Exam 4, study questions

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, the nurse would use the following formula:

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, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on his or her own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the 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, b, c. The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is loss that is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply. a. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days. b. A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. c. A nurse administering medications to a Muslim patient avoids touching the patient's lips d. A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday. e. The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient. f. The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

a, b, d, f. The nurse dietitian should ask a Buddhist if he has any diet restrictions related to the observance of holy days. Since Catholic Scientists avoid the use of pain medications, the nurse should ask a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. A nurse administering medications to a Hindu woman avoids touching the patient's lips. A nurse should ask a Roman Catholic woman if she would like to attend the local Mass on Sunday. The nurse is careful not to schedule treatment and procedures on Saturday for a Jewish patient due to observance of the Sabbath. The nurse would appropriately consult with the medicine man of a Native American patient and incorporates his or her suggestions into the care plan.

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, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet, but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches.

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, b, f. Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life), that make up the outward expressions of grief. A diagnosis of cancer and the coroner's pronouncing the patient's death are not behaviors of the family during a period of mourning. Arranging for hospice care would not be an expression of mourning.

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? Select all that apply. 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, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

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.

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, c, d. The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest.

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. a. The nurse makes a point to address the patient by name upon entering the room. b. The nurse avoids fatiguing the patient by performing all procedures in silence. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. e. The nurse ignores negative feelings from the patient since they are part of the grieving process. f. The nurse avoids conversing with the patient about her life, family, and occupation.

a, c, d. When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences.

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply a. .Teach the parents to reinforce their child's positive qualities. b. Teach the parents to overlook occasional negative behavior. c. Teach parents to ignore neutral behavior that is a matter of personal preference. d. Teach parents to listen and "fix things" for their children. e. Teach parents to describe the child's behavior and judge it. f. Teach parents to let their children practice skills and make it safe to fail.

a, c, f. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.

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 priorityintervention 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. 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. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services and U.S. Department of Agriculture.

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. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified.

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

a. An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) b. A young clergyperson whose vocal cords are paralyzed after a motorbike accident c. A 32-year-old accountant who survives a massive heart attack d. A 23-year-old model who just learned that she has breast cancer

a. Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach, the 32 year old's massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

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 leaves 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. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

A 70-year-old 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 health care provider 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. The patient b. The patient's daughter c. The patient's health care provider d. The ethics consult team

a. Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilities unless she asks them to do this. The ethics consult team is not a decision-making body; it can make recommendations but has no authority to order anything.

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.

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.

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 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. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress.

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing? a. Spiritual b. AlienationSpiritual c. DespairSpiritual d. AnxietySpiritual Pain

a. Spiritual Alienation occurs when there is a "separation from the faith community." Spiritual Despair occurs when the patient is feeling that no one (not even God) cares. Spiritual Anxiety is manifested by a challenged belief and value system, and Spiritual Pain may occur when a patient is unable to accept the death of a loved one.

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 (ANA) regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Yet, nurses may be confronted by patients who seek assistance in ending their lives and must be prepared to respond to the request: "Nurse, please help me die...."

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 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 could suggest that the husband speak to his wife's health care provider about which type of order? a. Comfort Measures Only b. Do Not Hospitalize c. Do Not Resuscitate d. Slow Code Only

a. The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order. The wife would want all aggressive treatment to be stopped at this point, and all care to be directed to a comfortable, dignified death. A Do Not Hospitalize order is often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive treatment. A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. A Slow Code means that calling a code and resuscitating the patient are to be delayed until these measures will be ineffectual. Many health care institutions have policies forbidding this, and a nurse could be charged with negligence in the event of a Slow Code and resulting patient death.

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.

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 is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? a. Realistic and positively motivating his development b. Unrealistic and negatively motivating his development c. Unrealistic but positively motivating his development d. Realistic but negatively motivating his development

a. The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

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. The patient's statement reflects the acceptance stage of death and dying defined by Kübler-Ross.

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare? a. POLST form b. Durable power of attorney for health care c. Living will d. Allow Natural Death (AND) form

b. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A Physician Order for Life-Sustaining Treatment form, or POLST form, is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. The living will is a document whose precise purpose is to allow people to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. Allow natural death on the medical record of a patient indicates the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient.

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? a. The patient will make above-B grades in all tests at school. b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. c. The patient reports that she feels more self-confident in her music and art, which she enjoys. d. The patient expresses that she is very smart in school.

b. All of these patient goals may be appropriate for the patient, but the only goal that directly addresses her body image disturbance is "the patient will demonstrate by diet control and skin care, increased interest in control of acne."

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 occurs when a person refuses to acknowledge the presence of a condition that is disturbing, in this case receiving a diagnosis of pancreatic cancer. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness. In the case described in question 9, the patient is not blocking out the fact that the diagnosis was made, the patient is refusing to believe it.

A nurse who is comfortable with 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

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 they would like to consult. Calling the patient's own spiritual adviser may be premature if it is a matter the nurse can handle. The other two options deny patients the right to speak privately with their spiritual adviser from the outset, if this is what they prefer.

