands that nursing implications for the grieving family include all except: Assist family members in understanding the signs of grief and acceptance of death. Help the dying client grieve for their own loss of life. Recognize complicated grief if symptoms occurs up to 2 months after a loss. Provide referral to assistance such as support groups and spiritual resources.

Recognize complicated grief if symptoms occurs up to 2 months after a loss. Rationale: Grief is an important consideration when working with end-of-life clients. Not only are these clients learning how to come to terms with the loss of their own lives, but their families experience a variety of hardships during this time. Nursing implications for the grieving family include: helping the dying client grieve for their own loss of life; assisting family members in understanding the signs of grief and acceptance of death; and provide referral to assistance such as support groups and spiritual resources. Complicated grief is diagnosed if it occurs at 6 months after a loss. The normal process of grief begins to fade 3 to 6 months after the loss.

... When a client has died, under what circumstance can healthcare providers proceed with the protocol for harvesting organs for transplantation? 1) The deceased client has a document indicating his or her desire to be an organ donor. 2) The nursing supervisor believes the deceased has suitable organs for transplantation. 3) The deceased client has died of homicide or suicide rather than natural causes. 4) The physician has declared and documented the client's time of death.

Test Taking Strategy: Eliminate any statements that contradict the criteria for donation of organs and tissue.

... If a terminally ill client made the following statements to a nurse, which is the best evidence that the client is in the bargaining stage? 1) "There must be some mistake in the pathology report." 2) "If I can just live until my son graduates, I won't ask for anything else." 3) "I don't know why I would deserve to die at such a young age." 4) "I hope my death comes quickly; I'm ready to go."

Test Taking Strategy: Note the key word and modifier, "best evidence." Use the process of elimination to select the one that corresponds with bargaining.

When the nurse cares for a client with no hope of recovery, which of the following is the most conclusive criterion for declaring the person brain dead? 1) A lack of response to verbal stimulation 2) Urine output less than 100 mL/24 hours 3) No spontaneous respiratory efforts 4) Unequal pupils in response to light

Test Taking Strategy: Note the key word and modifier, "most conclusive." Select the option that corresponds with evidence-based criteria for establishing brain death.

... When a terminally ill client refuses to eat or drink, what nursing measures can be independently implemented? Select all that apply. 1) Inserting a nasogastric feeding tube 2) Providing frequent oral hygiene measures 3) Humidifying the room air 4) Offering hard candies periodically 5) Administering intravenous fluids

Test Taking Strategy: Note the key word, "independently." Use the process of elimination to exclude options that require collaboration with a physician.

... Place the stages of dying in their usual sequence as identified by Dr. Elisabeth Kübler-Ross. Use all the options. 1) Depression 2) Anger 3) Acceptance 4) Denial 5) Bargaining

Test Taking Strategy: Recall the common sequence of behaviors that dying clients experience initially until the final terminal stage.

A client who had been in a substance abuse treatment program asks the nurse for a date after the client is discharged. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. The nurse is using which of the following techniques? a. Defining boundaries b. Reprimanding the client c. Letting the client down gently d. Defining therapy

a. Defining boundaries

A client is prescribed paroxetine (Paxil) to treat symptoms of stress after the unexpected death of her spouse. What should the nurse instruct the client about this medication? Select all that apply. This medication should not be taken with St. John's wort. This medication takes 4 to 6 weeks to achieve the full effect. This medication can cause bradycardia. This medication may cause difficulties in achieving an orgasm. This medication should not be stopped abruptly.

This medication should not be taken with St. John's wort. This medication takes 4 to 6 weeks to achieve the full effect. This medication may cause difficulties in achieving an orgasm. This medication should not be stopped abruptly. Rationale Paroxetine (Paxil) takes 4 to 6 weeks to achieve the full therapeutic effect; should not be stopped abruptly; may cause difficulties in achieving an orgasm; and should not be taken with St. John's wort. This medication does not cause bradycardia.

What element is the primary factor that dictates the rituals of mourning? a. culture b. age c. gender d. religion

Which of the senses is believed to be the last one lost as a person nears death? a.hearing b.vision c.touch d. smell

5. The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. c. A patient's pulse is increased following a myocardial infarction. d. A patient in pain strikes out at a nurse who attempts to bathe him. e. A patient who has chronic cancer pain is depressed and withdrawn. f. A child pulls away from a nurse trying to give him an injection.

a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. f. A child pulls away from a nurse trying to give him an injection.

2. One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply. a. A patient is receiving chemotherapy for bladder cancer. b. An adolescent is admitted to the hospital for an appendectomy. c. A patient is experiencing a ruptured aneurysm. d. A patient who has fibromyalgia requests pain medication. e. A patient has back pain related to an accident that occurred last year. f. A patient is experiencing pain from second-degree burns.

a. A patient is receiving chemotherapy for bladder cancer. d. A patient who has fibromyalgia requests pain medication. e. A patient has back pain related to an accident that occurred last year.

4. A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? a. Acceptance b. Anger c. Bargaining d. Denial

a. Acceptance

1. A nurse midwife is assisting a patient to deliver a full-term baby. The patient is firmly committed to natural childbirth and has attended each natural childbirth class in preparation for labor and delivery. A cesarean delivery becomes necessary when her fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational

a. Actual b. Perceived c. Psychological

11. Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed postoperative medications b. Impaired Physical Mobility related to surgical procedure c. Anxiety related to outcome of surgery d. Risk for Infection related to surgical incision

a. Acute Pain related to fear of taking prescribed postoperative medications

19. A patient with cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Administer the prescribed PRN immediate-acting morphine. b. Suggest the use of alternative therapies such as heat or cold. c. Utilize distraction by talking about things the patient enjoys. d. Consult with the doctor about increasing the MS Contin dose.

a. Administer the prescribed PRN immediate-acting morphine. The patient's pain requires rapid treatment and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies also may be needed, but the initial action should be to use the prescribed analgesic medications.

