EXAM 4 Practice Questions
The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? A Can you tell me your sexual orientation? B How do you and your wife feel about intimacy? C Do you have sex with men, women, or both? D Do you have sexual intercourse at your age
A A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Using a term such as sexual orientation and asking about preferred pronouns allows the patient to identify his or her unique sexuality and sexual health needs
A patient who is depressed is crying and verbalizes feelings of low self-esteem and self-worth, such as "I'm such a failure... I can't do anything right." What is the nurse's best response? A Remain with the patient until he or she validates feeling more stable. B Tell the patient that is not true and that every person has a purpose in life. C Review recent behaviors or accomplishments that demonstrate skill ability. D Reassure the patient that you know how he or she is feeling and that things will get better.
A Demonstrating acceptance of the patient by supportively sitting with him or her builds a therapeutic nurse-patient relationship. The nurse's presence signals value and allows the patient to explore issues of self-concept and self-esteem. In contrast, giving false hope is neither therapeutic nor conveys acceptance, while focusing on skill ability signals conditional approval.
A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? A Denial B Conversion C Dissociation D Displacement
A Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars.
Which statement made by the patient indicates an understanding of sleep-hygiene practices? A "I usually drink a cup of warm milk in the evening to help me sleep." B "If I exercise right before bedtime, I will be tired and fall asleep faster." C "I know it does not matter what time I go to bed as long as I am tired." D "If I use hypnotics for a long time, my insomnia will be cured."
A Drinking a warm beverage such as milk in the evening can help promote sleep. Milk contains l-tryptophan, which help promote sleep. Other snacks that contain l-tryptophan, such as cereal and cheese and crackers, may also promote sleep. Exercising right before bedtime may prevent sleep. Good sleep hygiene includes going to bed and getting up at the same time daily. Hypnotics can help with insomnia but are not curative.
The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? A "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." B "It usually takes longer for both sexes to reach an orgasm." C "Most of the normal changes in function are related to alteration in circulation and hormone levels." D "Many medications can interfere with sexual function."
A Pathological processes can interfere with sexual function and desire. Changes in circulation, neurological pathways, and hormone levels account for many of the normal physiological changes that occur with the aging process. Common medications such as diuretics, antihypertensives, antianxiety medications, and antidepressants can contribute to sexual dysfunction. Older males and females take long
A nurse is working with an older adult who recently moved to an assisted living center because of declining physical capabilities associated with the normal aging process. Which nursing interventions are directed at promoting self esteem in this patient? A Commending the patient efforts at completing self-care tasks B Assuming that the patient's physical complaints are attention seeking measures C Minimizing time discussing memories and past achievements spent with the patient D Limiting decision making opportunities for the patient to reduce stress
A Reinforce efforts to complete tasks, allowing additional time to complete tasks if needed and support efforts directed at independence. This fosters self-esteem and confidence. It is important for the nurse to refrain from assumptions, as in assuming that physical complaints are attention seeking or that limiting decisions will reduce stress. Time should be allocated to review of past accomplishments and memories.
Which action can a nurse delegate to assistive personnel (AP)? A Performing glucose monitoring every 6 hours on a patient B Teaching the client about the need for enteral feeding C Administering enteral feeding bolus after tube placement has been verified D Evaluating the client's tolerance of the enteral feeding
A The skills of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to AP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nurse is responsible for teaching the client and evaluating the tolerance to the enteral feeding
A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? A Have the patient turn on the left side and perform a Valsalva maneuver. B Clamp the intravenous (IV) tubing to prevent more air from entering the line. C Have the patient take a deep breath and hold it. D Notify the health care provider immediately
A Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down")
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? A Stop the instillation. B Ask the patient to take deep breaths to decrease the pain. C Tell the patient to bear down as he would when having a bowel movement. D Continue the instillation; then administer a pain medication
A When a patient complains of pain during an enema, you need to stop the instillation and conduct an assessment before discontinuing or resuming the procedure
nursing diagnosis of Situational Low Self-Esteem. Which of the A 20-year-old patient diagnosed with an eating disorder has a following nursing interventions are appropriate to address self-esteem? (Select all that apply.) A Offer independent decision-making opportunities. B Review previously successful coping strategies. C Provide a quiet environment with minimal stimuli. D Support a dependent role throughout treatment E Increase calorie intake to promote weight stabilization.
