exam 4 Nursing concepts Troy U
A nurse performing an assessment of a newborn in the neonatal unit records these findings: heart rate 85 bpm, irregular respiratory rate, normal muscle tone, weak crying, and bluish tint to skin. Using the APGAR scoring chart what would be the score for this newborn? *A.* 5 *B.* 7 *C.* 8 *D. 10
*A.* 5
A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be develop- mentally appropriate for this age group? *A.* Playing video games *B.* Playing peek-a-boo *C.* Playing in a sand box *D.* Playing board games
*C.* Playing in a sand box
a. Acceptance
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. 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.
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. The nurse places the patient in a sitting position while the family visits.
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. Actual b. Perceived c. Psychological
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 nurse providing health services for a 55 plus community setting formulates diagnoses for patients. Which of the following nursing diagnoses would be most appropriate for many middle adults? 1. Risk for Imbalanced Nutrition: Less Than Body Requirements 2. Delayed Growth and Development 3. Self-Care Deficit 4. Caregiver Role Strain
D
2. A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? a) "We're at the age when we should consider ceasing sexual activity." b) "We need more time for sexual stimulation than we used to." c) "If we are unable to have sex we can still have an intimate relationship." d) "If we change our position we can still have sex and be more comfortable."
a
14. Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. a) A patient who is breast-feeding b) A patient who is diagnosed with anorexia c) A patient who chooses to abstain from sexual intercourse d) A patient who has pelvic inflammatory disease e) A patient who is obsessed with exercising f) A patient who has a spinal cord injury
a,b,d,e
A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? a. "I must breathe in and out in rhythm." b. "I should take my pulse and expect it to be faster." c. "I can expect my muscles to feel less tense." d. "I will be more relaxed and less aware."
b. "I should take my pulse and expect it to be faster."
A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: A. Kidneys B. Lungs C. Adrenal glands D. Blood vessels
b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.
A mother tells the nurse that she is worried about her 4-year- old daughter because she is "overly attached to her father and won't listen to anything I tell her to do." What would be the nurse's best response to this parental concern? *A. Tell the mother that this is normal behavior for a preschooler. *B.* Tell the mother that she and her family should see a counselor. *C.* Tell the mother that she should try to spend more time with her daughter. *D.* Tell the mother that her child should be tested for autism.
*A. Tell the mother that this is normal behavior for a preschooler.
A nurse is teaching new mothers about infant care and safety. What would the nurse accurately include as a teaching point? *A.* Keep infants younger than 6 months out of direct sunlight. *B.* Use honey instead of sugar in homemade baby food. *C.* Place the baby on his or her stomach for sleeping. *D.* Keep crib rails down at all times.
*A.* Keep infants younger than 6 months out of direct sunlight.
The nurse records an APGAR score of 4 for a newborn. What would be the priority intervention for this newborn? *A.* No interventions are necessary; this is a normal score. *B.* Provide respiratory assistance. *C.* Perform CPR. *D.* Wait 5 minutes and repeat the scoring process.
*B.* Provide respiratory assistance.
The nurse encourages parents of hospitalized infants and toddlers to stay with their child to help decrease what potential problem? *A.* Problems with attachment *B.* Separation anxiety *C.* Risk for injury *D.* Failure to thrive
*B.* Separation anxiety
A nurse working with adolescents in a group home discusses the developmental tasks appropriate for adolescents with the staff. What is an example of a primary developmental task of the adolescent? *A.* Working hard to succeed in school *B.* Spending time developing relationships with peers *C.* Developing athletic activities and skills *D.* Accepting the decisions of parents
*B.* Spending time developing relationships with peers
Following assessment of an obese adolescent, a nurse considers nursing diagnoses for the patient. Which diagnosis would be most appropriate? *A.* Risk for injury *B.* Risk for delayed development *C.* Social isolation *D.* Disturbed body image
*D.* Disturbed body image
1. A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? a. Give the patient a hug and tell him that his life still has meaning. b. Arrange for a spiritual adviser to visit the patient. c. Ask if the patient would like to talk about his feelings. d. Call in a close friend or relative to talk to the patient.
1. c. When caring for a patient who is in spiritual distress, the nurse should listen to the patient first and then ask whether the patient would like to visit with a spiritual adviser. To arrange for a spiritual adviser first may not respect the wishes of the patient. A hug and false reassurances do not address the diagnosis of spiritual distress. Talking to friends or relatives may be helpful, but only if the patient desires their visits.