A patient is admitted for major depression. The nurse should expect to find which of the following in the assessment? a. Anhedonia, feelings of worthlessness, and difficulty focusing b. depressed mood, guilt, pressured speech c. changes in sleep pattern, tired, grandiose mood d. difficulty focusing, feelings of helplessness, flight of ideas

a. Anhedonia, feelings of worthlessness, and difficulty focusing

10. The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES scale b. COMFORT scale c. FLACC scale d. FACES scale

a. CRIES scale

9. A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse caring for the patient that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse and husband both agree that this seems to be all that therapy is now doing for her. The nurse would suggest that the husband speak to his wife's physician about which type of order? a. Comfort-measures-only b. Do-not-hospitalize c. Do-not-resuscitate d. Slow-code-only

a. Comfort-measures-only

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? a. Constant 24-hour, one-to-one observation at arm's length b. One-to-one observation while client is awake c. Every 15-minute observation around the clock d. Seclusion with 15-minute observation

a. Constant 24-hour, one-to-one observation at arm's length A client who will not enter into a no-suicide contract should be placed on the highest level of suicide watch since the client is unable to commit to seeking help to resist suicidal ideations.

Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? a. Having a staff member sit at the door and check packages as visitors enter. b. Having a staff member make frequent rounds during visiting hours to inspect gifts. c. Asking all visitors to report to the nurse's station before visiting a client. d. Asking clients to give staff any unsafe item that might have been left by a visitor.

a. Having a staff member sit at the door and check packages as visitors enter. A number of ways to inspect items are possible.Taking all potentially harmful gifts from visitors before allowing them to see clients, going through client's belongings (with client present) and removing all potentially harmful objects, ensuring that visitors do not leave potentially harmful objects in the client's room, and searching clients for harmful objects on return from pass are all effective methods to ensure a high rate of client safety. None of the other options provide a measure of control before clients and visitors meet. Self-reporting by the visitors is not reliable.

A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? a. Hopelessness b. Deficient knowledge c. Chronic low self-esteem d. Compromised family coping

a. Hopelessness The defining characteristics are present for the nursing diagnosis of hopelessness. The characteristics of the other options are not presented in the statement or behavior of the client.

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? a. It is high risk, or a hard method. b. It is low risk, or a soft method. c. It was not an actual suicide attempt because the client was intoxicated. d. Considering the results, it is a nonlethal means.

a. It is high risk, or a hard method. Higher risk methods, also referred to as hard methods, include using a gun, jumping from a high place, hanging, and carbon monoxide poisoning. The other responses are incorrect.

10. A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.

21. A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Remove the fentanyl patch. b. Notify the health care provider. c. Continue to monitor the patient's status. d.Give the prescribed PRN naloxone (Narcan).

a. Remove the fentanyl patch. The assessment data indicate possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring also are needed, but the patient's data indicate that more rapid action is needed.

2. A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow.

a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. f. The patient's daughter writes a poem expressing her sorrow.

8. A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death.

14. A patient who uses extended-release morphine sulfate (MS Contin) for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Wait until the patient wakes up and reassess the pain. c. Consult with the health care provider about changing the MS Contin dose. d. Suggest the use of nondrug therapies for pain relief instead of additional opioids.

a. Wake the patient and administer the hydrocodone. Since patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, the patient's sleep is not an indicator that she is pain free. The nurse should wake the patient and administer the hydrocodone.

18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The best initial action by the nurse is to a. administer the ordered antiemetic medication. b. tell the patient that the nausea will subside in about a week. c. order the patient a clear liquid diet until the nausea decreases. d. consult with the health care provider about using a different opioid

a. administer the ordered antiemetic medication. Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the antiemetic medication and allow the patient to eat.

5. A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply is based on the information that these strategies a. impact the cognitive and affective components of pain. b. increase the modulating effect of the efferent pathways. c. prevent transmission of nociceptive stimuli to the cortex. d. slow the release of transmitter chemicals in the dorsal horn.

a. impact the cognitive and affective components of pain. Cognitive therapies impact on the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.

A woman, recently widowed, tells the nurse, "I just can't even get out of bed in the mornings anymore." What response by the nurse would be most helpful in resolving the patient's grief? a. "I don't know why you feel that way." b. "This must be a difficult time for you." c. "Why do you think you feel this way?" d. "After you get up, you will feel better."

What is an important factor in the successful resolution of grief? a. social isolation b. support systems c. triggers of grief d. loss acknowledgement

1. When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d."How many times a day do you medicate for pain?"

b. "How would you describe your pain?" Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question.

During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, "I'm old, and my life has no purpose anymore. But promise me you won't tell anyone." How should the nurse respond? a. "Don't worry, I won't tell anyone else." b. "I'm sorry, but I can't keep that kind of secret." c. "Let's talk about something to cheer you up." d. "What can we do to help you feel better?"

b. "I'm sorry, but I can't keep that kind of secret."

6. A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? a. "Oh, don't worry about that now. You need to sleep." b. "What seems to be concerning you the most?" c. "I have talked to your wife and she told me she will be fine." d. "I have to go and give medicines, you should discuss this with your wife."

b. "What seems to be concerning you the most?"

Which is the greatest protective factor against the risk of suicide? a. One or more previous suicide attempts b. A sense of responsibility to family c. Fear of dying d. A cultural belief that suicide is a shameful resolution for a dilemma

b. A sense of responsibility to family Having family responsibilities makes a client less likely to commit suicide. Hopelessness is the greatest risk factor. Previous attempts are a high risk factor. None of the remaining options have the impact that support has on preventing suicide.

The nurse cares for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? a. Offer the patient a herbal supplement such as ginseng. b. Apply a cool washcloth to the forehead and provide mouth care. c. Take the patient for a walk in the hallway to promote peristalsis. d. Discontinue any medications that may cause nausea or vomiting.

b. Apply a cool washcloth to the forehead and provide mouth care. Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

When a colleague committed suicide, the nurse stated "I do not understand why she would take her own life." This is an expression of which feeling? a. Anger b. Disbelief c. Confusion d. Sympathy

b. Disbelief Denial and the minimization of suicidal ideation or gestures is a defense against experiencing the feelings aroused by a suicidal person. Denial can be seen in such statements as "I cannot understand why anyone would want to take his own life." The statement doesn't demonstrate any of the other options as significantly.