A, B Offering opportunities for decision making promotes a sense of control, which is essential for promoting independence and enhancing self-esteem. Reviewing successful coping strategies is also a priority intervention to signal previous mastery and promote effective coping in an individual with self-esteem issues. The amount of stimuli is unrelated to self-esteem. Promoting independence is an important part of treatment. Although weight stabilization may be needed, it is likely to have a negative effect on self-esteem early in treatment.
Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.) A Giving the patient a back rub B Turning on quiet music C Dimming the lights in the patient's room D Giving a patient a cup of coffee E Monitoring for the effect of the sleeping medication that was given
A, B, C . Giving the patient a back rub, turning on quiet music, and dimming the lights are all appropriate sleep-hygiene measures. These activities are within the scope of practice for assistive personnel. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night and should not be ingested before bedtime. Monitoring medication effect is a registered nurse activity
The nurse can increase a patient's self-awareness and self-concept through which of the following actions? (Select all that apply.) A Helping the patient define personal problems clearly B Allowing the patient to openly explore thoughts and feelings C Reframing the patient's thoughts and feelings in a more positive way D Having family members assume more responsibility during times of stress E Recommending self-help reading materials
A, B, C Helping a patient define problems clearly, allowing him or her to openly explore thoughts and feelings, and reframing his or her thoughts and feelings in a more positive way are designed to promote self-awareness and a positive self-concept. Having the family assume more responsibility does not help a patient achieve self-awareness; instead it is important to encourage the patient to assume more self-responsibility. The nurse should refrain from offering self-help reading materials unless directly asked; the nurse should then provide numerous options.
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) A How to change the pouch B How to empty the pouch C How to open and close the pouch D How to irrigate the colostomy E How to determine whether the ostomy is healing appropriately
A, B, C, E The patient must be able to do these tasks to successfully manage his or her colostomy when going home. Irrigation is not done routinely for a colostomy
While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) A With whom do you talk on a routine basis? B What do you do when you feel lonely? C Tell me what your husband was like. D I know this must be hard for you. Let me tell you what might help. E Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?
A, B, E A developmental crisis occurs as a person moves through the stages of life, including widowhood. It is important to gather information about how this crisis affects the woman's interactions, how she is currently coping with loneliness, and any changes in her lifestyle habits. Although losing her husband is a source of stress, discussing him now does not focus on her current situation. Saying "I know this must be hard for you. Let me tell you what might help" is unacceptable because the purpose of assessment is to gather data and let the patient tell his or her story
Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.) A "I will not watch television in bed." B "I will not drink caffeine later in the day." C "A short nap late in the evening will lead to a more restful night of sleep." D "I am going to start eating dinner closer to my bedtime" E "I will start to exercise regularly during the day."
A, B, E To promote sleep, you should not watch television in bed. The noise of television can be disruptive and adds stimulation that is disruptive to sleep. Caffeine should not be consumed late in the day because it can cause wakefulness at bedtime. A regular exercise program completed in the morning is part of sleep hygiene practices and can help promote sleep. Exercise or eating a meal should not be done right before bed because sleep can be disrupted.
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) A Change in bowel habits B Blood in the stool C A larger-than-normal bowel movement D Fecal impaction E Muscle aches F Incomplete emptying of the colon G Food particles in the stool H Unexplained abdominal or back pain
A, B, F, H According to the American Cancer Society current guidelines, persons with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms, but if colon cancer is present, early diagnosis is important.
A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) A Change the dressing using sterile technique. B Change TPN containers every 48 hours. C Change the TPN tubing every 24 hours. D Monitor glucose levels to watch and assess for glucose intolerance. E Elevate head of the bed 45 degrees to prevent aspiration.