10. A nurse who is comfortable with one's own spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients? a. Calling the patient's own spiritual adviser first b. Asking whether the patient has a spiritual adviser the patient wishes to consult c. Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser d. Advising the patient and spiritual adviser concerning health options and the best choices for the patient
10. b. Even when a nurse feels comfortable discussing spiritual concerns, the nurse should always check first with patients to determine whether they have a spiritual adviser to consult. Calling the patient's own spiritual adviser (answer a) may be premature if it is a matter the nurse can handle. Answers c and d deny patients the right to speak privately with their spiritual adviser from the outset, if this is what they prefer.
11. A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which NANDA-I-approved diagnostic label would the nurse use when assessment data point to a spiritual problem that can be treated by independent nursing intervention? a. Spiritual Alienation b. Spiritual Despair c. Spiritual Distress d. Spiritual Pain
11. c. The only NANDA-I-approved nursing diagnosis among the options is Spiritual Distress. The other options may be further specifications of the broader diagnosis Spiritual Distress.
12. A patient states she feels so isolated from her family and church, and even God "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress? a. The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living. b. The patient will identify spiritual beliefs that meet her need for meaning and purpose. c. The patient will express peaceful acceptance of limitations and failings. d. The patient will identify spiritual supports available to her in this medical center.
12. d. Each of the four options represents appropriate spiritual goals, but identifying spiritual supports available to her in the medical center demonstrates a goal to decrease her sense of isolation.
13. A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan? a. Ask the patient which spiritual adviser he would like you to call. b. Recommend that the patient read spiritual biographies or religious books. c. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past. d. Introduce the belief that God is a loving and personal God.
13. c. The nursing intervention of exploring with the patient what, in addition to his family, has given his life meaning and purpose in the past is more likely to correct the etiology of his problem, Spiritual Pain, than any of the other nursing interventions listed.
14. After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? a. Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands." b. Patient has slept from 10 PM to 6 AM for three consecutive nights without medication. c. Patient has developed mutually caring relationships with two women and one man. d. Patient has identified several spiritual beliefs that give purpose to her life
14. a. Because this patient's nursing diagnosis is Spiritual Distress: Guilt, an evaluative statement that demonstrates diminished guilt is necessary. Only answer a directly deals with guilt.
15. Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he can not face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness? a. Assure him that many parents feel the same way. b. Reassure him that many teenagers go through this kind of rebellion and that it will pass. c. Assist the patient to identify how unforgiving feelings toward others hurt the one who cannot forgive. d. Ask him if he is sure he has spent sufficient time with his daughter.
15. c. This is the only nursing intervention that directly addresses the patient's unmet spiritual need concerning forgiveness. Answers a and b may make him feel better initially, but neither addresses his need to forgive. Answer d is likely to make him feel guilty.
2. A nurse who was raised as a strict Roman Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also God—if there is a God." Analysis of these data reveals which unmet spiritual need? a. Need for meaning and purpose b. Need for forgiveness c. Need for love and relatedness d. Need for strength for everyday living
2. c. The data point to an unmet spiritual need to experience love and belonging given her estrangement from her family and God after leaving the church. The other options may represent other needs this nurse has, but the data provided do not support them.
3. A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question to assess for spiritual needs? a. Can you describe your usual spiritual practices and how you maintain them daily? b. Are your spiritual beliefs causing you any concern? c. How can I and the other nurses help you maintain your spiritual practices? d. How do your religious beliefs help you to feel at peace?
3. c. Questioning how the staff can meet patients' spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices assesses spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at peace assesses the need for forgiveness.
4. A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding? a. The nurse should have ordered kosher dishes also. b. The staff must have behaved condescendingly or critically. c. Mr. Goldstein is a problem patient and difficult to satisfy. d. Mr. Goldstein was stereotyped and not consulted about his dietary preferences.
4. d. On the basis of his name alone, the nurse jumped to the premature and false conclusion that this patient would want a kosher diet.
5. A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery? a. A patient of the Adventist faith b. A patient who practices Buddhism c. A patient who is a Jehovah's Witness d. A patient who is an Orthodox Jew
5. c. Patients who practice the Jehovah's Witness faith believe blood transfusions violate God's laws and do not allow them. The other religious groups do not restrict modern lifesaving treatment for their members.
6. The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provide for baptism to be performed? a. Baptism frequently postpones or prevents death or suffering. b. It is legally required that nurses provide for this care when the family makes this request. c. It is a nursing function to assure the salvation of the baby. d. Lack of baptism when desired may increase the family's sorrow and suffering.
6. d. Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family's sorrow and suffering, which is an appropriate nursing concern. Whether baptism postpones or prevents death and suffering is a religious belief that is insufficient to bind all nurses. There is no legal requirement regarding baptism, and although some nurses may believe part of their role is to ensure the salvation of the baby, this function would understandably be rejected by many.
