Fluid & Electrolytes Giddens/Fundamentals/Med-Surg, Concepts 2 Week 7 Combined, Concepts 2 Week 8 Combined

A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will have a need for which of the following electrolytes? 1. sodium 2. potassium 3. calcium 4. magnesium

Answer: 4 Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis.

The pt has been placed on a 1200 mL daily fluid restriction. The pt's IV is infusing at a keep open rate of 10 mL/hr. The pt has no additional IV medications. How much fluid should the pt be allowed from 0700 until 1500 daily?

Answer: 540 Rationale: Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case 1200mL - 240 mL = 960mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening shift, & the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? A. Waiting quietly for the client to reply B. Prompting the client if the reply is slow C. Repeating the question if the client does not answer promptly D. Reviewing the client's medical record to support the client's response

Answer: A Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply.

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? A. "That is a good observation. Depression does mostly strike people older than 50 years." B. "Depression is seen in people of all ages, from childhood to old age." C. "Depression is most often seen among the middle adult age group." D. "The age of onset for most depressive episodes is given as 18 years."

Answer: B Depression can occur at any age. Children, adolescents, adults, and the elderly may all experience depression.

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? A. Agreeing that this will help the client to remember the medications. B. Caution the client to drink several glasses of water daily. C. Suggest that the client also use a sun lamp daily. D. Explain the high possibility of an adverse reaction.

Answer: D Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. None of the other options are relevant to the situation

A nurse is assessing a cancer survivor and the caregiver. Which examples describe the possible caregiving patterns the nurse may observe? a. Patients and caregivers share activities of care. b. Family provides most of the care because the patient is unable. c. Patients mostly care for self with caregivers in a standby role. 1. The self-caregiving pattern 2. The collaborative care pattern 3. The family caregiving pattern

1. The self-caregiving pattern c. Patients mostly care for self with caregivers in a standby role 2. The collaborative care pattern a. Patients and caregivers share activities of care 3 The family caregiving pattern b. Family provides most of the care because the patient is unable

A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.) 1. A respiratory rate of 36 breaths per minute 2. Complaints of numbness in fingers and toes 3. Dizziness when attempting to sit upright 4. Difficulty holding a cup because of tremors 5. An irregular heartbeat on an electrocardiogram (ECG) 6. Warm, flushed skin

1. A respiratory rate of 36 breaths per minute 2. Complaints of numbness in fingers and toes 3. Dizziness when attempting to sit upright 4. Difficulty holding a cup because of tremors

A patient's family member brings in a list of medications the patient is taking for Alzheimer disease. The patient has begun experiencing psychotic symptoms as well as dementia. Medication from which class will likely be discontinued? 1. Antipsychotics 2. Anticonvulsants 3. Antidepressants 4. Antianxiety agents

1. Antipsychotics When administered to patients with dementia, antipsychotics can cause psychotic side effects. Antidepressants, antianxiety agents, and anticonvulsants can be used in various combinations without causing psychotic symptoms.

In reviewing the results of the client's blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is: 1. Calcium 3.9 mEq/L 2. Sodium 140 mEq/L 3. Potassium 3.5 mEq/L 4. Magnesium 2.1 mEq/L

1. Calcium 3.9 mEq/L

The majority of the body's water is contained in which of the following fluid compartments? 1) interstitial 2) intracellular 3) extracellular 4) intravascular

2

Which of the following interventions would be the best choice to monitor fluid and electrolyte balance? 1) assess if client is voiding 2) assess daily weight 3) evaluate daily urine specimens 4) check daily sodium levels

2

Which of the following diets contain the most sodium? 1) Roast beef sandwich with mustard and an apple 2) Turkey sandwich with mashed potatoes 3) Bologna sandwich with pickles and potato chips 4) Veggie wrap with pears

3

An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as: 1. 32 gtt/min 2. 60 gtt/min 3. 125 gtt/min 4. 250 gtt/min

3. 125 gtt/min

A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematoma, the nurse needs to hold pressure on the IV site for: 1. 1 to 2 minutes 2. 2 to 3 minutes 3. 3 to 5 minutes 4. 5 to 10 minutes

4. 5 to 10 minutes

Client Needs: Psychosocial Integrity 4. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training c. Desensitization techniques b. Relaxation training classes d. Use of complementary therapy

A

On assessment, the patient has respiratory muscle weakness resulting in shallow respirations. Which electrolyte abnormality would the nurse suspect? A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia

A

Which serum value does the nurse expect to see for a patient with hyponatremia? A. Sodium less than 136 mEq/L B. Chloride less than 95 mEq/L C. Sodium less than 145 mEq/L D. Chloride less than 103 mEq/L

A

ANS: D The patient with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: B All the options are reasonable interventions for a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes

Which findings indicate that patient may have hypervolemia? Select all that apply. A. Increased, bounding pulse B. Jugular vein distention C. Presence of crackles D. Excessive thirst E. Elevated Blood pressure F. Orthostatic Hypotension

A, B, C, E

Client Needs: Psychosocial Integrity 4. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A, D, E

What are the consequences for a patient who does not meet the obligatory urine output? Select all that apply. A: Lethal electrolyte imbalances B: Alkalosis C: Urine becomes diluted D: Toxic build up of nitrogen E: Urine out put decreases F: Acidosis

A, D, F

The nurse is working in a long term care facility where there are numerous patients who are immobile and at risk for dehydration. Which test is best to delegate to the UAP? A. Offer patients a choice of fluids every 1 hour B. Check patients at the beginning the shift to see who is thirsty. C. Give patients extra fluids around medication times. D. Evaluate oral intake and urinary output.

A.

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? Select all that apply. A. A motivational interview B. Observing for stress reaction C. Converting narcotic use from an illicit to a legally controlled drug D. Observing for delirium tremens E. Encouraging involvement in Narcotics Anonymous

A. A motivational interview B. Observing for stress reaction E. Encouraging involvement in Narcotics Anonymous

What are some primary prevention activities a nurse can perform related to substance abuse? Select all that apply. A. Education to prevent substance abuse B. Focusing on relapse prevention C. Identification of risk factors for abuse D. Medical detoxification E. Referral to a self-help group for stress relief and meditation

A. Education to prevent substance abuse C. Identification of risk factors for abuse E. Referral to a self-help group for stress relief and meditation

Which patient is at risk for excess insensible water loss? A. Patient with constant GI suctioning B: Patient with slow, deep respirations C. Patient receiving O2 therapy D. Patient with hypothermia

A. Gastric Suctioning

When conducting a health history, the nurse identifies some of the following social risk factors as possible predictors of a diagnosis of schizophrenia. Select all that apply. A. Urban residence B. Recent immigration C. Impaired physical or mental health D. Older paternal age E. First-degree relative diagnosed with schizophrenia F. Ethnic and racial discrimination

A. Urban residence B. Recent immigration F. Ethnic and racial discrimination

While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"

ANS A

21.The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

ANS: A 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.