A, C The central line is inserted into a large vein that leads to the superior vena cava. This increases risk for infection. Therefore to prevent infection, change the TPN infusion tubing every 24 hours. Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours. Use sterile technique during central line dressing changes (see Chapter 42). Monitoring glucose levels and elevating the head of bed are not interventions that will prevent central line infections
When assessing a patient's adjustment to the role changes brought about by a medical condition such as a stroke, the nurse asks about which of the following? (Select all that apply.) A What are your thoughts about returning to work? B What questions do you have about your medications C How has your health affected your relationship with your partner? D What levels of physical activity are you able to preform E What concerns do you have about another stroke
A, C The nurse must assess role performance as related to professional identity (work) and personal relationships (partner). The other questions are important, but not related to self-concept.
The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) A Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. B Peer approval and acceptance are not important in this agegroup. C Lesbian, gay, bisexual, and transgender (LGBTQ+) youth often experience stress from identification with a sexual minority group. D Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. E Adolescence is a time of emotional stability and self-acceptance
A, C, D Adolescents are establishing their identity and exploring their sexual preference. Those who identify with a sexual minority group often experience stress and isolation from peers. They need clear and accurate information about physiological and emotional changes occurring in their body. Peer influence is high during this time, but support from family and health care professionals is equally important to adolescents
What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) A Maintain regular bowel elimination. B Limit water intake to 1 to 2 glasses a day. C Wear cotton underwear. D Cleanse the perineum from front to back. E Practice pelvic muscle exercise (Kegel) daily
A, C, D Maintaining regular bowel elimination prevents the rectum from filling with stool, which can irritate the bladder. Adequate hydration will ensure that the bladder is regularly flushed and will help prevent a UTI. Cotton undergarments are recommended. Pelvic muscle exercises promote pelvic health but do not necessarily prevent UTIs.
An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (WHNP) informs the patient that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." Which responses by the WHNP would be appropriate? (Select all that apply.) A "Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women." B "Bacterial STIs don't usually cause symptoms, or you could have an asymptomatic viral STI." C "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." D "People between the ages of 15 and 24 are often asymptomatic and have the highest incidence of STIs." E "There is no need to screen for infection since you aren't having any problems or symptoms."
A, C, D Serious complications can result from untreated STIs in pregnancy, complications such as preterm labor, rupture of membranes, and premature delivery of the newborn. The risk of untreated STIs in any female is pelvic inflammatory disease, which, if untreated, can cause serious problems such as infertility. Routine screening for chlamydia is recommended for all sexually active women up to age 25. Many people do not know they are infected because they do not experience symptoms. Bacterial STIs are more likely to cause symptoms, whereas viral STIs are often asymptomatic.
A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) A Referral to social service process reestablishing the child's disability payment B Sending the child home in 72 hours and having the child return to school C Coordinating hospital-based and home-based schooling with the child's teacher D Teaching the mother signs and symptoms of a respiratory tract infection E Telling the mother that the stress will decrease in 6 weeks when everything is back to normal
A, C, D The stressors for this parent are her child's illness, missing school, and loss of disability payments. Obtaining resources to resolve these stressors will reduce the mother's stress load and allow her to focus on helping her child improve and on preventing another respiratory tract infection. Discharging the child in 72 hours with a return to school may not be best for the child's physical condition and may make the situation worse. Giving the mother a 6-week time frame is unrealistic because everyone's time frame is different. The mother may also need to adjust
The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) A "I don't need to use condoms since there is no risk for pregnancy." B "I should be screened for an STI each time I'm with a new partner." C "I know I'm not infected because I don't have discharge or sores." D "I was tested for STIs last year, so I know I'm not infected." E "The infection rate in older adults is low because most are not sexually active."