7. A nurse is formulating diagnoses for patients in a hospice program who are experiencing spiritual distress. In which diagnoses is spiritual distress the etiology of another problem? Select all that apply. a. Ineffective Individual Coping related to loss of religion as a major support in life b. Powerlessness related to feeling unprepared for death and the afterlife experience c. Self-Esteem Disturbance related to failure to reconcile illness with spiritual beliefs d. Risk for Impaired Religiosity related to inability to attend church as usual e. Spiritual Distress related to fear of dying alone f. Impaired Religiosity related to inability to exercise reliance on spiritual beliefs
7. a, b, c. Spiritual distress may affect other areas of human functioning. In the first three nursing diagnoses, spiritual distress is the etiology of another problem. In the last three diagnoses, spiritual distress is the problem.
8. A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality? a. The child's church or religious organization b. What parents say about God and religion c. How parents behave in relationship to one another and their children, to others, and to God d. The spiritual adviser for the family
8. c. Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God/higher being. The remaining three options are less important sources of learning.
9. Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation? a. Patients usually want to conceal information about their spiritual needs. b. Patients are not concerned about spiritual needs until after their spiritual adviser visits. c. Family members and close friends often initiate spiritual concerns. d. Illness increases spiritual concerns, which may be difficult for patients to express in words.
9. d. Illness may increase spiritual concerns, which many patients find difficult to express. The other options do not correspond to actual experience.
A nurse is caring for an 80-year-old patient who is living in a long-term care facility. To help this patient adapt to the present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? 1. "Tell me about how you celebrated Christmas when you were young." 2. "Tell me how you plan to spend your time this weekend." 3."Did you enjoy the choral group that performed here yesterday? 4. "Why don't you want to talk about your feelings?"
A
a. Patient
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. 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.
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."
c. Dysfunctional
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
b. "What seems to be concerning you the most?"
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. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient
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. "It does seem unfair. Tell me more about how you are feeling."
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?"
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.
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. Comfort-measures-only
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
c. Living will
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
A high school nurse is counseling parents of teenagers who are beginning high school. Which issues would be priority topics of discussion for this age group? Select all that apply *A.* The influence of peer groups *B.* Bullying *C.* Water safety *D.* Eating disorders *E.* Risk taking behavior *F.* Immunizations
A,B,D,E
A nurse caring for older adults in a skilled nursing home observes physical changes in patients that are part of the normal aging process. Which changes reflect this process? Select all that apply. 1. Fatty tissue is redistributed. 2. The skin is drier and wrinkles appear. 3. Cardiac output increases. 4. Muscle mass increases. 5. Hormone production increases. 6. Visual and hearing acuity diminishes.
A,B,F
A nurse is teaching patterns of preschoolers what type of behavior to expect from their children based on developmental theories. Which statements describe this stage of developmental? Select all that apply? A- According to Freud, the child is in the phallic stage B- According to Eirkson, the child is in the trust versus mistrust stage C- According to Havighurst, the child is learning to get along with others D- According to Fowler, the child imitates religious behavior of others E-According to Kohlberg, the child defines satisfying acts as right F- According to Havighurt, the child is achieving gender-specific roles
A- According to Freud, the child is in the phallic stage D- According to Fowler, the child imitates religious behavior of others E-According to Kohlberg, the child defines satisfying acts as right
A nurse caring for older adults in a long-term care facility encourages an older adult to reminisce about past life events. This life review, according to Erikson, is demonstrating what developmental stage of the later adult years? A- Ego Integrity B- Generativity C- Intimacy D- Initiative
A- Ego Integrity
A Nurse researcher studies the effects of genomic on current nursing practice. Which statements identify genetic principles that will challenge nurses to integrate genomics in their research, education, and practice? Select all that apply. A- Genetic tests plus family history tools have the potential to identify people at risk for diseases B - Pharmacogentic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication C- Evidence-based review panels are in place to evaluate the possible risks and benefits related to genetic testing D- Valid and reliable national data are available to establish baseline measures and track progress toward targets E- Genetic variation can either accelerate or slow the metabolism of many drugs F- It is beyond the role of the nurse to answer questions and discuss the impact of genetic findings on health and illness
A- Genetic tests plus family history tools have the potential to identify people at risk for diseases B - Pharmacogentic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication E- Genetic variation can either accelerate or slow the metabolism of many drugs
A school nurse is studying Kohlberg's theory of moral development to prepare present discussion addressing the problem of bullying, According to Kohlberg, which factor initially influences the normal development of children? A- Parent/caregiver-child communications B- Societal rules and regulations C- Social and religious rules D- A person's beliefs and values
A- Parent/caregiver-child communications
A 2-year-old grabs a handful of cake from the table and stuffs it in his mouth. According to Freud, What part of the mind is the child satisfying? A-Id B-Superego C-Ego D-Unconscious Mind
A-Id
The Nurse caring for infants in a hospital nursery knows that newborns continue to grow and develop according to individual growth patterns and developmental levels. Which terms describe these pattern? Select all that apply A-Orderly B-Simple C-Sequential D-Unpredictable E-Differentiated F-Integrated
A-Orderly C-Sequential E-Differentiated F-Integrated
A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. D. A patient who is HIV positive. E. A patient who is taking corticosteroids for arthritis. F. A patient with a urinary tract infection.