A patient is talking to a nurse about sodium intake. Which statement by the patient indicates an understanding of high sodium food sources? A. "I have bacon and eggs every morning for breakfast" B. "We never eat seafood because of the salt water" C. " I love Chinese food, but I gave it up because of the soy sauce" D. "Pickled herring is a fish, and my doctor told me to eat a lot of fish"

C

Client Needs: Physiological Integrity 16. Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness c. Situational low self-esteem b. Defensive coping d. Disturbed personal identity

C

The nurse is reviewing orders for several patients who are at risk for fluid volume overload. For which patient condition does the nurse question and order for diuretics? A. Pulmonary Edema B. Congestive Heart Failure C. End Stage Renal Disease D. Ascites

C

Tony, a 45-year-old patient with schizophrenia, sometimes moves his lips silently or murmurs to himself when he does not realize others are watching. Sometimes when talking to others, he suddenly stops, appears distracted for a moment, and then resumes. Based on these observations, Tony most likely is experiencing: a. Illusions b. Delusional thinking c. Auditory hallucinations d. Impaired reality testing

C

A 50-year-old female develops skin cancer on her head and neck following years of sunbathing. Which of the following cancers is the most likely? a. Lymphoma b. Adenoma c. Basal cell carcinoma d. Leukemia

C. Basal cell is related to UV radiation primarily from the sun. Lymphoma is not related to sunbathing. Adenoma is not related to sunbathing. Leukemia is not related to sunbathing.

The patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin? A. Use Dial soap to feel clean and fresh. B. Scented lotion can be used on the area. C. Avoid heat and cold to the treatment area. D. Wear the new bra to comfort and support the area.

C. Avoid heat and cold to the treatment area. Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, nonmedicated lotions may be used to prevent skin damage. The patient will want to avoid wearing tight-fitting clothing such as a bra over the treatment field and will want to expose the area to air as often as possible.

The patient is told that the adenoma tumor is not encapsulated but has normally differentiated cells and that surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? A. It will recur. B. It has metastasized. C. It is probably benign. D. It is probably malignant.

C. It is probably benign. Benign tumors usually are encapsulated and have normally differentiated cells. They do not metastasize and rarely recur as malignant tumors do.

A 20-year-old male patient diagnosed with chronic schizophrenia is placed on an antipsychotic, 20 mg twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103° F (39.4° C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. This patient is most likely suffering from which of the following? A. Tardive dyskinesia B. Pneumonia C. Neuroleptic malignant syndrome D. Pseudoparkinsonism

C. Neuroleptic malignant syndrome

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? -Chest pain -Hypertension -Slow pulse -Jaundice

Chest pain

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? -Choose a hairless site if available. -Consider potential effects on the client's mobility when selecting a site. -Have the client briefly hold his arm over his head before insertion. -Leave the tourniquet on for at least 3 minutes.

Consider potential effects on the client's mobility when selecting a site.

The nurse assesses a pt's weight loss as being 22 lbs. How many liters of fluid did this pt lose?

Correct Answer: 10 Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This pt has lost 10 liters of fluid.

A young adult patient is in the early stages of being treated for severe burns. Which electrolyte imbalance does the nurse expect to assess in this patient? A. Hypernatremia B. Hypokalemia C. Hypercalcemia D. Hyperkalemia

D

The nurse is caring for several patients at risk for fluid and electrolyte imbalances. Which patient problem or condition can results in hypernatremia? A. use of salt substitute B. Presence of a feeding tube C. Drinking too much water D. Long-term NPO status

D

The patient is receiving biologic and targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? A. Morphine sulfate B. Ibuprofen (Advil) C. Ondansetron (Zofran) D. Acetaminophen (Tylenol)

D. Acetaminophen (Tylenol) Acetaminophen is administered before therapy and every 4 hours to prevent or decrease the intensity of the severe flu-like symptoms, especially with interferon which is frequently used for ovarian cancer. Morphine sulfate and ibuprofen will not decrease flu-like symptoms. Ondansetron is an antiemetic, but not used first to combat flu-like symptoms of headache, fever, chills, myalgias, etc.

A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells genetic structure is mutated. Exposure to what may have functioned as a carcinogen for this patient? A. Bacteria B. Sun exposure C. Most chemicals D. Epstein-Barr virus

D. Epstein-Barr virus Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.

When caring for the patient with cancer, what does the nurse understand as the response of the immune system to antigens of the malignant cells? A. Metastasis B. Tumor angiogenesis C. Immunologic escape D. Immunologic surveillance

D. Immunologic surveillance Immunologic surveillance is the process where lymphocytes check cell surface antigens and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells' evasion of immunologic surveillance that allows the cancer cells to reproduce.

An older adult patient at risk for fluid and electrolyte problems is carefully monitored by the nurse for the first indication of a fluid balance problem. What is the indication? A. Fever B. Elevated BP C. Poor Skin Turgor D. Mental Status Changes

D. Mental status Changes

Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? A. Acute pain B. Hypothermia C. Powerlessness D. Risk for infection

D. Risk for infection Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? Nutritional status Potassium balance Calcium balance Fluid volume status

Fluid Volume status

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder. d. cyclothymic disorder.

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? -Generalized -Dependent -Brassy -Pitting

Generalized

The nurse monitors a patient who is being evaluated for hyperkalemia. She is aware that ECG changes and serum potassium levels are diagnostic. Which of the following are the earliest changes that the nurse should report? -K+ = 5 mEq/L; prolonged T waves -K+ = 6 mEq/L; elevated ST segment -K+ = 7 mEq/L; peaked T waves -K+ = 8 mEq/L; shortened PR interval

K+ = 7 mEq/L; peaked T waves

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

What is the usual progression of Alzheimer's disease? A single, short episode followed by years of normal function Recurring remissions and exacerbations Progressive deterioration There is no usual progression

Progressive deterioration The usual progression of Alzheimer's disease is steadily downward.REF: 438

What does the nurse recognize as one of the best indicators of the patient's renal function? -Blood urea nitrogen -Serum creatinine -Specific gravity -Urine osmolality

Serum creatinine

b

The plan of care for a patient who takes lithium should include a. Dietary teaching to restrict daily sodium intake b. Periodic laboratory monitoring of renal and thyroid function c. The requirement for laboratory tests to monitor serum potassium level d. The importance of discontinuing the medication if fine hand tremors occur

a

The priority nursing diagnosis for a hyperactive manic patient during the acute phase is a. Risk for injury b. Ineffective role performance c. Risk for other-directed violence d. Impaired verbal communication

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? -third-spacing -pitting edema -anasarca -hypovolemia

Third-spacing

a

To plan care for a manic patient the nurse must consider that lithium cannot be started until a. The physical examination and laboratory tests are analyzed b. The initial doses of antipsychotic medication have brought behavior under control c. Seclusion has proven ineffective as a means of controlling assaultive behavior d. Electroconvulsive therapy can be scheduled to coincide with lithium administration

d

What action should the nurse take on learning that a manic patient's serum lithium level is 1.8 mEq/L? a. Advise the patient to limit fluids for 12 hours. b. Continue to administer medication as prescribed. c. Advise the patient to curtail salt intake for 24 hours. d. Withhold medication and notify the health care provider.

b

What is the usual age of onset for cyclothymic disorders? a. Childhood b. Adolescence c. Middle adulthood d. Late adulthood

abcd

Which closed-ended assessment question focuses on identifying a classic comorbid condition of bipolar disorder? Select all that apply. a. Have you ever experienced a panic attack? b. Are you comfortable when you are among strangers? c. Have you ever been arrested by the police for fighting? d. Do you rely on alcohol to help cope with your problems? e. Have you ever been told you have obsessive-compulsive disorder?