A, C, D, E One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in males or females. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Older adults may engage in risky sexual behaviors because of lack of knowledge about STIs and condom usage. Research indicates that older adults are remaining sexually active longer than previously believed and the incidence of STI and human immunodeficiency virus (HIV) infections has steadily increased for the past 12 years. Screening after each new sex partner is the most effective method to detect and manage STIs, so this statement shows understanding of the teaching by the patient
Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) A Limit fluids 2 to 4 hours before sleep. B Ensure that the room is completely dark. C Ensure that the room temperature is comfortably cool. D Provide warm covers. E Encourage walking an hour before going to bed.
A, C, E Limiting fluids reduces incidence of nocturia. For safety reasons complete darkness should be avoided. A soft nightlight lessens the chance of a fall should the patient require ambulation to the bathroom during the night. Older adults sometimes require extra blankets or covers to achieve a comfortable sleeping temperature. Keeping the bedroom temperature at a cooler, comfortable temperature is conducive to sleep.
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) A Ask the patient about any allergies and reactions. B Instruct the patient that a full bladder is required for the test. C Instruct the patient to save all urine in a special container. D Ensure that informed consent has been obtained. E Instruct the patient that facial flushing can occur when the contrast media is given
A, D, E An IVP involves intravenous injection of an iodine-based contrast media. Patients who have had a previous hypersensitivity reaction to contrast media are at high risk for another reaction. Informed consent is required. The patient may experience facial flushing during injection of the contrast media. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with a cystoscopy.
A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) A Take brief, 20-minute naps no more than twice a day. B Drink a glass of wine with dinner. C Eat a large meal at lunch rather than dinner. D Establish a regular exercise program. E Teach the patient about the side effects of modafinil
A, D, E Taking short naps, no longer than 20 minutes, during the day, and regular exercise are management strategies that help reduce the feeling of sleepiness. Modafinil is a stimulant used to treat narcolepsy; therefore, it is important for patients to understand its side effects.
The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) A Serum total protein B Potassium C Lipids D Albumin E Serum BUN
A, E When a client is malnourished, he or she is in a state of negative nitrogen balance—meaning, the body is experiencing protein loss and requires more protein to maintain healing. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is a serum binding protein, and lower levels can be an indicator of malnutrition, but it is really more indicative of inflammation or kidney and liver disease. As a result, this is not the gold standard for diagnosing malnutrition. BUN is also an indicator because urea is the end product of protein metabolism, and when a patient is not getting enough protein, you will see a decreased BUN.
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) A Increase fiber and fluids in the diet. B Use a low-volume enema daily. C Avoid gluten in the diet. D Take laxatives twice a day. E Exercise for 30 minutes every day. F Schedule time to use the toilet at the same time every day. G take probiotics 5 times a week.
A, E, F These are the steps a patient needs to take to resolve chronic problems with constipation before considering regular laxative or enema use.
A 72-year-old patient asks the nurse about using an over-thecounter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? A "Antihistamines are better than prescription medications because prescription medications can cause a lot of problems." B "Antihistamines should not be used because they can cause confusion and increase your risk of falls." C "Antihistamines are effective sleep aids because they do not have many side effects." D "Over-the-counter medications when combined with sleep
B . Older adults should avoid the use of over-the-counter antihistamines. These medications have a long duration of action in older adults and can cause confusion, constipation, urinary retention, and an increased risk of falls
A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? A Fastening tube to the gown with new tape B Placing client supine while giving a bath C Monitoring the client's weight as ordered D Ambulating patient with enteral feedings still infusing
B A patient receiving continuous enteral feedings should never be placed supine because it increases the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feedings should be stopped and restarted when the head of the bed is at 45 degrees.
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? A Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution B Hanging the urinary drainage bag below the level of the bladder C Emptying the urinary drainage bag daily D Irrigating the urinary catheter with sterile water
B Evidence-based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? A Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. B Initiate bowel or habit training program to promote continence. C Help the patient to toilet once every hour. D Use sanitary pads in the patient's underwear
B Patients who are cognitively impaired often forget how to respond to the urge to defecate and benefit from a structured program of bowel retraining
The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: A The patient cannot be sexually active since he is moving into a nursing home. B The patient may be requesting a private room to facilitate an intimate relationship with his partner. C There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. D Older adults in nursing homes usually do not participate in sexual activity
B Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest. Sometimes sexual health is not addressed by the nurse, but it is important to include a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Long-term care facilities need to make arrangements to allow for continuation of sexual experiences of residents as long as no health risks are involved.