During the working phase of a therapeutic relationship, which of the following actions by the nurse would best help the client to explore problems? a. Comparing past and present coping strategies b. Encouraging the client to clarify feelings and behavior c. identifying possible solutions for the client's problems d. Referring the client to a self-help group

b. Encouraging the client to clarify feelings and behavior

The nurse fails to assess personal values surrounding homosexuality before caring for a patient that is openly gay. The nurse is most at risk for which of the following when working with this patient? a. Neglecting to include the patient's desires in the plan of care. b. Holding a prejudice toward this patient. c. Being manipulated by this patient. d. Expressing shock when assessing the patient's history.

b. Holding a prejudice toward this patient.

1. The health care provider plans to titrate a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assessing for signs that the patient is becoming addicted to the opioid b. Monitoring for therapeutic and adverse effects of opioid administration c. Emphasizing that the risk of some opioid side effects increases over time d. Educating the patient about how analgesics improve postoperative activity level e. Teaching about the need to decrease opioid doses by the second postoperative day

b. Monitoring for therapeutic and adverse effects of opioid administration d. Educating the patient about how analgesics improve postoperative activity level Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need decreasing amount of opioids by the second postoperative day, each patient's response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.

The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which of the following is the most therapeutic response by the nurse? a. Move to another chair closer to the client and say, "The staff is here to help you." b. Move to a chair a little further away and say, "We can just sit together quietly." c. Remain in place and say, "How are you feeling today?" d. Say, "I'll visit with you a little later," and leave the client alone for a while.

b. Move to a chair a little further away and say, "We can just sit together quietly."

16. The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider? a. The patient complains of nausea after eating. b. The patient's respiratory rate is 10 breaths/minute. c. The patient has not had a bowel movement for 3 days. d. The patient has a distended bladder and has not voided.

b. The patient's respiratory rate is 10 breaths/minute. The patient's respiratory rate indicates a need to decrease the PCA dose or change the medication in order to avoid further respiratory depression. The other information also may require intervention, but is not as urgent to report as the respiratory rate.

3. A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial d. Somatic

b. Visceral

Which of the following statements best describes loss? a. It is determined by one's cultural values. b. It is largely dependent on support of family and friends. c. It can be determined only by the person who experiences it. d. It is the same as grief and mourning.

Which of the following statements best describes the treatment of pain at the end of life? a.As patient nears death, no pain is perceived and no medications are necessary. b. It is important to withhold pain medications if the patient has respiratory changes. c. There is no maximum allowable dose for opioids during end-of-life care. d. Nurses should not administer opioids to the dying patient

Margaret, age 68, is a widow of 6 months. Since her husband dies, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with major depressive disorder. The PRIORITY nursing diagnosis for Margaret would be: A. Imbalanced nutrition: less than body requirements B. Complicated grieving C. Risk for suicide D social isolation

c Rationale This client is indicating thoughts of suicide. Safety should always be considered the priority with the other diagnoses being addressed after the initial threat has passed.

A student nurse on the psychiatric unit expresses being uncomfortable about discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? a. "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." b. "You are right; however, because of professional liability, we have to ask that question." c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." d. "If I were you, I'd ask the health provider to talk to the patient about that subject."

c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." Asking about suicidal thoughts does not "give person ideas" and is, in fact, a professional responsibility similar to asking about chest pain in cardiac conditions. Talking openly leads to a decrease in isolation and can increase problem-solving alternatives for living. Patients have usually been already thinking about suicide; it is a myth that bringing up the topic will somehow cause someone to become suicidal. Liability is not the reason we ask patients about suicidal thoughts or plan; it is for patient safety. Asking the physician to speak to the patient on that subject does not educate the student regarding the need for asking about suicidal ideation and abdicates professional and ethical responsibility for keeping the patient safe.

A patient asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. The best explanation by the nurse would be which of the following? a. "You have reservations about going to therapy?" b. "Both are recommended. Since your insurance covers both that is the best plan for you." c. "Medications help your brain function better, but the therapy helps you achieve lasting behavior change." d. "The effects of medications will not last forever. You will need to eventually

c. "Medications help your brain function better, but the therapy helps you achieve lasting behavior change."

The nurse receives an order for a parenteral dose of promethazine (Phenergan) and prepares to administer the medication to a 38-year-old male patient with nausea and repeated vomiting. Which action is most important for the nurse to take? a. Administer the medication subcutaneously for fast absorption. b. Administer the medication into an arterial line to prevent extravasation. c. Administer the medication deep into the muscle to prevent tissue damage. d. Administer the medication with 0.5 mL of lidocaine to decrease injection pain.

c. Administer the medication deep into the muscle to prevent tissue damage. Promethazine (Phenergan) is an antihistamine administered to relieve nausea and vomiting. Deep muscle injection is the preferred route of injection administration. This medication should not be administered into an artery or under the skin because of the risk of severe tissue injury, including gangrene. When administered IV, a risk factor is that it can leach out from the vein and cause serious damage to surrounding tissue.

11. All of the following diagnoses may apply to a young couple who gave birth to a premature infant with serious respiratory problems who has been in the neonatal intensive care unit for the last 3 months. The couple has a 22-month-old son at home. Which diagnosis would be most appropriate based on the following assessment data: report of chronic fatigue and decreased energy, guilt about neglecting son at home, shortness of temper with one another, and apprehension about continued ability to go on this way? a. Grieving b. Ineffective Coping c. Caregiver Role Strain d. Powerlessness

c. Caregiver Role Strain

3. A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? a. Abbreviated b. Anticipatory c. Dysfunctional d. Inhibited

c. Dysfunctional

The nurse is assessing a client who is talking about her son's recent death but who shows no emotion of any kind. The nurse recognizes this behavior as which of the following defense mechanisms? a. Dissociation b. Displacement c. Intellectualization d. Suppression

c. Intellectualization

7. A patient tells a nurse that he has no one he trusts to make health care decisions for him should he become incapacitated. What should the nurse suggest he prepare? a. Combination advance medical directive b. Durable power of attorney for health care c. Living will d. Proxy for health care

c. Living will

A 74-year-old female patient with gastroesophageal reflux disease (GERD) takes over-the-counter medications. For which medication, if taken long-term, should the nurse teach about an increased risk of fractures? a. Sucralfate (Carafate) b. Cimetidine (Tagamet) c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)

c. Omeprazole (Prilosec) There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine. Lower doses or shorter duration of therapy should be considered.