ANS: C These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive patient could eat while in motion. The foods in the incorrect options cannot be eaten without utensils

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

d

Which is an advanced sign of lithium toxicity? a. Sedation b. Polyuria c. Mild thirst d. Blurred vision

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Notify the patients health care provider. b. Give the prescribed PRN lorazepam (Ativan). c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Encourage the patient to take deep, slow breaths.

a. Notify the patients health care provider.

A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a. Powerlessness c. Chronic low self-esteem

Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

a. The patient is experiencing laryngeal stridor. Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the patient's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action.

patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. lung sounds. b. urinary output. c. peripheral pulses. d. peripheral edema.

a. lung sounds

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

b. "Taking the medication every day helps prevent relapses and recurrences

When a delirious client insists that a vacuum hose is a large, poisonous snake, the nurse recognizes that this client is hallucinating. experiencing an illusion. hypervigilant. demonstrating agnosia.

experiencing an illusion. Illusions are errors in the perception of a sensory stimulus.REF: 433

Which nerve is implicated in the Chvostek's sign?

facial

Client Needs: Health Promotion and Maintenance 28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. c. cardiac dysrhythmia. b. hypertensive crisis. d. cardiogenic shock.

B

The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs and increasing peripheral edema. Which disorder do the findings reflect? A. Fluid volume deficit B. Fluid volume excess C. Fluid Homeostasis D. Fluid Dehydration

B

The patient has severe hypokalemia (2.4 mEq/L). For which intestinal complication does the nurse monitor? A. hypoactive bowel sounds B. Paralytic ileus C. Nausea D. Constipation

B

Client Needs: Health Promotion and Maintenance 25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

C

Client Needs: Psychosocial Integrity 27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

C

Client Needs: Psychosocial Integrity 12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

C

Client Needs: Psychosocial Integrity 8. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

C

Which is considered an isotonic solution? -0.9% normal saline -Dextran in normal saline -0.45% normal saline -3% NaCl

0.9% normal saline

Aldosterone promotes which of the following? 1) Reabsorption of sodium. 2) Reabsorption of potassium. 3) Excretion of renin. 4) Excretion of water.

1

The plasma oncotic pressure does which of the following? 1) Pulls fluid back into the vascular space at the venous side of the capillary 2) Pushes fluid out of the vascular space at the venous side of the capillary 3) Pushes fluid out of the vascular space at the arterial side of the capillary 4) All of the above

1

Which of the following actions is important to observe when giving potassium chloride (KCl) 100 mEq intravenously (IV) to a client with severe hypokalemia? 1) Use an IV pump to ensure safe delivery. 2) Warm the solution to room temperature. 3) Give rapidly to counteract the hypokalemia. 4) Give undiluted as a rapid bolus.

1

Which of the following are symptoms of hypovolemia? 1) oliguria 2) weight gain 3) decreased pulse and increased BP 4) distended jugular veins

1

Which of the following meals is highest in calcium? 1) Salmon sandwich with spinach and a glass of milk. 2) Fried egg sandwich with nuts. 3) Taco with tomatoes 4) Ham sandwich with pickles .

1

An elderly patient has been ill with fever, muscle cramps, nausea and vomiting. His daughter calls the physician's office and asks what she should do. The nurse knows that these symptoms mostly likely represent what? 1) Hypovolemia 2) Hypocalcemia 3) Hypophosphatemia 4) Hypoaldosteronism

1 Fever, thirst and CNS system changes are signs of intracellular dehydration (more serious than extracellular). The N&V might have been the precipitating factor that led to the fluid volume loss resulting in hypovolemia. Fever also contributes to insensible water loss. The fact that he is elderly puts him at higher risk of fluid imbalance. Signs of hypocalcemia are bleeding, hypotension, palpitations, laryngospasm, double vision or tetany and seizures. Signs of hypophosphatemia are fatigue, weakness, bone pain, decreased cardiac function, confusion or seizures.

A client has long-term exposure to asbestos. The nurse should assess the client for which type of cancer? 1 Lung 2 Kidney 3 Bladder 4 Stomach

1 Lung

A patient developed a bowel obstruction after surgery and a nasogastric tube was inserted. The most common electrolyte imbalances secondary to gastric suctioning is what? 1) Hyponatremia / hypokalemia 2) Hyponatremia / hyperkalemia 3) Hypernatremia / hypocalcemia 4) Hypernatremia / hypokalemia

1 Patients with NG tubes are at risk for electrolyte disturbances especially if suction is used because electrolytes normally in the stomach secretions are removed from the body. Sodium, potassium, calcium, chloride, and magnesium deficiency are possible. Only NS should be used to irrigate an NG tube so it will not further alter the patient's fluid and electrolyte balance.

A client is infected with the human papillomavirus type 16. Which cancer will the client most likely develop? 1 Penis 2 Ovary 3 Breast 4 Prostrate

1 Penis

52. A client is being discharged from an alcohol treatment program. The client's wife states, "I'm so afraid that when my husband leaves here, he'll relapse. How can I deal with this?" Which nursing statement would be most appropriate? 1) "Many family members of alcoholics find the Al-Anon support group to be helpful." 2) "You could try going out and having a few beers with him when he gets the urge to drink." 3) "Just make sure he doesn't drink at home. Find all of his hidden bottles and empty them." 4) "Tell your husband that if he drinks again, you will leave him."

1) "Many family members of alcoholics find the Al-Anon support group to be helpful." Al-Anon is a nonprofit organization that provides group support for the family and close friends of alcoholics.

Which of the following foods will have the greatest impact on the water balance of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

1. A pickle

Which question should be asked when considering the evaluation of outcomes for a patient experiencing cognitive dysfunction? Select all that apply. 1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 4. Are the caregivers capable of creating outcomes? 5. When were the patient's outcomes last evaluated?

1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 5. When were the patient's outcomes last evaluated?