A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.
A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A. Arrange for assessment for depression and treatment. B. Discourage napping during the day. C. Decrease fluids during the evening. D. Administer diuretics in the morning. E. Encourage patient to engage in some type of physical activity. F. Assess medication for side effects of sleep pattern disturbances.
A. Arrange for assessment for depression and treatment. B. Discourage napping during the day. E. Encourage patient to engage in some type of physical activity. F. Assess medication for side effects of sleep pattern disturbances. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.
A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. A. Daily mental activities B. Daily physical activities C. Morning and evening body temperature D. Daily measurement of fluid intake and output E. Presence of anxiety or worries affecting sleep F. Morning and evening blood pressure readings
A. Daily mental activities B. Daily physical activities E. Presence of anxiety or worries affecting sleep A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.
To promote sleep in a patient, a nurse suggests what intervention? A. Follow the usual bedtime routine if possible. B. Drink two or three glasses of water at bedtime. C. Have a large snack at bedtime. D. Take a sedative-hypnotic every night at bedtime.
A. Follow the usual bedtime routine if possible. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.
A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? A. Increase physical activities during the day. B. Encourage short periods of napping during the day. C. Increase fluids during the evening. D. Dispense diuretics during the afternoon hours
A. Increase physical activities during the day. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening
A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A. No action is necessary as this is a normal finding during sleep. B. Call the primary care provider to report possible neurologic deficit. C. Lower the temperature in the patient's room. D. Awaken the patient as this is an indication of night terrors.
A. No action is necessary as this is a normal finding during sleep. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.
c. Caregiver Role Strain
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
A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. Place your answer on the line provided below.
Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL,
A nurse caring for patients in a primary care setting refers to Erikson's theory that middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which patient statement is an example of this finding? 1. "I am helping my parents move into an assisted-living facility." 2. "I spend all of my time going to the doctor to be sure I am not sick." 3. "I have enough money to help my son and his wife when they need it." 4. "I earned this gray hair and I like it!"
B
A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings related to the normal aging process would the nurse be likely to observe? Select all that apply. 1. Patients with wrinkles on the face and arms due to increased skin elasticity 2. A patient with skin pigmentation caused by exposure to sun over the years 3. A patient with thinner toenails with a bluish tint to the nail beds 4. A patient healing from a hip fracture that occurred due to porous and brittle bones 5.Bruising on a patient's forearms due to fragile blood vessels in the dermis 6. Decreased patient voiding due to increased bladder capacity
B,D,E
Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. 1. S—Senility 2. P—Problems with feeding 3. I—Irritability 4. C—Confusion 5. E—Edema of the legs 6. S—Skin breakdown
B,D,F
A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A. "I can expect my newborn to sleep an average of 16 to 24 hours a day." B. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C. "I will place my infant on his back to sleep." D. "I will not place pillows or blankets in the crib to prevent suffocation."
B. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.
A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A. A patient who is taking iron supplements for anemia. B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. D. A patient who is taking antibiotics for an ear infection. E. A patient who is prescribed antidepressants. F. A patient who is taking low-dose aspirin prophylactically.
B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. E. A patient who is prescribed antidepressants. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are see
A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A. Keep the room light dimmed during the day. B. Keep the room cool. C. Keep the door of the room open. D. Offer a sleep aid medication to patients on a regular basis.
B. Keep the room cool. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.
A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A. Circadian rhythm sleep-wake disorder B. Narcolepsy C. Enuresis D. Sleep apnea
B. Narcolepsy Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.
A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. What is the leading cause of cognitive impairment in old age? 1. Stroke 2. Malnutrition 3. AD 4. Loss of cardiac reserve
C
A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? 1. Most older adults live in their own homes. 2. Healthy older adults enjoy sexual activity. 3. Old age means mental deterioration. 4. Older adults want to be attractive to others.