Which suicide prevention intervention that has the greatest impact on a client's safety? a. Educating visitors about potentially dangerous gifts. b. Restricting the client from potentially dangerous areas of the unit. c. One-on-one observation by the staff. d. Removal of personal items that might prove harmful.

c. One-on-one observation by the staff. One-on-one observation allows for constant supervision, which minimizes the client's opportunities to cause self-harm. While the remaining options provide some protection, none have the impact of constant supervision.

9. When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient has cramping abdominal pain. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient complains of a "pounding" headache.

c. The patient has not voided for over 10 hours. Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a "spinal" headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns.

What are the most important characteristics for staff members who work with suicidal clients? a. Organization b. Problem-solving skills c. Warm, consistent interaction d. Effective interview and counseling skills

c. Warm, consistent interaction Crucial characteristics of staff members who work with suicidal clients include warmth, sensitivity, interest, and consistency since they support the nurse-client relationship. While helpful, none of the other options have the impact of a effective nurse-client relationship.

3. A postoperative patient asks the nurse how the prescribed ibuprofen (Motrin) will control the incisional pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. modulating effect of descending nerves. b. sensitivity of the brain to painful stimuli. c. production of pain-sensitizing chemicals. d. spinal cord transmission of pain impulses.

c. production of pain-sensitizing chemicals. Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by the NSAIDs.

A patient nearing death requests that no medication be given that would cause a loss of consciousness, including pain medication. What would a nurse do to provide the best end-of-life care in this situation? a. Give the medication; comfort is the highest priority. b. Give half the ordered dose to provide compassionate care. c. Discuss this with family members and follow their wishes. d. Respect the patient's wishes and withhold pain medications.

A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? a. "I understand" and allow the client to close the door. b. Keep the door open, but step to the side out of the client's view. c. Leave the client's room and wait outside in the hall. d. "For your safety I can be no more than an arm's length away."

d. "For your safety I can be no more than an arm's length away." This level of suicide watch does not make adjustments based on client preference. The explanation quoting the protocol and the reason (your safety) is appropriate. The correct statement reinforces the basic need for client safety. The other options fail to provide for the degree of client safety required.

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? a. "I know a lot of people care about me and want me to get better." b. "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself." c. "I don't have a good support system, but I am planning on joining a recovery group." d. "I think things will be better soon."

d. "I think things will be better soon." This response may be a covert, or indirect, clue that the patient is thinking of suicide. The other options are all statements that, while they may be discussed further, are not clues to suicidality but rather clear communication.

8. A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? a. "It's not a good idea to ask for pain medication regularly as it can be addictive." b. "It is better to wait until the pain gets unbearable before asking for pain medication." c. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." d. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

d. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

Which patients would be at highest risk for developing oral candidiasis? a. A 74-year-old patient who has vitamin B and C deficiencies b. A 22-year-old patient who smokes 2 packs of cigarettes per day c. A 58-year-old patient who is receiving amphotericin B for 2 days d. A 32-year-old patient who is receiving ciprofloxacin (Cipro) for 3 weeks

d. A 32-year-old patient who is receiving ciprofloxacin (Cipro) for 3 weeks Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies are rare but may lead to Vincent's infection. Use of tobacco products leads to stomatitis.

Which statement factually describes the act of suicide? a. More women than men commit suicide. b. The Jewish culture has the lowest suicide rate. c. Suicide is the leading cause of death in the United States. d. A client diagnosed with schizophrenia is at great risk for attempting suicide.

d. A client diagnosed with schizophrenia is at great risk for attempting suicide. Individuals with schizophrenia are 8 times more likely to attempt suicide than is the general public. Suicide is the tenth leading cause of death in the United States. Protestants and the Jewish culture have a higher rate of suicide than do Catholics. More women attempt suicide, but more men are successful.

When working with a client who may have made a covert reference to suicide, the nurse should base the response on what statement? a. Being careful not to mention the idea of suicide. b. Listening carefully to see whether the client mentions suicide more overtly. c. Asking about the possibility of suicidal thoughts in a covert way. d. Asking the client directly if they are thinking of attempting suicide.

d. Asking the client directly if they are thinking of attempting suicide. Covert references should be made overt. The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis. None of the other options should direct this discussion.

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect? a. Blunt affect b. Restricted affect c. Broad affect d. Flat affect

d. Flat affect

Which of the following occurrences is considered a breach of professional boundaries? a. Patient asking a nurse for her phone number b. Refusing a gift from a patient c. Changing the subject in response to a patient complement d. Having a lengthy social conversation with a patient

d. Having a lengthy social conversation with a patient

The nurse observes the meal tray about to serve a suicidal client. Which item should be removed from the tray? a. Plastic plate b. Cloth napkin c. Styrofoam cup d. Metal utensils

d. Metal utensils In most health care agencies, suicidal clients receive plastic dinnerware on their meal trays since metal utensils can be used to cause physical harm. None of the other options carry that same degree of risk.

Which of the following statements is true about a nurse's self-disclosure? a. It is the basis for effective communication. b. Self-disclosure should be used with all clients to some degree. c. The more the nurse discloses, the more the client will disclose. d. Self-disclosure on the nurse's part should benefit the client.

d. Self-disclosure on the nurse's part should benefit the client.

A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which of the following actions by the nurse is most likely to help the client be successful in this group? a. Allowing the client to direct her participation at her own pace b. Giving the client several choices of projects so she can choose her favorite c. Staying away from the client during the session to encourage free expression d. Structuring the activity to facilitate completion of one specific task

d. Structuring the activity to facilitate completion of one specific task

4. A patient with chronic cancer pain is receiving imipramine (Tofranil) in addition to long-acting morphine for pain control. Which information is the best indicator that the imipramine is effective? a. The patient sleeps 8 hours every night. b. The patient has no symptoms of anxiety. c. The patient states, "I feel much less depressed since I've been taking the imipramine." d. The patient states, "The pain is manageable, and I can accomplish my desired activities.

d. The patient states, "The pain is manageable, and I can accomplish my desired activities. Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication also is prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.