A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of: 1. Cardiac dysrhythmias 2. Severe diarrhea 3. Hyperactive reflexes 4. Peripheral cyanosis

1. Cardiac dysrhythmias

A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of: 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypocalcemia

1. Hypokalemia

When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? 1. Neurological 2. Gastrointestinal 3. Pulmonary 4. Hepatic

1. Neurological

Which practice demonstrates a proactive approach to minimizing the stress commonly experienced by nursing staff caring for the cognitively impaired patient? Select all that apply. 1. Realistic patient outcomes 2. Mandatory transfers off of units 3. Small nurse-to-patient care ratios 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities

1. Realistic patient outcomes 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities Because stress is a common occurrence when working with persons with cognitive impairments, nurses need to be proactive in minimizing its effects, which can be facilitated by having an understanding of the disease and realistic expectations. Small nurse-to-patient care ratios and mandatory transfers off of units are not realistic and are unnecessary when staff is informed and well supported in their caregiving.

The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor: 1. Urine output 2. Intake of sodium 3. Activity level 4. Oxygen level

1. Urine output

Patients with which conditions are at risk for developing hypernatremia? Select all that apply. A. Chronic constipation B. Heart Failure C. Severe Diarrhea D. Decreased kidney function E. Profound Diaphoresis F. Cushing's syndrome

C, D,E,F

A coworker asks the nurse why genistein should be increased in the diet. How should the nurse respond? 1 It decreases apoptosis in cancer cell. 2 It prevents proliferation of cancer cells. 3 It is a macronutrient that prevents cancer. 4 It is a miRNA that protects against cancer.

2 It prevents proliferation of cancer cells.

The patient was told that he would have intraperitoneal chemotherapy. He asks the nurse when the IV will be started for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery? A. It is delivered via an Ommaya reservoir and extension catheter. B. It is instilled in the bladder via a urinary catheter and retained for 1 to 3 hours. C. A Silastic catheter will be percutaneously placed into the peritoneal cavity for chemotherapy administration. D. The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion pump.

C. A Silastic catheter will be percutaneously placed into the peritoneal cavity for chemotherapy administration. Intraperitoneal chemotherapy is delivered to the peritoneal cavity via a temporary percutaneously inserted Silastic catheter and drained from this catheter after the dwell time in the peritoneum. The Ommaya reservoir is used for intraventricular chemotherapy. Intravesical bladder chemotherapy is delivered via a urinary catheter. Intraarterial chemotherapy is delivered via a surgically placed catheter that delivers chemotherapy via an external or internal infusion pump.

Cancer survivors are at risk for treatment-related problems. Which of the pts. listed below has the greatest risk for developing such a problem? 1. An 80-year-old woman undergoing surgery for removal of a basal cell carcinoma on the face 2. A 71-year-old man receiving high-dose chemotherapy and radiation for an advance stage lymphoma 3. A 26-year-old man receiving chemotherapy for testicular cancer that is localized to the testicle 4. A 48-year-old woman receiving radiation for Hodgkin's disease that involves lymph nodes extending above and below the diaphragm

2. A 71-year-old man receiving high-dose chemotherapy and radiation for an advance stage lymphoma

Which of the following foods will have the greatest impact on the heart's conductivity of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

2. A banana

A patient diagnosed with Alzheimer's disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose. The nurse will document this behavior using which term? 1. Apraxia 2. Agnosia 3 Aphasia 4 Agraphia

2. Agnosia Agnosia is the loss of the sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.

The family caregivers of an elderly Alzheimer's disease patient are feeling overburdened and overwhelmed by the situation and wish to admit the patient to an assisted care facility. What could be the primary reason? 1. Family discord 2.Caregiver role strain 3 Disruption of social life 4 Distress, guilt, rejection

2. Caregiver role strain Many families take care of the patient with Alzheimer's disease until death. Others, however, find that they can no longer cope with aggressive behavior, incontinence, wandering, unsafe behaviors, or disruptive nocturnal activity. This is known as caregiver role strain. In such cases, the caregivers may admit the patient to an assisted care facility. Disruption of social life, distress, guilt, rejection, and family discord can all be burdens on the family but are not the primary reasons in this case.

For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? 1. Weak, thready pulse 2. Hypertension 3. Dry mucous membranes 4. Flushed skin

2. Hypertension

A client has cervical cancer. Upon review of the laboratory results, which subtype of the human papillomavirus (HPV) will the nurse most likely observe? 1 HPV-6 2 HPV-11 3 HPV-16 4 HPV-20

3 HPV-16

A nurse is teaching at a wellness clinic about obesity and cancer. Which information should the nurse include? 1 Obesity causes hypoglycemia. 2 Obesity is a risk factor for lung cancer. 3 Obesity can increase certain cancer risks. 4 Obesity may help people with cancer live longer.

3 Obesity can increase certain cancer risks.

The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is: 1. Hyperventilation to decrease the CO2 levels 2. Hypoventilation to increase the CO2 levels 3. Retention of HCO3 by the kidneys to increase the pH level 4. Excretion of HCO3 by the kidneys to decrease the pH level

3. Retention of HCO3 by the kidneys to increase the pH level

The nurse knows which is the normal serum value for potassium?

3.5-5.0

The active process by which sodium moves out of the cell and potassium moves into the cell is called: 1) filtration. 2) osmosis. 3) diffusion. 4) active transport.

4

Which of the following are symptoms of hypocalcemia (low calicum)? 1) Positive Chvostek's and Trousseau signs and seizures 2) Prolonged QT interval 3) Numbness and tingling of the hands and muscle cramps 4) All of the above

4

Which of the following is responsible for the oncotic pressure in the blood stream? 1) Antidiuretic hormone 2) Blood urea nitrogen 3) Creatinine 4) Albumin

4

An example of an isotonic solution is: 1) D5 1/2 Normal Saline 2) D5 Lactated Ringers 3) 1/2 Normal Saline 4) Normal Saline

4 An isotonic solution has an osmotic pressure equal to plasma (0.9 NS). Dextrose Solutions (D5 1/2 NS, D5 NS, or D5 LR) are hypertonic and anything less than 0.9 NS is hypotonic. Ringer's solution without dextrose is isotonic. Hypertonic fluids also include fluids with 3-5% NS or high destrose solutions such as D10 or D50 in water.