C
A nurse caring for adults in a provider's office researches aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. 1. Chemical reactions in the body produce damage to the DNA. 2. Free radicals have adverse effects on adjacent molecules. 3. Decrease in size and function of the thymus results in more infections. 4. There is much interest in the role of vitamin supplementation. Lifespan depends on a great extent to genetic factors. 5. Organisms wear out from increased metabolic functioning.
C,D
A school nurse is preparing a talk on safety issues for parents of school-aged children to present at a parent-teacher meeting. Which topics should the nurse include based on the age of the children? Select all that apply. *A.* Child-proofing the home *B.* Choosing a car seat *C.* Teaching pedestrian traffic safety *D.* Providing swimming lessons and water safety rules *E.* Discussing alcohol and drug consumption related to motor vehicle safety *F.* Teaching child how to "stop, drop, and roll
C,D,F
A nurse is interviewing a 42-year-old patient who is visiting an internist for a blood pressure screening. The patient states: " I'm currently a sales associate, but I'm considering a different career and I'm a little anxious about the process" According to Levinson, what phase of adult life is this patient experiencing? A-Entering the adult world B- Settling Down C- Midlife transition D- Entering middle-adulthood
C- Midlife transition
A nurse who is working with women in a drop-in shelter studies Carol Gilligan's theory of morality in women to use when planning care. According to Gilligan, What is the motivation for female morality? A- Law and Justice B- Obligations and rights C- Response and care D- Order and Selfishness
C- Response and care
A nurse examining a toddler in a pediatric office documents that the child is in the 90th percentile for height and weight and has blue eyes. These physical characteristics are primarily determined by which of the following? A- Socialization with caregivers B- Maternal Nutrition during pregnancy C-Genetic information on chromosomes D-Meeting Development tasks
C-Genetic information on chromosomes
A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A. Preparing the family for a diagnosis of insomnia and related treatments. B. Preparing the family for a diagnosis of narcolepsy and related treatments. C. Anticipating the scheduling of polysomnography to confirm OSA. D. No action would be taken, as this is a normal finding for hospitalized children.
C. Anticipating the scheduling of polysomnography to confirm OSA. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.
A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A. The use of a central nervous system stimulant B. Continuous positive airway pressure machine (CPAP) C. Chronotherapy D. The application of heat or cold therapy to promote sleep
C. Chronotherapy Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.
A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A. Drinking a cup of regular tea at night induces sleep. B. Using alcohol moderately promotes a deep sleep. C. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D. Exercising right before bedtime can hinder sleep.
C. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.
A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A. He is aware of his surroundings at this point. B.He is in delta sleep at this time. C. It would be most difficult to awaken him at this time. D. This is most likely an NREM stage. E. This stage constitutes around 20% to 25% of total sleep. F. The muscles are relaxed in this stage.
C. It would be most difficult to awaken him at this time. E. This stage constitutes around 20% to 25% of total sleep. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.
An experienced nurse tells a less-experienced nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? 1. Harassment 2. Whistle blowing 3. EA 4. Ageism
D
The School nurse uses the principles and theories of growth and development when planning programs for high school students. According to Havighurst, What is a development task for this age group? A- Development task for this age group B- Developmental task for this age group C- Achieving personal independence D- Achieving a masculine or feminine gender role
D- Achieving a masculine or feminine gender role
A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. A. REM sleep constitutes much of the sleep cycle of a preschool child. B. By the age of 8 years, most children no longer take naps. C. Sleep needs usually decrease when physical growth peaks. D. Many adolescents do not get enough sleep. E. Total sleep decreases in adults with a decrease in stage IV sleep. F. Sleep is less sound in older adults and stage IV sleep may be absent.
D. Many adolescents do not get enough sleep. E. Total sleep decreases in adults with a decrease in stage IV sleep. F. Sleep is less sound in older adults and stage IV sleep may be absent. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.
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.
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.
11. A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? a) "HPV causes genital warts and cervical and other genital cancers." b) "HPV causes a single painless genital lesion and can lead to sterility." c) "50% of women between the ages of 14 and 19 are infected with HPV" d) "The HPV vaccination is only recommended for the female population."
a
7. A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? a) Diaphragm b) Oral contraceptive pills c) Depo-Provera d) Evra patch
a
8. A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? a) Getting the patient into a safe environment and mobilizing support for her. b) Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped. c) Convincing the student to be assessed for pregnancy, STIs, or other complications. d) Convincing the student to tell her parents so that she can receive their support.
a
A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. A. "Try to drink at least six to eight glasses of water each day." B. "Try to limit your fluid intake to 1 quart of water daily." C. "Limit sugar, salt, and alcohol in your diet." D. "Report side effects of medications you are taking, especially diarrhea." E. "Temporarily increase foods containing caffeine for their diuretic effect." F. "Weigh yourself daily and report any changes in your weight."
a, c, d, f. In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.