17. A patient who has chronic musculoskeletal pain tells the nurse, "I feel depressed because I ache too much to play golf." The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will exhibit fewer signs of depression. b. The patient will say that the aching has decreased. c. The patient will state that pain is at a level 2 of 10. d. The patient will be able to play 1 to 2 rounds of golf.

d. The patient will be able to play 1 to 2 rounds of golf. For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse also should assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.

10. When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control. c. Tell the patient that additional morphine can be administered when the respirations are 12. d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.

d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.

When preparing for the first clinical experience with patients on a forensic unit at a psychiatric hospital, the nursing instructor discusses students' beliefs and fears surrounding forensic patients. The primary reason for discussing personal beliefs is to: a. practice reflective communication skills in a role play situation. b. assign the most compatible patients to the students. c. assess the appropriateness of the setting for implementing nursing skills. d. become aware of possible barriers to developing therapeutic relationships.

d. become aware of possible barriers to developing therapeutic relationships.

6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which of these prescribed medications will be best for the nurse to administer? a. lorazepam (Ativan) 1 mg orally b. amitriptyline (Elavil) 10 mg orally c. ibuprofen (Motrin) 400 to 800 mg orally d. immediate-release morphine 30 mg orally

d. immediate-release morphine 30 mg orally The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. The Motrin and Elavil may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patient's anxiety is caused by the pain.

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

4. Symptoms indicate lithium carbonate toxicity.

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention? 1.Comply with the client's wishes at all times. 2.Encourage the client to be dependent on hospital staff. 3.Refuse to answer questions related to impending death. 4.Encourage the client to maintain maximum self-control.

4.Encourage the client to maintain maximum self-control. Rationale: Interventions appropriate when caring for a terminally ill adolescent include avoiding alliances with either the parent or child, structuring hospital admission to allow for maximum self-control and independence, and answering the adolescent's questions honestly. Complying with the client's wishes at all times is not therapeutic.

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement? 1."Palliative care interventions hasten death." 2."Palliative care promotes optimal functioning." 3."Palliative care will provide pain management." 4."Palliative care will provide symptom management."

1."Palliative care interventions hasten death." Rationale: Palliative care interventions do not serve to hasten death; rather, they provide pain and symptom management, attention to issues faced by the child and family with regard to death and dying, and promotion of optimal functioning and quality of life.

Which of the following is a key feature of palliative care? A- One goal of palliative care is to control pain. B- One goal of palliative care is to cure the patient. C- One goal of palliative care is to find the cause of disease. D- One goal of palliative care is to eliminate the source of disease.

A- One goal of palliative care is to control pain.

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action? 1.Agree to act as a witness. 2.Call the health care provider (HCP). 3.Ask another nurse to serve as a witness. 4.Ask the client who might be available to serve as a witness.

4.Ask the client who might be available to serve as a witness. Rationale: A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the client who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the HCP. A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation?

A patient has been receiving palliative care for the past several weeks in light of her worsening condition after a series of strokes. The caregiver has rung the call bell, stating that the patient "stops breathing for a while, then breathes fast and hard, and then stops again." You recognize that the patient is experiencing A. Apnea B. Bradypnea C. Death rattle D. Cheyne-Stokes respirations

D. Cheyne-Stokes respirations Cheyne-Stokes respirations are a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is usually seen as a person nears death.

A patient with bronchial carcinoma reports anorexia and nausea. What measures should the nurse implement to help this patient? A. Provide large meals twice a day. B. Offer bland food with spices. C. Provide small portions of favorite foods. D. Immediately put the patient on intravenous fluids.

A nurse finds that a terminally ill patient has cold, clammy, and wax-like skin. What should the nurse infer from this assessment? A. The patient is improving. B. The patient is likely to die soon. C. The patient has edema and needs diuretics. D. The intravenous fluids have extravasated.

Which is not true about advance directives? A- They are a useful tool for eliciting patient preferences. B- All patients should be encouraged to make their wishes known. C- Ideally, they cover proxy decision makers, DNR orders, intubation choices, and the use of artificial hydration and feedings. D- They should be ignored if the doctor doesn't agree with the choices listed.

D- They should be ignored if the doctor doesn't agree with the choices listed.

A family is considering hospice for their loved one who is terminally ill, but they are concerned that they cannot afford hospice care. Which response by the nurse is accurate? A. "The hospice program usually has a small co-pay." B. "The hospice provides better quality of care than the family can." C. "The hospice assists with curative treatments for dying patients and their families." D. "The hospice Medicare program pays for all equipment and medications that are related to the patient's primary hospice diagnosis."

The nurse is caring for a dying client who adheres to Judaism. The nurse demonstrates cultural sensitivity when caring for this client by taking which action? 1.Encouraging a rabbi to sit with the client 2.Encouraging the client to have time alone 3.Asking the family if they would like an autopsy done 4.Encouraging family to agree to removal of life support

1.Encouraging a rabbi to sit with the client Rationale: When caring for a client who adheres to Judaism, end-of-life care includes recognizing that prolongation of life is important (a client on life support must remain so until death). A dying client should not be left alone (a rabbi's presence is desired), and autopsy and cremation are forbidden.

11. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

1. Provide client with high-calorie finger foods throughout the day.

The nurse is providing physical care to the end-of-life patient who remains in a state of confusion, incoherence, and anxiety and often hallucinates. The nurse anticipates that the patient's condition is caused by the administration of opioids and corticosteroids. What nursing management does the nurse implement for this patient? Select all that apply. A. Assess for spiritual distress. B. Encourage consumption of ice chips. C. Assess the patient's tolerance for activities. D. Stay physically close to the frightened patient. E. Provide a room that is quiet, well-lit, and familiar.

D,E

A good practice for providing adequate end-of-life care is: A-Not let the patient talk about religion or spiritual concerns B- Avoid "giving up" on the patient by shifting from curative to palliative care C- Use appropriate medical jargon when talking about diagnosis, prognosis, and care options D- Ask open-ended questions to help identify the patient's values, concerns, and goals for care

D- Ask open-ended questions to help identify the patient's values, concerns, and goals for care

Which is the best statement about communication: A- Simple yes/no questions are best. B- It is better to talk to the family and leave the patient out when discussing end-of-life care. C- The use of big medical words will make the patient respect you more. D- Open-ended questions help the patient to express his or her preferences.