Which carcinogenic agent is used in the production of rubber and paint? 1 Radon 2 Arsenic 3 Asbestos 4 Benzidine

4 Benzidine

A nurse is teaching about the enzyme housekeepers involved in the metabolism of environmental carcinogens and reactive oxygen species. Which term should the nurse use to describe these substances? 1 Benzols 2 Aflatoxins 3 Isothiocyanates 4 Glutathione S-transferases

4 Glutathione S-transferases

A nurse is teaching a health class about primary factors responsible for the majority of cancers. Which information should the nurse include? 1 Economic factors 2 Psychological factors 3 Overall systemic health 4 Lifestyle/environmental factors

4 Lifestyle/environmental factors

A nurse is teaching a health class. Which information from the class indicates successful teaching about the single most preventable cause of cancer? 1 Alcohol 2 Caffeine 3 Saturated fat 4 Tobacco smoke

4 Tobacco smoke

Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

4. A spinach salad

The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should: 1. Start with the most proximal site 2. Look for hard, cordlike veins 3. Use the dominant arm 4. Avoid sites on the extremity away from a dialysis graft

4. Avoid sites on the extremity away from a dialysis graft

The single best indicator of fluid status is the nurse's assessment of the client's: 1. Skin turgor 2. Intake and output 3. Serum electrolyte levels 4. Daily weight

4. Daily weight

The nurse is assessing a patient with a mild increase in sodium level. What early manifestation does the nurse observe in this patient? A. Muscle twitching and irregular muscle contractions B. Inability of muscles and nerves to respond to a stimulus C. Muscle weakness occurring bilaterally with no specific pattern D. Reduced or absent bilateral deep tendon reflexes.

A

c

A patient diagnosed with bipolar disorder has taken lamotrigine (Lamictal) for 3 months with good results. Today, the patient phones the nurse with these complaints. Which complaint should receive the nurse's priority attention? a. "Last night I slept for only 7½ hours." b. "I have not had a bowel movement in 2 days." c. "I have a new rash on my chest and abdomen." d. "I bumped into a table yesterday and got a bruise on my elbow."

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

d

A patient with mania says to a nurse, "I will not talk with you, the nurse in the night shift advised me to stay away from you." What appropriate action does the nurse take? a. The nurse secludes the patient. b. The nurse asks the reason for avoiding. c. The nurse stops interacting with the patient. d. The nurse reports the patient's behavior in the staff meeting.

Which of the following statements is essential when teaching a patient who has received an injection of iodine-131? A) "Do not share a toilet with anyone else for 3 days." B) "You need to save all your urine for the next 7 days." C) "No special precautions are needed, because this is a weak type of radiation." D) "You need to avoid contact with everyone except family members until the radiation device is removed."

A) "Do not share a toilet with anyone else for 3 days."

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? A) "It is okay to cry; mourning the loss of your breast is important for getting past this." B) "I know this is hard, but chances of survival are greatly improved now." C) "Would you like to talk to someone who also has had a mastectomy?" D) "How have you coped with difficult situations in the past?"

A) "It is okay to cry; mourning the loss of your breast is important for getting past this."

Which patients are at risk for developing hyponatremia? Select all that apply. A. Post-op patient who has been NPO for 24 hour with no IV fluid infusing. B. Patient with decreased fluid intake for 3 days. C. Patient receiving excessive IV fluids with 5% Dextrose. D. Diabetic patient with blood glucose of 250 mg/dL E. Patient with overactive adrenal glands F. Tennis player in 100 F weather who has been drinking water

A, C, D, F

Which conditions cause a patient to be at risk for hypocalcemia? Select all that apply. A. Chrohn's Disease B. Acute Pancreatitis C. Removal or destruction of parathyroid glands D. Immobility E. Use of Digitalis F. GI wound drainage

A,B,C,D,F

The nurse is teaching a patient with hypokalemia about foods high in potassium. Which food items does the nurse recommend to the patient? Select all that apply A. Soybeans B. Lettuce C. Cantaloupe D. Potatoes E. Peaches F. Bananas

A,C,D,F

Which changes on the patient's ECG reflects hyperkalemia? A. Tall peaked T waves B. Narrow QRS complex C. Tall p waves D. Normal P-R interval

A.

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is the nurse's best response? Select all that apply. A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." B. "You will likely experience euphoria from the medication." C. "You will likely become dependent on this medication and require other medications to control your pain." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." E. "You will not become physically addicted, but you may develop a physiological addiction."

A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal."

Which intervention associated with bipolar disorder best minimizes the risk for the development of suicidal ideations? a. Early diagnosis b. Family counseling c. Medication therapy d. Stress identification

A. Early diagnosis Bipolar disorder often remains unrecognized, and early detection can help diminish co-occurring substance use disorders, suicide, and declines in social and personal relationships and may help promote more positive outcomes. While the remaining options are appropriate interventions they are not best for minimizing risk for suicide.DIF: Cognitive Level: Application (Applying)REF: Page 240TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

1.A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

ANS: A Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment.

A patient has a tissue growth that was diagnosed as cancer. Which of the following terms best describes this growth? a. Malignant tumor b. Lipoma c. Meningioma d. Hypertrophy

ANS: A Some tumors initially described as benign can progress to cancer and then are referred to as malignant tumors. Lipomas are benign growths, while a meningioma is a benign tumor. Hypertrophy refers to tissue overgrowth, but not cancer. REF: p. 234

A 45-year-old male presents with persistent, severe stomach pain. Testing reveals a peptic ulcer. Further laboratory tests reveal the presence of Helicobacter pylori. Which of the following is of concern for this patient? a. Gastric cancer b. Leukemia c. Lung cancer d. Adenocarcinoma of the colon

ANS: A The presence of Helicobacter pylori is associated with gastric cancer, not leukemia, lung cancer, or colon cancer.

A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.) A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.) a. Blood thinners b. Diphenhydramine c. Alcohol d. Penicillin e. Mouthwash

ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using. REF: Page 363 OBJ: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

ANS: A, E Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 204 | Page 211-212 | Page 215 (Box 12-6) | Page 224 TOP: Nursing Process: Planning/Outcomes Identification MSC: Client Needs: Health Promotion and Maintenance

10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.

ANS: B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully."

ANS: B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug

ANS: B Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

37. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: B The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

30.A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday

ANS: B 250 mL ÷ 50 mL/hr = 5 hr 1845 + 5 hr = 2345, which would be 2345 on Monday.

35.A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

ANS: B A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.

15.In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis

ANS: B A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

The interprofessional core team includes members from a. nursing, medicine, pharmacy, and nutrition. b. medicine, nursing, social work, and clergy. c. medicine, nursing, physical therapists, and volunteers. d. nursing, home health aides, volunteers, and clergy.

ANS: B An interprofessional team approach involving health care professionals from different disciplines is central to optimal palliative care practice and quality outcomes. The interdisciplinary core team includes members from medicine, nursing, social work, and clergy. Ancillary disciplines are also included.

An oncologist is discussing when a cancer cell loses differentiation. Which of the following is the oncologist describing? a. Autonomy b. Anaplasia c. Pleomorphic d. Metastasis

ANS: B Anaplasia, not autonomy, is the loss of differentiation. The term pleomorphic refers to a marked variability of size and shape. A malignant tumor has the ability to spread far beyond the tissue of origin by the process of metastasis.