There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? A Remove the catheter and start all over with a new kit and catheter. B Leave the catheter there and start over with a new catheter. C Pull the catheter back and reinsert at a different angle. D Ask the patient to bear down and insert the catheter farther.
B The catheter may be in the vagina; leave the catheter in the vagina as a landmark indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for catheter-associated urinary tract infection (CAUTI).
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? A Recommend that she be evaluated for an overactive bladder (OAB) medication. B Establish a toileting schedule. C Recommend that she be evaluated for an indwelling catheter. D Start a bladder-retraining program.
B The first nursing intervention for any patient with incontinence who is able to toilet is to help him or her with toilet access. This patient has dementia; therefore a bladder-retraining program is inappropriate for her. There is nothing in the assessment to indicate that she may have an overactive bladder. A catheter increases risk for infection and is never the best intervention for incontinence.
Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? A "I'll give the baby a bottle to help her fall asleep." B "We'll place the baby on her back to sleep." C "We put the baby's stuffed animals in the crib to make her feel safe." D "I know the baby will not need to be fed until morning."
B This is based on the current evidence that shows that parents need to place an infant on his or her back to prevent suffocation. Bottles, stuffed animals, and pillows should not be placed in the bed with an infant.
The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. A Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. B "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." C "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis." D Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F)
B, A, D, C SBAR is Situation, Background, Assessment, and Recommendation. This is the correct sequence of steps in SBAR for the patient and sleep problem
A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) A Increase the rate of the CBI. B Assess the patency of the drainage system. C Measure urine output. D Assess vital signs. E Administer ordered pain medication.
B, C An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irritant solution infused. If the system is not draining urine and irritant, the irritant should be stopped immediately; the catheter may be occluded and the bladder distended. Pain medication should not be administered until after assessment is completed.
Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) A Attach a 3-mL syringe to the inflation port. B Allow the balloon to drain into the syringe by gravity. C Initiate a voiding record/bladder diary. D Pull the catheter quickly. E Clamp the catheter before removal
B, C By allowing the balloon to drain by gravity, it is possible to avoid the development of creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal.
Which of the following assessment findings suggest an altered self concept? A Uneven Gait B Slumped posture and poor personal hygiene C Avoidance of eye contact when answering a question D Requests for visits from the chaplain E Frequent Use of the call light
B, C Common assessment findings for an individualwith altered self-concept can mirror depressive symptoms, such as slumped posture, poor hygiene, and avoiding intermittent eye contact.An individualwith an unsteady or uneven gait may have successfully adjusted to an underlying condition; this does not automatically signal an altered self-concept. Requests for spiritual support and nursing care should be honored and are not related to an altered self-concept.
The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) A Heart disease B Sepsis C Hemorrhage D Skin breakdown E Diarrhea
B, C, D Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, skin breakdown, sepsis, or hemorrhage during hospitalization.
The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) A Loss of autonomy caused by health problems B Physical appearance and body image C Accepting one's personal identity D Separation from family E Taking tests in school
B, C, D, E As adolescents search for identity with peer groups and separate from their families, they also experience stress. In addition, they face stressful questions about sex, jobs, school, career choices, and using mind-altering substances. During this stage of development, stress can occur because of a preoccupation with appearance and body image. A loss of autonomy caused by health problems usually applies to the older adult
Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) A Give patients a cup of coffee 1 hour before bedtime. B Plan vital signs to be taken before the patients are asleep. C Turn television on 15 minutes before bedtime. D Have patients follow at-home bedtime schedule. E Close the door to patients' rooms at bedtime.