D- Open-ended questions help the patient to express his or her preferences.

Which of the following best expresses the relationship of hospice care and palliative care? A- The main goal of palliative care is cure, while hospice care begins when nothing else can be done. B- Hospice care provides palliative care at the end-of-life. C- Hospice care is only for those with cancer, while palliative care is appropriate with other diagnoses. D- Hospice care and palliative care are the same thing

B- Hospice care provides palliative care at the end-of-life.

Which is the most accurate statement regarding spiritual and religious issues? A- People at the end of life are too preoccupied with pain to consider what happens after death. B- The interdisciplinary team usually includes a chaplain to assist with any spiritual concerns. C- You should avoid discussing religion because you might upset the patient. D- Patients of a different culture from their nurse will never want to discuss their beliefs with you.

B- The interdisciplinary team usually includes a chaplain to assist with any spiritual concerns.

The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of which of the following? A. 3 months or less to live B. 6 months or less to live C. 12 months or less to live D. 18 months or less to live

B. 6 months or less to live Two criteria must be met to be eligible for hospice care. First, the patient must wish to receive it, and second, the physician must certify that the patient has a prognosis of 6 months or less to live.

The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. Who is responsible for making the decision about EOL measures when the patient cannot communicate his or her specific wishes? A) Notary and attorney B) Physician and family C) Wife and adult children D) Physician and nursing staff

The patient who is actively dying: A- Is always fully aware of his or her surroundings B- Should be isolated from any visitors C- Tends to have a somewhat predictable set of signs and symptoms D- Always has an increased appetite

C- Tends to have a somewhat predictable set of signs and symptoms

The primary purpose of hospice is to A) Allow patients to die at home. B) Provide better quality of care than the family can. C) Coordinate care for dying patients and their families. D) Provide comfort and support for dying patients and their families.

The caregiver of a patient with chronic illness experiences grief after the death of the patient. The caregiver recalls positive memories of the deceased patient, and the nurse notices that the caregiver is accepting the reality of the death of the patient. What type of grief does the nurse identify in the caregiver? A. Adaptive grief B. Anticipatory grief C. Complicated grief D. Prolonged grief disorder

When going to the hospital, which forms should patients be encouraged to bring with them in case end-of-life care becomes an ethical or legal issue? A. Euthanasia B. Organ donor card C. Advance directives D. Do not resuscitate (DNR)

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? 1.Provide a dark room. 2.Provide a well-lighted room. 3.Reorient the client every 8 hours only. 4.Withhold benzodiazepines and sedatives.

2.Provide a well-lighted room. Rationale: Delirium may occur during the last days of life. Nursing management of a terminally ill client experiencing delirium includes providing a room that is quiet, well lighted, and familiar to reduce the effects of delirium; reorienting the dying client to client, place, and time with each; and administering prescribed benzodiazepines and sedatives as needed.

A tearful patient tells the nurse that her brother (who is in prison) just received a diagnosis of terminal metastatic lung cancer. She is worried that her brother will die in pain and alone. What is the nurse's best response? A) "It's too bad that they don't have hospice services in prison." B) "I'm sure the prison will let him out if they know he is dying." C) "Maybe if he had not committed a crime, he wouldn't be in this situation." D) "Many prisons offer health care services, including hospice and palliative care."

A nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate? 1.Keeps the client's body in a flat, supine position 2.Closes the client's eyes by taping the eyelids shut 3.Elevates the head of the bed 30 degrees as soon as possible after death 4.Removes the client's dentures and places them in a denture cup with the client's name on the lid

3.Elevates the head of the bed 30 degrees as soon as possible after death Rationale: The nurse may delegate postmortem care to unlicensed assistive personnel, but the nurse must supervise the postmortem care. The care given must protect the client's body from damage or disfigurement. Elevating the head of bed immediately after the client's death can help reduce facial discoloring from livor mortis. Using tape may damage the delicate eyelid tissues; dentures should be placed inside the client's mouth during postmortem care to maintain facial structure.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

3.Encourage expression of feelings, concerns, and fears. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which best describes Cheyne-Stokes respirations? 1.Continuous rapid regular breathing 2.Periods of apnea followed by bradypnea 3.Periods of apnea followed by deep rapid breathing 4.Periods of bradypnea followed by periods of tachypnea

3.Periods of apnea followed by deep rapid breathing Rationale: Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. Therefore options 1, 2, and 4 are incorrect.

A family member of a patient who is nearing death expresses that the patient is having audible and irregular breath sounds. Which explanation to the family member is appropriate? A. The irregular sounds will improve with regular suctioning of secretions. B. The issue could be due to an incorrect position. C. The irregular breathing will likely correct itself in a short time. D. The issue is caused by accumulation of mucus or fluid in the airways.

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool

2. "FIND" tool Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

The nurse is caring for a patient whose spouse died two weeks ago. The nurse observes that the patient does not engage in active conversation and avoids eye contact. Which stage of grief is the patient in? A. Denial B. Anger C. Depression D. Acceptance

For the past 5 years, Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? A. Adaptive grief B. Disruptive grief C. Anticipatory grief D. Prolonged grief disorder

D. Prolonged grief disorder Prolonged grief disorder is prolonged and intense mourning. It includes symptoms such as recurrent distressing emotions, intrusive thoughts related to the loss of a loved one, severe pangs of emotion, self-neglect, and denial of the loss for longer than 6 months.

Acceptance of an impending loss, spiritual beliefs, and adequate preparation time are all associated with positive outcomes regarding anticipatory grief. The age and diagnosis of the patient are not key factors in influencing the quality of caregivers' anticipatory grief. What is the primary purpose of hospice? A. Allow patients to die at home. B. Provide better quality of care than the family can. C. Coordinate care for dying patients and their families. D. Provide comfort and support for dying patients and their families.

D. Provide comfort and support for dying patients and their families. Hospice provides support and care at the end of life to help patients live as fully and as comfortably as possible. The emphasis is on symptom management, advance care planning, spiritual care, and family support, including bereavement.