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. Which condition should the nurse suspect? a. Alcohol-induced psychosis b. Delirium tremens (DTs) c. Neurologic injury related to a fall d. Posttraumatic stress reaction

ANS: B During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations. REF: Page 361 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action? a. Report the findings to the health care provider. b. Assess the patient for a history of renal problems. c. Assess the patient's family history for cardiac problems. d. Arrange for the patient's hospitalization on the psychiatric unit.

ANS: B Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and then share the findings with the health care provider.

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

ANS: B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours.

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

A nurse is giving an example of inflammation as an etiology for cancer development. What is the best example the nurse should give? a. Pneumonia and lung cancer b. Ulcerative colitis and colon cancer c. Prostatic hypertrophy and prostate cancer d. Hypercholesterolemia and leukemia

ANS: B Individuals with a 10+ year history of ulcerative colitis have a 30-fold increase in developing colon cancer. There is no relationship between pneumonia and lung cancer; between prostatic hypertrophy and cancer of the prostate; and between hypercholesterolemia and leukemia. REF: pp. 248-249

A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

8.The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate

ANS: B Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.

14.A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

ANS: B Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain.

ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression.

To prevent Wernicke's encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex c. Vitamins C and D3 d. Klonopin

ANS: B The B vitamins will prevent or reverse Wernicke's if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal. REF: Page 361 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. The nurse's best response to this behavior is to a. ignore his remarks. b. express doubt that there are spiders on the wall. c. ask the client if he also sees spiders in the day room. d. tell the client there are no spiders and he should stop worrying about it.

ANS: B The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

When considering the trajectory of a specific disease, what is the most important concept? a. Hospital admissions b. Physical functioning c. Quality of life d. Symptom management

ANS: B The disease trajectory occurs from the onset of a life-limited diagnosis until death. Physical functioning determines the decline in the patient's physical status. Decline in status is used to determine when to intervene with palliative and end-of-life care.

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

12.A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

ANS: B The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information? a. "Where did you go to elementary school?" b. "What did you have for breakfast this morning?" c. "Can you name the current president of the United States?" d. "A few minutes ago, I told you my name. Can you remember it?"

ANS: B The patient's recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patient's fund of knowledge.

After formulating the nursing diagnoses for a new patient, what is a nurse's next action? a. Designing interventions to include in the plan of care b. Determining the goals and outcome criteria c. Implementing the nursing plan of care d. Completing the spiritual assessment

ANS: B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

Select all that apply. A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? a. The patient was uncooperative b. The patient's subjective responses c. Only data obtained from the patient's verbal responses d. A description of the patient's behavior during the interview e. Analysis of why the patient was unresponsive during the interview

ANS: B, D Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate.

Select all that apply. What information is conveyed by nursing diagnoses? a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.

ANS: C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiological intervention.

ANS: C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Social isolation d. Powerlessness

ANS: C Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

24.A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

ANS: C Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit 32% b. Pain with deep inspiration c. Serum sodium 126 mEq/L d. Decreased breath sounds on left side

ANS: C Syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and will require rapid treatment in order to prevent complications such as seizures and coma. The other findings also require intervention, but are common in patients with lung cancer and not immediately life threatening.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

19.The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

ANS: C The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action. Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is the second action. Increasing fluids is contraindicated and would make the situation worse.

During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.

ANS: C The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.

A 45-year-old female was recently diagnosed with cervical cancer. Which of the following is the most likely cause of her cancer? a. Herpes virus b. Rubella virus c. Human papillomavirus (HPV) d. Hepatitis B virus

ANS: C The presence of HPV is a factor in cervical cancer. The presence of herpes virus, rubella virus, or hepatitis B virus is not a factor in cervical cance

A primary care provider is attempting to diagnose cancer and is looking for a tumor marker. Which of the following could be a possible marker? a. Red blood cells b. Apoptotic cells c. Enzymes d. Neurotransmitters

ANS: C Tumor markers include hormones, enzymes, genes, antigens, and antibodies, but not red blood cells, apoptotic cells, or neurotransmitters.

39.A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

ANS: C When administering a transfusion you need an appropriate-size IV catheter and blood administration tubing that has a special in-line filter. The patient's blood should not be mixed with the infusion blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.

4. A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

ANS: C, D The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years old and Tara at 31 years old. Based on your knowledge of early and late onset of schizophrenia, which of the following is true A. Tara and Aaron have the same expectation of a poor long-term prognosis. B. Tara will experience more positive signs of schizophrenia such as hallucinations. C. Aaron will be more likely to hold a job and live a productive life. D. Tara has a better chance for positive outcomes because of later onset.

ANS: D Female patients diagnosed with schizophrenia between the ages of 25 and 35 years have better outcomes than do their male counterparts diagnosed earlier. These two patients do not have the same expectation of a poor prognosis. There is no evidence suggesting that Tara will have more positive signs of schizophrenia. It is actually more unlikely that Aaron will be able to live a productive life because of his earlier onset, which has a poorer prognosis.

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. b. medication noncompliance. c. chronic deterioration. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 213-215 (Box 12-6) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Schizophrenia is best characterized as presenting which personality trait? A. Split B. Multiple C. Ambivalent D. Deterioration

ANS: D The course of schizophrenia is marked by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 206-207 | Page 212-213 (Box 12-3)

5. A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses.

20.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

ANS: D A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with normal ECV. Asking the patient about urination habits will help determine whether the body is trying to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not help determine the cause of the problem. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a. consistently demonstrated. b. often demonstrated. c. sometimes demonstrated. d. never demonstrated.

ANS: D Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to audience response question.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment? a. "How did you get to the United States?" b. "Would you like for a family member to help you talk with me?" c. "An interpreter is available. Would you like for me to make a request for these services?" d. "Are you comfortable conversing in English, or would you prefer to have a translator present?"

ANS: D The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.

5.A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

ANS: D The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: a. childhood growth and development b. substance use and abuse c. educational background d. coping strategies

ANS: D When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient's faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

Which side effect of antipsychotic medication is generally nonreversible? A. Anticholinergic effects B. Pseudoparkinsonism C. Dystonic reaction D. Tardive dyskinesia

ANS: D Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The other side effects often appear early in therapy and can be minimized with treatment.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? 1. fluid volume excess 2. fluid volume deficit 3. seizure activity 4. liver failure

Answer: 1 Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system. Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system. Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances. Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.

The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this pt? Select all that apply. 1. IV normal saline 2. calcium containing antacids 3. IV potassium phosphate 4. encouraging milk intake 5. increasing vitamin D intake

Answer: 1,2 Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate.