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 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. No matter what the technique, relaxation involves rhythmic breathing, a slower (not a faster) pulse, reduced muscle tension, and an altered state of consciousness.

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.

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

b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body, and many patients retain a sense of hearing almost to the moment of death; therefore, nurses should explain to the comatose patient the nursing care being given. The nurse should address caregiver role endurance by actively listening to family members. Because it is good to encourage dying patients to be as active as possible for as long as possible, it is generally not good practice to perform basic self-care measures the patient can perform simply because it is "easier" to do it this way.

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? a. Lack of self-esteem b. Deficient self-knowledge c. Unrealistic self-expectation d. Inability to evaluate himself

b. The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance c. Altered Role Performance

b. This patient's concern is with body image. The information provided does not suggest a nursing diagnosis of Personal Identity Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

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. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness.

A nurse is visiting a 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. Which response by the nurse would be mostappropriate? a. "You can't be feeling this way. You know you are going to die." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll be all right; who knows how much time any of us has." d. "Tell me about your pain. Did it keep you awake last night?"

b. This response by the nurse validates that what the patient is saying has been heard and invites him to share more of his feelings, concerns, and fears. The other responses either deny the patient's feelings or change the subject.

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'm not qualified to advise you, I suggest you discuss this with your wife."

b. Using an open-ended question allows the patient to continue talking. An open-ended question, such as, "What seems to be concerning you the most?" provides a means of encouraging communication. False reassurances are not helpful. Also, the patient's feelings and restlessness should be addressed as soon as possible.

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 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. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient know what to expect—for example, when the nurse tells the patient about the pain he or she should expect to experience during a procedure, and describes related pain relief measures—the patient's anxiety is reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.

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, their children, others, and to God d. The spiritual adviser for the family

c. Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family's spiritual advisor, and the child's church or religious organization are less important sources of learning

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. Somatic grief b. Anticipatory grief c. Unresolved grief d. Inhibited grief

c. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Somatic grief is not a classification of grief, rather somatic symptoms are the expression of grief that may occur with inhibited grief. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place.

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? a. "I love my child so much I 'hug him to death' every day." b. "I think children need challenges, don't you?" c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." d. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

c. Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot 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 Mr. Brown that many parents feel the same way. b. Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass. c. Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive. d. Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

c. Helping Mr. Brown identify how his unforgiving feelings may be harmful to him is the only nursing intervention that directly addresses his unmet spiritual need concerning forgiveness. Assuring Mr. Brown that many parents would feel the same way or that many teenagers shoplift out of rebelliousness may make him feel better initially, but neither option addresses his need to forgive. Suggesting that Mr. Brown may not have spent enough time with his daughter is likely to make him feel guilty

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 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

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.

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use 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?

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.

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. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing 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 from 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

c. The data point to an unmet spiritual need to experience love and belonging, given the nurse's 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.

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? a. Negative self-concept and low self-esteem b. Negative self-concept and high self-esteem c. Positive self-concept and fairly high self-esteem d. Positive self-concept and low self-esteem

c. The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document? a. Grieving b. Ineffective Coping c. Caregiver Role Strain d. Powerlessness

c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided. The other diagnoses do not fit the assessment data.

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? a. Recommend that she discipline her daughter more strictly and consistently. b. Make a list of things her husband can do to give her more time and help her improve her parenting skills. c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. d. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

c. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

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. The most appropriate nursing diagnosis is Anxiety, which indicates situational/maturational crises or changes in role status. Ineffective Coping refers to an inability to appraise stressors or use available resources. Ineffective Denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem refers to feelings of worthlessness related to the situation the person is currently experiencing, not to the fear of role changes.

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.

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.

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

c. This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

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.

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.

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 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. A person providing care at home for a family member for long periods of time often experiences caregiver burden, which may be manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker or arrange for respite care for the family.

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 states she feels so isolated from her family and church, and even from 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.

d. Each of the four options represents an appropriate spiritual goal, but identifying spiritual supports available to this patient in the medical center demonstrates a goal to decrease her sense of isolation.

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 provides for this 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. Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

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.

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. Fear is a feeling of dread in response to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation.

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.

d. Illness may increase spiritual concerns, which many patients find difficult to express. The other options do not correspond to actual experience.

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

d. Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance.

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. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. The nurse should explain all procedures and sensations likely to be experienced during the procedures, and stay with the patient to promote safety and reduce fear.

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.

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.

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

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? a. Negative self-concept b. Modesty (lack of conceit) c. Body image disturbance d. Low self-esteem

d. The nurse can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (what we think we really are) and the "ideal self" (what we think we would like to be). The nurse would have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? a. There is no disturbance in self-concept. b. This patient has ego strength and high self-esteem but may have a disturbance of body image. c. The area of self-esteem has very low priority at this time and should be ignored until much later. d. It is probable that there are disturbances in self-esteem and body image.

d. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

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.