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

D. Symptoms indicate lithium carbonate toxicity

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply. 1.Close the client's eyes. 2.Elevate the head of the bed. 3.Place a warm compress on the eyes. 4.Place a dry sterile dressing over the eyes. 5.Place wet saline gauze pads and a cool pack on the eyes.

1.Close the client's eyes. 2.Elevate the head of the bed. 5.Place wet saline gauze pads and a cool pack on the eyes. Rationale: When a corneal donor dies, the eyes are closed, the head of the bed is elevated to prevent edema formation, and gauze pads wet with saline are placed over them with a cool pack or small ice pack. A warm compress will promote edema. Placing dry sterile dressings over the eyes serves no useful purpose. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted with 24 to 48 hours.

The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. 1.Retain ritualism. 2.Avoid significant changes in lifestyle. 3.Maintain sensitivity toward the parents. 4.Encourage the parents to be near the child. 5.Encourage as normal an environment as possible. 6.Discourage the parents from dealing with their feelings.

1.Retain ritualism. 2.Avoid significant changes in lifestyle. 3.Maintain sensitivity toward the parents. 4.Encourage the parents to be near the child. 5.Encourage as normal an environment as possible. Rationale: Once infants and toddlers have established trust with a parent, separation, even if temporary, from the parent is profound. Prolonged separation during the first several years is thought to be more significant in terms of future physical, social, and emotional growth than at any subsequent age. When interacting with parents of a terminally ill toddler, the parents should be assisted in dealing with their feelings and encouraged to remain as near to the child as possible. It is also important to maintain as normal an environment as possible to retain ritualism.

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2. Valproic acid (Depakote)

The community health nurse is providing an educational session to a group of community members at a local high school regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make? 1."Written consent is never required to become a donor." 2."A donor must be 18 years of age or older to provide consent." 3."A person can sign papers to become a donor at 16 years of age." 4."The family is responsible for decision making about organ donation at the time of death."

2."A donor must be 18 years of age or older to provide consent." Rationale: Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs. Therefore options 1, 3, and 4 are incorrect.

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? 1.Pain 2.Anxiety 3.Depression 4.Withdrawal

2.Anxiety Rationale: Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptom.

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. 1.Increased appetite 2.Loss of consciousness 3.Loss of bowel control 4.Loss of bladder control 5.Decreased blood pressure 6.Decreased tactile sensation

2.Loss of consciousness 3.Loss of bowel control 4.Loss of bladder control 5.Decreased blood pressure 6.Decreased tactile sensation Rationale: Physical signs of approaching death include decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control, and decreased tactile sensation.

The nurse cares for a patient in the terminal stage of leukemia who has opted for hospice care. When is the patient considered to be eligible for hospice care? A. When two primary health care providers certify that the patient has less than 6 months to live. B. When a primary health care provider certifies that the patient has less than 6 months to live. C. When it is certain that the patient is going to die within 9 months. D. When one primary health care provider guarantees that the patient cannot recover further.

7. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3. "Weight gain is a common, but troubling, side effect."

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests no autopsy be performed. Which response to the family is most appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done?"

3."I will contact the medical examiner regarding your request." Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family? 1.The nurse encourages the client and family to identify and discuss feelings openly. 2.The nurse assists the client and family in carrying out spiritually meaningful practices. 3.The nurse makes decisions for the client and family to relieve them of unnecessary demands. 4.The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

3.The nurse makes decisions for the client and family to relieve them of unnecessary demands. Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communications. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 4 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The correct option describes the nurse removing autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could impair communication further.

The children caregivers of an older patient whose death is imminent have not left the bedside for the past 36 hours. In the nurse's assessment of the family, what findings indicate the potential for an abnormal grief reaction to occur (select all that apply)? A) Family cannot express their feelings to one another. B) Dying patient is becoming more restless and agitated C). A family member is going through a difficult divorce. D) Family talks with and reassures the patient at frequent intervals. E) Siblings who were estranged from each other have now reunited.

A, C

10. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

4. "Treatment is compromised when clients choose not to take their medications."

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? 1.It reduces the secretions in the bronchi. 2.It causes dilation of the bronchial smooth muscles. 3.It relieves pain, which helps to reduce the dyspnea. 4.It helps to reduce anxiety and oxygen consumption.

4.It helps to reduce anxiety and oxygen consumption. Rationale: Dyspnea is a terrifying and yet common symptom in clients who are near death. The use of opioids is considered standard treatment for dyspnea in clients who are near death. It helps to help reduce dyspnea by reducing anxiety, thus reducing the consumption of oxygen and altering the client's perception of dyspnea. Morphine does not reduce secretions or cause dilation of smooth muscles in the bronchi. Although morphine does relieve pain, this client is not experiencing any pain.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do-not-resuscitate (DNR) order. What is the nurse's priority action? 1.Prepare the client for intubation and mechanical ventilation. 2.Talk to the family about the client's right to change his mind. 3.Administer an anti-anxiety medication to the client to ease his breathing. 4.Notify the health care provider that the client is rescinding the DNR order.

4.Notify the health care provider that the client is rescinding the DNR order. Rationale: COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the health care provider to reverse the DNR prescription on the chart. The health care provider also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the health care provider. Option 2 is incorrect because the health care provider should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions.

The hospice nurse visits with the wife of a dying patient. The nurse is most concerned if the patient's wife makes which statement? A) "I don't think that I can live without my husband to take care of me." B) "I wonder if expressing my sadness makes my husband feel worse." C) "We have shared so much that it is hard to realize that I will be alone." D) "I don't feel guilty about leaving him to go to lunch with my friends."

A Normal reactions to loss include the statements in options b, c, and d. Option a indicates an abnormal grief reaction and possible suicidal thinking.

An 80-year-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to (select all that apply) A) Improve her quality of life. B) Assess her coping ability with disease. C) Have time to teach patient and family about disease. D) Focus on reducing the severity of disease symptoms. E) Provide care that the family is unwilling or unable to give.