Which problem is NOT considered a causative agent in delirium? Elevated blood urea nitrogen levels Infection Anticholinergic drugs Antibiotic therapy

Antibiotic therapy Although delirium may be a result of an infection, antibiotic therapy is not known to cause cognitive disorders.REF: 432-433

ANS: B The environment for a manic patient should be as simple and nonstimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

Client Needs: Psychosocial Integrity 5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

B

Client Needs: Psychosocial Integrity 21. A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness c. Stress overload b. Risk for suicide d. Spiritual distress

B

What are the functions of potassium in the body? Select all that apply. A. Regulates hydration status B. Controls intracellular osmolarity and volume C. Stimulates the secretion of ADH D. Functions as the major cation the ICF E. Regulates glucose use and storage F. Helps maintain cardiac rhythms

B,D,E,F

A client's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? a. banana b. apple c. fish d. carrot

Bananas

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which abnormality associated with this oncologic emergency? A. Hypokalemia B. Hypouricemia C. Hypocalcemia D. Hypophosphatemia

C. Hypocalcemia TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.

31. The ED nurse assesses a confused client diagnosed with alcohol use disorder and notes the use of confabulation. Which complication of alcohol use disorder would the nurse suspect? 1) Korsakoff's psychosis 2) Vascular neurocognitive disorder 3) Wernicke's encephalopathy 4) Esophageal varices

Korsakoff's psychosis is identified by a syndrome of confusion, loss of memory, and confabulation. Confabulation is the creating of imaginary events to fill in memory gaps.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? -Respiratory acidosis -Metabolic alkalosis -Respiratory alkalosis -Metabolic acidosis

Respiratory Acidosis

d

The first-line drug used to treat mania is a. Lamotrigine b. Clonazepam c. Carbamazepine d. Lithium carbonate

d

The nurse is writing a plan of care for a patient in the manic phase of bipolar I disorder. What is the most important outcome for the patient? a. Decreasing food intake b. Increasing physical activity c. Sleeping for 8 to 10 hours a night d. Maintaining a stable cardiac status

The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character if the client truly has stage 2 Alzheimer's disease? (Select all that apply) Willingness to respond directly to questions posed by nurse Charming behavior designed to hide memory deficit Confabulation to compensate for forgotten information Avoidance of questions by subject changing

Willingness to respond directly to questions posed by nurse During stage 1 Alzheimer's disease the client is aware of memory impairment and may attempt to disguise it or cover it by being evasive or using confabulation.REF: Page 440 (Table 23-3)

1. Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? a. Always afraid another student will steal her belongings. b. An unusual interest in numbers and specific topics. c. Demonstrates no interest in athletics or organized sports. d. Appears more comfortable among males.

a. Always afraid another student will steal her belongings.

The family of a client diagnosed with Alzheimer's disease mentions to the nurse that seeing his loss of function has been very difficult. A nursing diagnosis that might be considered for such a family would be ineffective denial. anticipatory grieving. disabled family coping. ineffective family therapeutic regimen management.

anticipatory grieving. Anticipatory grieving involves working through potential loss.REF: 442-443

A 40-year-old female developed adenocarcinoma of the vagina. Which of the following is the most likely cause of her cancer? a. Rb gene mutation b. Prenatal exposure to diethylstilbestrol (DES) c. Prenatal exposure to solvents d. Prenatal exposure to radiation

b The patient with adenocarcinoma of the vagina experienced prenatal exposure to DES.

which comment by a patient diagnosed with bipolar disorder best indicates the pt is experiencing mania a. "i have been sleeping about 6 hrs each night b. "yesterday i made 487 posts on my social network pg c. " i am having dreams about my fathers death 8 yrs ago d. "my appetite is so robust that ive gained 4 lbs in the past 2 weeks

b. "yesterday i made 487 posts on my social network pg

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern

When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is a. skin turgor. b. daily weight. c. presence of edema. d. hourly urine output.

b. daily weight

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.

b. if the oral mucosa feels dry.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. an elevated serum potassium level. b. the presence of Chvostek's sign. c. a decreased thyroid hormone level. d. bleeding on the patient's dressing.

b. the presence of Chvostek's sign The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

13. When planning for cancer survivor care needs, which information should the nurse consider? a. Survivorship care plans are reviewed with the patient at home. b. All health care agencies provide survivorship care plans. c. Some survivors are discharged with no survivor plan. d. The plan does not deal with future cancer screenings.

c. Some survivors are discharged with no survivor plan. Some patients receive care at cancer centers without this type of resource and may not have a survivor care plan. Thus nurses and other health care providers need to become more vigilant in recognizing cancer survivors and attempting to link them with the support and resources they require. Ideally, the nurse reviews a survivorship care plan with a patient at the time of discharge from a treatment program and not at home. The plan becomes a guide for any future cancer or cancer-related care.

A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you."

7. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes? a. "I know you say you hear voices, but I cannot hear them." b. "Stop listening to the voices, they are NOT real." c. "You say you hear voices, what are they telling you?" d. "Please tell the voices to leave you alone for now."

c. "You say you hear voices, what are they telling you?"

The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patients condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg

c. Absence of peripheral edema

The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg

c. Absence of peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

10. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with: a. Generally good health despite the mental illness. b. An aversion to drinking fluids. c. Anxiety and depression. d. The ability to express his needs.

c. Anxiety and depression.

2. Which intervention demonstrates a nurse's understanding of the initial action associated with the assessment of a patient's spiritual beliefs? a. Offering to pray with the patient b. Providing a consult with the facility's chaplain c. Asking the patient what role spirituality plays in his or her daily life d. Arranging for care to be provided with respect to religious practices

c. Asking the patient what role spirituality plays in his or her daily life

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, apple

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58

c. Urine output 8 mL/hr

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal)

When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. skin turgor. b. heart sounds. c. mental status. d. capillary refill.

c. mental status. Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.

A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

c. put a blanket around the patient, and walk with the patient to a quiet room.

When a client's ventilation is impaired, the body retains which substance? Sodium bicarbonate Carbon dioxide Nitrous oxide Oxygen

carbon dioxide

6. A breast cancer survivor has chemotherapy-related cognitive impairment. Which area should the nurse assess? a. Pain b. Grief c. Nightmares d. Short-term memory

d. Short-term memory Breast cancer survivors report having difficulty with short-term memory, focusing, working, reading with comprehension, and driving with chemotherapy-related cognitive impairment (CRCI). Pain occurs with other long-term effects of cancer survival but does not occur with CRCI. Grief and nightmares occur with post-traumatic stress disorder.

A 13-year-old female is admitted to the hospital for evaluation and treatment of an osteosarcoma in her left distal femur. Which statement best describes osteosarcoma? a. Myelogenic, develops in red bone marrow only b. Benign, develops in spongy bone tissue c. Collagenic, originates in the periosteum d. Osteogenic, most often develops in the bone marrow

d. Osteogenic, most often develops in the bone marrow

A 13-year-old female presents with pain at night, cough, and dyspnea. Testing reveals a metastasizing malignant bone tumor. The most likely type of tumor is: a. Nonossifying fibroma b. Chondrosarcoma c. Ewing sarcoma d. Osteosarcoma

d. Osteosarcoma

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

d. Psychoeducation

A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bed rest. b. auscultating lung sounds every 4 hours. c. monitoring for Trousseau's and Chvostek's signs. d. encouraging fluid intake up to 4000 ml every day.

d. encouraging fluid intake up to 4000 ml every day.