6. A 16-year-old female visits a local women's health clinic to obtain contraception. She asks the nurse, "What can I do to protect myself from diseases like AIDS?" Which recommendations are appropriate for anyone who is sexually active to prevent STIs? Select all that apply. a) Have regular checkups for STIs even in the absence of symptoms. b) Learn the common symptoms of STIs and seek help immediately if any develop—even if the symptom is mild. c) If a partner is infected, consider having sex during menstruation when the risk is greatly decreased. d) Douche regularly to remove any bacteria that may form in the vagina. e) Avoid anal intercourse, but if practiced, use a male condom. f)Consider the fact that the younger people are when having sex for the first time, the less susceptible they become to developing an STI.
a,b,e
1. A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. a) "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." b) "I should wean my infant by 4 months and encourage him to use a sippy cup." c) "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." d) "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." e) "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." f) "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."
a,b,e,f
3. A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. a) A 72-year-old male with a history of diabetes b) A 78-year-old male who has a new partner c) A 75-year-old male who has Parkinson disease d) An 80-year-old male who is an alcoholic e) An 85-year-old male who takes antihypertensive medication f) A 76-year-old male who smokes tobacco
a,d,e
A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? a. "Are you worried about failing your exams?" b. "Have you been staying up late studying?" c. "Are you using any recreational drugs?" d. "Do you have trouble managing your time?"
a. "Are you worried about failing your exams?"
A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? a. "I need to identify the problem first." b. "Listing alternatives is the initial step." c. "I will list alternatives after I develop the plan." d. "I do not need to evaluate the outcome of my plan."
a. "I need to identify the problem first."
A patient's spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess? a. Transmission of tactile stimuli b. Adequate stimulation to the environment c. Reception of visual and auditory stimuli d. General orientation and ability to follow commands
a. Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of lesser importance at this time.
A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors
a. Changes in appetite b. Changes in elimination pattern
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? A. Remove the IV from the site and start at another location. B. Immediately notify the primary care provider. C. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. D. Aspirate the catheter and attempt to flush again.
a. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.
A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? a. Monitoring food and drink temperatures to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Providing meals high in carbohydrates to promote healing
a. Monitoring food and drink temperatures to prevent burns (A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids.)
A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery
a. Progressive muscle relaxation b. Meditation e. Rhythmic breathing f. Guided imagery
In a group home in which most of the patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns? a. Maintaining safety and preventing sensory deterioration. b. Insisting that every patient participate in as many self-care activities as possible. c. Emphasizing and reinforcing individual patient strengths. d. Encouraging reminiscence and life review in groups.
a. Safety is a basic physiologic need that must be met before higher-level needs - such as love and belonging, self-esteem, and self-actualization, can be met.
A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.
a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.
Which patient would a nurse assess as being at greatest risk for sensory deprivation? a. An older man confined to bed at home after a stroke b. An adolescent in an oncology unit working on homework supplied by friends c. A woman in labor d. A toddler in a playroom awaiting same-day surgery
a. The patient confined to bedrest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate.
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. B. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. C. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. D. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.
a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.
A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a.Increased heart rate b.Decreased muscle strength c.Increased mental alertness d. Increased blood glucose levels e.Decreased cardiac output f.Decreased peristalsis
a. increased heart rate c. increased mental alertness d. increased blood glucose levels
5. The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? a) "Children should be taught not to masturbate because most people believe self-stimulation is wrong." b) "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." c) "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." d) "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."
b
A nurse who is assessing an older female patient in a long-term facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding? Select all that apply. a. Use a lower tone when communicating with the patient. b. Provide interaction with children and pets. c. Decrease environmental noise. d. Ensure that the patient shares meals with other patients. e. Discourage the use of sedatives. f. Provide adequate lighting and clear pathways of clutter.
b,d,e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit, decreasing environmental noise is an intervention for sensory overload, and providing adequate lighting and removing clutter is an intervention for a vision deficit.
A nurse is diagnosing a 11-year old 6th grade student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Which nursing diagnosis would be most appropriate? a. Deficient Knowledge related to visual impairment b. Ineffective Role Performance (Student) related to visual impairment c. Disturbed Body Image related to visual impairment d. Delayed Growth and Development related to visual impairment
b. An important role for an 11-year old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may represent accurate diagnoses for this patient, they do not flow from the data presented.