A, D

The caregiver children of an elderly patient whose death is imminent have not left the bedside for the past 36 hours. In your assessment of the family, which of the following findings indicates the potential for an abnormal grief reaction by family members (select all that apply)? A. Family members cannot express their feelings to one another. B. The dying patient is becoming more restless and agitated. C. A family member is going through a difficult divorce. D. The family talks with and reassures the patient at frequent intervals. E. Siblings who were estranged from each other have now reunited.

A. Family members cannot express their feelings to one another. C. A family member is going through a difficult divorce. You must be able to recognize signs and behaviors among family members who may be at risk for abnormal grief reactions. These may include dependency and negative feelings about the dying person, inability to express feelings, sleep disturbances, a history of depression, difficult reactions to previous losses, perceived lack of social or family support, low self-esteem, multiple previous bereavements, alcoholism, and substance abuse. Caregivers with concurrent life crises are especially at risk.

An 80-year-old patient is receiving palliative care for heart failure. What are the primary purposes of her receiving palliative care (select all that apply)? A. Improve her quality of life. B. Assess her coping ability with disease. C. Have time to teach patient and family about disease. D. Focus on reducing the severity of disease symptoms. E. Provide care that the family is unwilling or unable to give.

A. Improve her quality of life. D. Focus on reducing the severity of disease symptoms. The focus of palliative care is to reduce the severity of disease symptoms. The goals of palliative care are to prevent and relieve suffering and to improve quality of life for patients with serious, life-limiting illnesses.

A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

A. Provide client with high-calorie finger foods throughout the day.

A hospice nurse is visiting with a dying patient. During the interaction, the patient is silent for some time. What is the best response? A. Recognize the patient's need for silence, and sit quietly at the bedside. B. Try distraction with the patient. C. Change the subject, and try to stimulate conversation. D. Leave the patient alone for a period.

A. Recognize the patient's need for silence, and sit quietly at the bedside. Frequently, silence is related to the overwhelming feelings experienced at the end of life. Silence can also allow time to gather thoughts. Listening to the silence sends a message of acceptance and comfort.

Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient (select all that apply)? A. Strong spiritual beliefs B. Medical diagnosis of the patient C. Advanced age of the palliative patient D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death

A. Strong spiritual beliefs D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death

The home health nurse visits a 40-year-old breast cancer patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, you would do which of the following first? A. Auscultate for breath sounds. B. Administer prn pain medication. C. Check pressure points for skin breakdown. D. Ask family members about patient's dietary intake.

B. Administer PRN pain medication. Meeting the patient's physiologic and safety needs is the priority. Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. The patient is not experiencing oxygenation problems; the priority is to treat the severe pain with pain medication.

The nurse explains to a patient with advanced cancer about the differences between hospice and palliative care. Which statement, if made by the patient, indicates that teaching was effective? A) "Hospice care is not available if I am in the hospital." B) "Palliative care provides better methods of pain control." C) "Hospice care will help me and my family prepare for death." D) "Palliative care does not include any advance directives."

C Hospice care provides compassion, concern, and support for the dying. The emphasis of care at end of life is on symptom management, advance care planning, spiritual care, and family support, including bereavement. Hospice care may be delivered in a variety of settings, including home, inpatient settings, and long-term care facilities.

A patient in the terminal stage of acute myeloid leukemia has become unconscious. On examination, a nurse finds that the patient's mouth is very dry. How would the nurse help the patient to restore the moisture? Select all that apply. A. Give ice chips. B. Give sips of fluids. C. Use moist cloths for the oral mucosa. D. Apply lubricant to the lips and oral mucus membrane as needed. E. Provide complete and regular oral care.

C,D,E

Which of the following is important for meeting the needs of a dying person's family? A- Restrict family members from performing simple care tasks. B- Make firm predictions about the patient's exact clinical course. C- Provide a clear description of what the dying process will look like. D- Strictly enforce visiting hours and limitations on number of visitors.

C- Provide a clear description of what the dying process will look like.

The nurse provides care on an oncology unit and is discussing the difference between hospice care and palliative care with the patient's family. What is an appropriate explanation by the nurse? A. Hospice care involves only chemotherapy that is given in a hospital. B. Hospice care involves radiation therapy and chemotherapy that are given in a hospital. C. Hospice care is provided after a person decides to forgo curative treatment. D. Hospice care allows a person to undergo both curative and palliative treatment together.

You have been working full time with terminally ill patients for 3 years. You are experiencing irritability and mixed emotions when expressing sadness since four of your patients died on the same day. To optimize the quality of your nursing care, you should examine your own A. full-time work schedule. B. past feelings toward death. C. patterns for dealing with grief. D. demands for involvement in patient care.

C. patterns for dealing with grief. Caring for dying patients is intense and emotionally charged, and you need to be aware of how grief affects you personally. You will have feelings of loss, helplessness, and powerlessness when dealing with death. Feelings of sorrow, guilt, and frustration need to be expressed. Recognizing personal feelings allows openness in exchanging feelings with the patient and family.

The nurse finds that a terminally ill patient is experiencing nausea and vomiting. Which would be an appropriate nursing action? A. Encourage or provide three big meals rather than small frequent meals. B. No action is required, as this issue is common during the last days of life. C. Prevent family members from bringing home-cooked food, which might overwhelm the patient. D. Administer antiemetic drugs before meals, as ordered.

There has been improvement in the health of an elderly patient who has been in hospice care for 6 months. What should the nurse suggest to this patient? A. The patient can leave hospice care only when the primary health care provider allows doing so. B. The patient must continue for another 6 months in hospice care before leaving. C. The patient is in hospice care and is not eligible for curative treatment. D. The patient can withdraw from hospice care and can receive other health services.

The hospice nurse identifies an abnormal grief reaction by the wife of a dying patient, who says A. "I don't think that I can live without my husband to take care of me." B. "I wonder if expressing my sadness makes my husband feel worse." C. "We have shared so much that it is hard to realize that I will be alone." D. "I don't feel guilty about leaving him to go to lunch with my friends."

D. "I don't feel guilty about leaving him to go to lunch with my friends." Being present during a family member's dying process can be highly stressful. It is important for the hospice nurse to recognize signs and behaviors among family members who may be at risk for abnormal grief reactions and be prepared to intervene if necessary.

Exam 4 Health and Illness II NCLEX Question Bank

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