B, C, E Bedtime routines relax patients in preparation for sleep. Patients in the hospital should follow their at-home bedtime routine. Taking vital signs before sleep onset prevents disruption of sleep and improves sleep duration and quality. Closing the door to patients' rooms decreases noise that can disrupt sleep. Noise is one of the main factors contributing to poor sleep in hospitalized patients. Excessive stimulation, such as watching television, should be avoided close to bedtime.
A nurse is caring for a 40-year-old male diagnosed with Crohn's disease several years ago, resulting in numerous hospitalizations each year for the past 3 years. Which of the following behaviors interfere with the developmental tasks of middle adulthood? (Select all that apply.) A sends birthday cards to friends and family B Refuses visitors while hospitalized C Self absorbed in physical and psychological issues D Preforms self care activities E Communicates feelings of inadequacy
B, C, E Developmental tasks of adulthood can be impacted by chronic illness. Self-absorption and the refusal to stay connected with others are of concern to the nurse, as are verbalizations of inadequacy. Staying in touch with friends and performing self-care behaviors demonstrate developmental mastery of adulthood.
The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) A Nurses are not expected to discuss sexual issues with male patients and the physician should address this. B Sexual function can be affected by some medications. C Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. D Some men with health issues experience erectile dysfunction. E Medications used to treat hypertension and depression seldom interfere with sexual function
B, D Nurses should complete a holistic assessment on all patients to be able to personalize a plan of care. Nurses who are uncomfortable discussing sexual concerns of patients should seek out training and resources to develop this skill. Many drugs and illnesses can affect sexual function. Antidepressants can alter sexual functioning by blocking neurotransmitters. Antihypertensives can affect sexual function by altering circulation. Erectile dysfunction occurs more frequently in older men but can occur in men as young as 40. STIs may affect sexual functioning but are less likely than medications or illness to be the cause of erectile dysfunction.
A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-yearold is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. A "Can I contact someone to help you?" B "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." C "I'll have the doctor come out and talk to you as soon as possible." D "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her.
B, D, C, A First and most important the parents need to know the immediate status of their daughter. Letting them know the situation will help to relieve their immediate stress. Second, helping the parents discuss their concerns will reduce their stress and will allow them to see their daughter without increasing the 10-year-old's anxiety. Third, let the parents know that you recognize their need to talk to the doctor as soon as possible and that you will act as their advocate to get that accomplished. Last, but also important, you want to ask whether there is anyone you can call to help. There may be children who need to be picked up from camp/ day care, for example, and a neighbor or grandparent may be able to assist.
A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) A Sexual issues are expected in a woman this age. B Women experience sexual dysfunction more frequently than men. C Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. D Medical conditions such as cancer often contribute to HSDD. E Disturbances in self-concept affect sexual functioning.
B, D, E . Women of all ages (not just older women) can experience reduced sexual desire or libido. Biological, organic, or psychosocial factors; pain; depression; and body image concerns can result in sexual problems in men and women. Sexual dysfunction is common in men and women, but it occurs more frequently in women. Self-concept issues, including changes in body image, identity, and role performance, can impact self-esteem and sexual functioning.
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) A Lift the patient's hips off the bed and slide the bedpan under the patient. B After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. C Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. D Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. E Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
B, E Elevating the head of the bed allows the patient the most normal and comfortable position for defecation on a bedpan. Sitting on a bedpan for a prolonged time is uncomfortable and exerts pressure on the ischial bony prominences, so it is important for the patient to have privacy but to be able to let the nurse know when he or she is finished using the bedpan
What is a critical step when inserting an indwelling catheter into a male patient? A Slowly inflate the catheter balloon with sterile saline. B Secure the catheter drainage tubing to the bedsheets. C Advance the catheter to the bifurcation of the drainage and balloon ports. D Advance the catheter until urine flows, then insert ¼ inch more.
C Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or tension on the catheter. Advancing the catheter until urine flows and then inserting it ¼ inch more is not unique to the male patient.
A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: A "Latex condoms are the most effective way to eliminate the risk of HPV transmission." B "Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity." C "The HPV 9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts." D "You are past the recommended age to receive the vaccine."