A nurse observes that a patient who has cataracts is sitting closer to the television than usual. The nurse would interpret that the etiologic basis of this sensory problem is an alteration in: a. Environmental stimuli b. Sensory reception c. Nerve impulse conduction d. Impulse translation
b. Cataracts are interfering with the patient's ability to receive visual stimuli: altered sensory reception. The nature of incoming stimuli, the conduction of nerve impulses, and the translation of incoming impulses in the brain are not a problem here.
A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression
b. Denial
When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? A. 1 B. 2 C. 3 D. 4
b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.
A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. B. Keeping fluids readily available for the patient. C. Emphasizing the long-term outcome of increasing fluids when the patient returns home. D. Planning to offer most daily fluids in the evening.
b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? A. Encourage foods and fluids with high sodium content. B. Administer oral K supplements as ordered. C. Caution the patient about eating foods high in potassium content. D. Discuss calcium-losing aspects of nicotine and alcohol use.
b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.
Which action would be most important for a nurse to include in the plan of care for a patient who is 85 years old and has presbycusis? a. Obtaining large-print written material b. Speaking distinctly, using lower frequencies c. Decreasing tactile stimulation d. Initiating a safety program to prevent falls
b. Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. The other choices refer to interventions for other sensory problems.
10. A nurse is assessing a 27-year-old female patient who visits her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? a) Human papillomavirus (HPV) b) Syphilis c) Trichomoniasis d) Herpes simplex virus
c
12. A 38-year-old patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. The nurse documents this data as: a) Masochism b) Pedophilia c) Voyeurism d) Sadism
c
13. An 18-year-old female presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? a) "Vaginal intercourse is most commonly performed in the missionary position." b) "The side by side position achieves better clitoral stimulation than the missionary position." c) "Achieving simultaneous orgasms is the goal of vaginal intercourse." d) "The period after coitus is just as significant as the events leading up to it."
c
A nurse formulates the following diagnosis for an older female patient in a long-term care facility: Disturbed Sensory Perception: Chronic Sensory Deprivation related to the effects of aging. The patient walked out the door unobserved and was lost for several hours. Which interventions would be most effective for this patient? Select all that apply. a. Ignore when the patient is confused or go along to prevent embarrassment. b. Reduce the number and type of stimuli in the patient's room. c. Orient the patient to time, place, and person frequently. d. Provide daily contact with children, community people, and pets. e. Decrease background or loud noises in the environment. f. Provide a radio and television in the patient's room.
c,d,f. Even if well motivated, ignoring a patient's confusion to prevent embarrassment may be dangerous, as it was in this case in which the appropriate safety precautions were never implemented. Reducing the type of stimuli in the room and decreasing environmental noise is appropriate for a patient who is experiencing sensory overload. The other options are related to sensory deprivation and are appropriate for this patient.
A nurse is assessing a 78-year old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. a. The nurse asks the patient if he is bored, and if so, why. b. The nurse asks the patient if anything interferes with the functioning of his senses. c. The nurse asks the patient if he noticed any changes in the way he perceives his body. d. The nurse notes if the patient withdraws from being touched. f. The nurse notes if the patient seems unsure of his body parts and/or position.
c,e,f. To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation, asking if anything interferes with his senses assesses reception, and asking about difficulty communicating assesses for transmission-perception-reaction.
A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema
c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.
Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.
A nurse is caring for a male patient with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would be best to prevent sensory alterations for this patient? a. Turn the radio or television volume up very loud and close the door to his room. b. Prevent embarrassment and emotional discomfort as much as possible. c. Provide daily opportunity for him to participate in a social hour with six to eight people. d. Encourage daily participation in exercise and physical activity.
c. Although all the options listed are appropriate, providing daily opportunities for this patient to participate in a social hour builds on his strength of being able to lip-read and provides sufficient sensory stimulation to prevent sensory deprivation resulting from his hearing loss, thereby meeting his needs.
A nurse formulated the following nursing diagnosis for an 8-month old infant: Disturbed Sensory Perception: Sensory Deprivation related to inadequate parenting. Since that diagnosis was made, both parents have attended parenting classes. However, both parents work while the infant stays with her 86-year old grandmother, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor sucking her thumb and rocking her body. Her facial expression is dull, and she vocalizes only in a low monotone ("uh-h-h"). Which statement accurately reflects evaluation about the child's sensory deprivation? a. The infant's parents lack motivation to provide necessary stimulation. b. The grandmother is unable to improve the infant's care. c. The infant's sensory deprivation is still severe. d. This is normal behavior for an 11-month old infant.
c. Although the data show that the parents have been motivated to improve their parenting skills, it is clear from the data that the infant's sensory deprivation is still severe. The data suggest that the grandmother is not improving the infant's care, but there is nothing to suggest that she is unable to do so if shown how.
A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? a. An infant who learns to turn over b. A school-aged child who learns how to add and subtract c. An adolescent who is a "loner" d. A young adult who has a variety of friends
c. An adolescent who is a "loner"
A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a. Ineffective Coping related to the new parenting role b. Ineffective Denial related to ability to care for a newborn c. Anxiety related to change in role status d. Situational Low Self-Esteem related to fear of parenting
c. Anxiety related to change in role status
A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a. Decreasing pulse b. Increasing sleepiness c. Increasing energy levels d. Decreasing respirations
c. Increasing energy levels
A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A. A pinched and drawn facial expression B. Deep, rapid respirations. C. Moist crackles heard upon auscultation D. Tachycardia
c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.
A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing? a. Gustatory b. Olfactory c. Tactile d. Kinesthetic
c. The nurse is assessing for tactile (touch) by brushing the skin with a cotton ball and touching the skin with a safety pin. Gustatory disturbances involve taste, olfactory disturbances involve the sense of smell, and kinesthetic disturbances are related to body positioning.
A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? a. The nurse teaches a patient rhythmic breathing to perform prior to the procedure. b. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. d. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.
c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it.
15. Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? a) "Do you currently have a new partner?" b) "Have you been diagnosed with a neurologic disorder?" c) "Do you take anti-hypertensive medication?" d) "Do you use antihistamines?"
d
4. A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? a) "Each person is born with a certain amount of sexual drive, which can be depleted in later years." b) "If you want to be a great athlete, sexual abstinence is necessary when you are training." c) "If you have a nocturnal emission (wet dream) it is an indicator of a sexual disorder." d) "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."
d
9. A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? a) "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." b) "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." c) "Abstinence may be an effective method of contraception and may be used as a periodic or continuous strategy." d) "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."
d
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. A. 5% dextrose in 0.9% NaCl B. 0.9% NaCl (normal saline) C. Lactated Ringer's solution D. 0.33% NaCl (⅓-strength normal saline) E. 0.45% NaCl (½-strength normal saline) F. 5% dextrose in Lactated Ringer's solution
d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.
A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a. "Patient displays moderate anxiety related to her situation." b. "Patient manifests panic related to feelings of impending doom." c. "Patient describes severe anxiety related to her situation." d. "Patient expresses fear of her husband."
d. "Patient expresses fear of her husband."
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A. Recording intake and output. B. Testing skin turgor. C. Reviewing the complete blood count. D. Measuring weight daily.
d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.
A patient is in the late stages of AIDS, which is now affecting his brain as well as other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least likely underlying etiology for his sensory problems would be: a. Stimulation b. Reception c. Transmission-perception-reaction d. Emotional responses
d. Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for his condition. This patient is receiving decreased environmental stimuli (a) (e.g. from his friends), is more than likely experiencing problems with reception because of major organ involvement (b), and his impaired brain function will impair impulse transmission-perception-reaction (c).
A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? a. Discouraging oververbalization of fears and anxieties b. Focusing on the outcome as opposed to the details of the surgery c. Providing time alone for reflection on personal strengths and weaknesses d. Mutually determining expected outcomes of the care plan
d. Mutually determining expected outcomes of the care plan
A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a. Arrange to have the infant removed from the home. b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse. d. Notify the care provider and recommend respite care for the mother.
d. Notify the care provider and recommend respite care for the mother.
A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A. Reposition the extremity and raise the height of the IV pole. B. Apply pressure to the dressing on the IV. C. Pull the catheter out slightly and reinsert it. D. Put on gloves; remove the catheter
d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.
A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8 PM. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that the patient is probably experiencing: a. Sufficient sensory stimulation b. Deficient sensory stimulation c. Excessive sensory stimulation d. Both sensory deprivation and overload
d. This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses.
An older female patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient? a. Assist the patient to ambulate by walking slightly behind the person and grasping the patient's arm. b. Concentrate on the sense of sight and limit diversions that involve other senses. c. Stay outside of the patient's field of vision when performing personal hygiene for the patient. d. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.
d. When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when he or she is leaving the room, assist with ambulation by slightly walking ahead of the person and allowing her to grasp the nurse's arm, provide diversions using other senses, and stay in the person's field of vision if she has partial or reduced peripheral vision.