C An HPV vaccine that protects both men and women against the types of HPV that cause serious health issues is available and recommended for individuals ages 11 to 26. The use of latex condoms reduces the risk of contracting a sexually transmitted infection (STI), but abstinence is the only practice that eliminates the risk. Longitudinal research indicates that vaccination does not increase sexual risk-taking behaviors among youths and is safe.
A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? A Assess bowel sounds. B Raise the head of the bed to at least 45 degrees. C Continue the feedings; this is normal gastric residual for this feeding D Hold the feeding until you talk to the primary care provider.
C Delayed gastric emptying is a concern if 250 mL or more remains in a patient's stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL. Therefore the best action is to continue the tube feedings at this time
A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A "I feel refreshed when I wake up in the morning." B "I use soft music at night to help me relax." C "It takes me about 45 to 60 minutes to fall asleep." D "I take the pain medication for my leg pain about 30 minutes before I go to bed.
C Good sleep-hygiene practices indicate that individuals should fall asleep within 30 minutes of going to bed. Taking 45 to 60 minutes to fall asleep indicates a potential sleep problem and requires follow-up on sleep-hygiene practices. If an individual does not fall asleep within 30 minutes, encourage him or her to get out of bed and do a quiet activity until he or she feels sleepy
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? A Get three fecal smears from one bowel movement. B Obtain one fecal smear from an early-morning bowel movement. C Collect one fecal smear from three separate bowel movements. D Get three fecal smears when you see blood in your bowel movement.
C Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result
When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? A The amount of family support B A 3-day diet recall C A thorough physical assessment D Threats to safety in her home
C Stress often causes symptoms similar to physical illnesses. Physical causes for problems need to be investigated and treated before treatment for stress-related symptoms can be initiated.
Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? A Limit oral fluid intake to avoid possible urinary incontinence. B Expect patient complaints of suprapubic fullness and discomfort. C Report the time and amount of first voiding. D Instruct patient to stay in bed and use a urinal or bedpan
C To adequately assess bladder function after a catheter is removed, voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a urinary tract infection
A 30 year old patient diagnosed with major depressive disorder has a nursing diagnosis of Situational Low Self Esteem Related to Negative View of Self. Which of the following are appropriate interventions by the nurse: (Select all that apply) A Encourage reconnecting with high school friends B Role Play to increase assertiveness skills C Focus on identifying strengths and accomplishments D Provide time for journaling to explore underlying thoughts and feelings
C, D Focusing on strengths and accomplishments to minimize the emphasis on failures helps the patient alter distorted and negative thinking. Journaling can allow a patient to explore thoughts and feelings that can promote insight and eventual behavioral change. The other interventions represent the nurse imposing ideas on what needs to occur for the patient to be healthier; allowing the patient to direct the change process is important.
A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) A Instruct the patient to discuss any sexual concerns with his or her partner after discharge. B Avoid discussing the topic unless the patient brings it up. C Ask a more experienced nurse to cover this with the patient and learn from the example. D Plan to attend conferences or training soon on how to discuss such issues. E Encourage the patient to discuss any personal concerns with the cardiologist.
C, D Nurses often avoid discussing sexual issues with patients because they are uncomfortable, lack knowledge, or have personal values in conflict with the patients' values. Nurses who have difficulty addressing sexual issues need to seek education and experiences to increase knowledge and explore their personal values.
The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) A Post-traumatic stress disorder B Rising hormone levels C Chronic illness D Insomnia E Depression
C, D, E An increased allopathic load can result in long-term physiological and psychological problems such as chronic illness, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders. Post-traumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage.
The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) A "I'm going to learn to drive a car, so I can be more independent." B "My sister says she feels better when she goes shopping, so I'll go shopping." C "I'm going to let the occupational therapist assess my home to improve efficiency." D "I've always felt better when I go for a long walk. I'll do that when I get home." E "I'm going to attend a support group to learn more about multiple sclerosis."
C, E Inviting the occupational therapist into the patient's home and attending support groups are early indicators that the patient is recognizing some of the challenges of the disease and participating in positive realistic activities to cope with the stressors related to changes in physical functioning. The other options relate to independence and other coping strategies but do not address coping with the specific challenges of the disease.
The home health nurse is visiting a 90-year old man who lives with his 89-year old wife. He is legally blind and is 3 weeks post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? A Impaired Self Toileting B Lack of Knowledge Regarding Resources for the Visually Impaired C Disturbed Body Image D Risk for Situational Low Self Esteem
D Blindness coupled with difficulty ambulating places him at risk for situational low self-esteem. He and his wife most likely have adapted to the blindness, but his difficulty with ambulation affects many aspects of his life, including self-esteem. However, this low self-esteem is situational; as his mobility improves, his low self-esteem will also resolve. Nothing in the question itself suggests that the other diagnoses are true
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? A Have you eaten more high-fiber foods lately? B Have you taken antibiotics recently? C Do you have gluten intolerance? D Have you experienced frequent, small liquid stools recently?
D Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction
Which statement made by the parents of a 2-month-old infant requires further education by the nurse? A "I'll continue to use formula for the baby until he is at least a year old." B "I'll make sure that I purchase iron-fortified formula." C "I'll start feeding the baby cereal at 4 months." D "I'm going to alternate formula with whole milk, starting next month."
D Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies
The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? A Suction her mouth and throat. B Turn her on her side. C Put on oxygen at 2 L nasal cannula. D Stop feeding her.
D Stop feeding and then place patient on side. If choking persists, suction airway. Notify health care provider. Keep patient NPO
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? A A food allergy B Irritable bowel syndrome C Increased peristalsis D Lactose intolerance
D These symptoms are consistent with lactose intolerance, and they occur with ingestion of dairy products
A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? A When 25% of the patient's nutritional needs are met by the tube feedings B When bowel sounds return C When the central line has been in for 10 days D When 75% of the patient's nutritional needs are met by the tube feedings
D When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.
A 50 year old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little to no attention to her appearance. One morning, the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? A "What's the special occasion?" B "You must be feeling better today." C "This is the first time I've seen you look this good." D "I see that you have combed your hair and put on makeup"
D When the nurse uses a matter of fact approach and acknowledges a change in the patient's behavior or appearance, it allows the patient to establish it's meaning. Telling the patient she has never looked this good conveys criticism; making assumptions about it being a special occasion or about an obvious improvement in mood imposes the nurse's opinion and limits the assessment.
Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. A Insert and advance catheter. B Lubricate catheter. C Inflate catheter balloon. D Cleanse urethral meatus with antiseptic solution. E Drape patient with the sterile square and fenestrated drapes. F When urine appears, advance another 2.5 to 5 cm. 7 G Prepare sterile field and supplies. H Gently pull catheter until resistance is felt. I Attach drainage tubing.
E, G, B, D, A, F, C, H, I
Place the steps for an ileostomy pouch change in the correct order. A Close the end of the pouch. B Measure the stoma. C Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. D Press the pouch in place over the stoma. E Remove the old pouch. F Trace the correct measurement onto the back of the wafer. G Assess the stoma and the skin around it. H Cleanse and dry the perisomal skin
E, H, G, B, F, C, D, A
When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.
PTSD PTSD originates with a person's experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The home break-in is the traumatic event that is causing intense fear and/or flashbacks when the noises of the break-in are replicated.
A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? A "Are you thinking of suicide?" B "You've been doing a good job raising your children. You can do it!" C "Is there someone who can help you during the evenings and weekends?" D "Tell me what you mean when you say you can't go on any longer."
You need to get information about what the gentleman means when he says he can't go on any longer. He might be thinking of turning his children over to a grandparent or seeking other child-care arrangements. Asking about suicide initially might be premature. Asking "Are you thinking of suicide?" prematurely might shut the patient down entirely. If the patient talks about suicide, for safety reasons it is very important to further discuss his suicidal thoughts and refer to the appropriate health care professional. Asking the open-ended question provides an opportunity to understand what the person is thinking and open lines of communication.