An initial intervention the nurse might suggest to the family members of a client diagnosed with Alzheimer's disease who has begun incontinence would be to label the bathroom door with a picture. provide toileting on an as-needed basis. apply disposable diapers. encourage hourly toileting.

label the bathroom door with a picture. Labeling doors and various items with pictures can be helpful for a client who has forgotten where things are and what certain items are.REF: Page 447 (Table 23-7)

Which set of arterial blood gas (ABG) results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+

pH, PaCO2, HCO3

A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

2. Pull fluid from the cells

An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from: 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis

2. Respiratory acidosis

A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately? 1. Check the vital signs. 2. Stop the blood transfusion. 3. Slow down the rate of blood flow. 4. Notify the health care provider and blood bank personnel

2. Stop the blood transfusion.

Mr. Timmons has been receiving treatment for colon cancer on and off for a year. He received multiple chemotherapy regimens and a course of radiation. The 58-year-old pt. is able to perform his own hygiene but needs assistance from his wife to move about safely in the home because of ongoing fatigue and weakness. His wife assists him with dressing when he becomes excessively tired. This caregiving skill pattern is best desccribed as which of the following? 1. The self-caregiving pattern 2. The collaborative care pattern 3. The family caregiving pattern 4. The team caregiving pattern

2. The collaborative care pattern

An elderly patient, who had been healthy and living independently, was hospitalized with heart failure. The patient was treated with diuretics and antihypertensive medications. On the third hospital day, the patient became very irritable and said, "Little yellow bugs are crawling across my sheets." What is the best analysis of this scenario? 1. the pt has delusions secondary to depression 2. the pt is experiencing illusions secondary to delirium 3. Early dementia emerged because of the stress of the physical illness 4. doses of antihypertensive drugs have not managed the patients BP

2. The patient is experiencing illusions secondary to delirium Delirium is the most common complication of hospitalizations in the older adults. Illusions (errors in perception of sensory stimuli) indicate this patient is confused. Illusions, irritability, and restlessness are common in delirium. The scenario doesn't suggest the pt has dementia or depression. The pt is likely experiencing toxicity associated with the multiple medications, which is a common cause of delirium.

An elderly patient is hospitalized with pneumonia and treated with multiple antibiotics. After two days, the patient becomes irritable and restless, and says to the nurse, "My pet parakeet flew across the room." A family member says the patient has been healthy and living independently but does not own a pet. What is the most likely analysis of this scenario? 1. The patient is delusional and likely experiencing depression. 2. The patient is experiencing illusions secondary to delirium. 3. The antibiotic doses have been inadequate to treat the infection. 4. Dementia has emerged as the result of the stress of the physical illness.

2. The patient is experiencing illusions secondary to delirium. The onset of the change in mental status is acute, which is characteristic of delirium. The vision of a bird flying in the room is likely an illusion, another common characteristic of delirium. The patient's condition could be the result of the medical illness, toxicity of the drug regimen, overstimulation from the hospital environment, alcohol withdrawal, or other reasons.

A patient with cognitive impairment is diagnosed with aphasia. Which symptom is the nurse most likely to find in the patient? 1. The patient wears socks on the hands. 2. The patient talks rapidly and foolishly. 3. The patient doesn't answer the nurse. 4. The patient doesn't identify sounds.

2. The patient talks rapidly and foolishly. Patients with impaired cognition show symptoms like aphasia, apraxia, preservation, and agnosia. The patient with aphasia has reduced language ability, seen as inability to use the correct word and talking rapidly and foolishly. Loss of purposeful movement is called apraxia. The person is unable to put on clothes and may wear socks on hands. The patient with preservation avoids answering the question to maintain self-esteem. Inability to identify sounds, objects, and people is known as agnosia.

A client has intravenous therapy for the administration of antibiotics and is stating that the "IV site hurts and is swollen." Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? 1. Intensity of the pain 2. Warmth of integument surrounding the IV site 3. Amount of subcutaneous edema 4. Skin discoloration of a bruised nature

2. Warmth of integument surrounding the IV site

A client is hyponatremic and the cause is thought to be fluid overload. When this is the etiology, what would be the intervention of choice? 1) restrict sodium intake 2) do nothing and allow it to resolve itself 3) restrict oral fluids 4) force fluids

3

A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms? 1) Restlessness and agitation 2) Paresthesias and irritability 3) Weak, irregular pulse, cardiac arrhythmias, and muscle weakness 4) Increased blood pressure and muscle spasms

3

A nurse is teaching a client about the role of cigarette smoking in the development of cancer. Which information should the nurse include in the teaching session? 1 Smoking is noncarcinogenic. 2 Risk is greatest in those who begin to smoke when older. 3 Cigarette smoking is the most important cause of cancer. 4 Evidence is strong linking tobacco smoking to prostate cancer.

3 Cigarette smoking is the most important cause of cancer.

When evaluating the effectiveness of IV fluid re-hydration for severe dehydration, which of the following is the best indicator? 1) Weight gain 2) Skin turgor 3) Increased urinary output 4) Increased temperature

3 For a person with more acute or severe dehydration, you would expect to see increase in urine output and decrease in urine osmolarity with re-hydration. Other signs re-hyrdration include moist mucous membranes, absence of tongue furrows, absence of orthostatic hypotension. Careful monitoring of I&O can help assess the patient's progress towards the goal of re-hydration.

The preferred route for potassium replacement is: 1) IV push 2) IV Piggyback 3) Oral 4) Continuous drip

3 Low potassium is most often seen in patients who have polyuria such as in diabetes or those on diuretics. An oral potassium supplement is usually prescribed and is the preferred route if tolerated. IV potassium should only be used with extreme caution. IV Boluses of potassium (IV push) may cause severe and potentially fatal heart rhythm disturbances, so careful cardiac monitoring is required during IV drug administration. IV piggyback doses of potassium can be given slowly if correction is needed quickly. Potassium can be added to IV solutions for maintenance or slower replenishment of the electrolyte.

A nurse is asked which structure plays a major role in controlling growth and development in utero. How should the nurse respond? 1 Uterus 2 Ovaries 3 Placenta 4 Vaginal canal

3 Placenta

Which information should the nurse include when teaching adults in a wellness clinic about ultraviolet (UV) light? 1 The principal source of ultraviolet radiation is tanning beds. 2 The degree of damage is not affected by wavelength. 3 UV light causes basal cell carcinoma and squamous cell carcinoma. 4 UV light can cause the most damage in the abdominal area.

3 UV light causes basal cell carcinoma and squamous cell carcinoma.

Which of the following laboratory results places the patient at greatest risk for dysrhythmias? 1) Na+ 148 mEq/L 2) Ca++ 8.9 mg/dL 3) K+ 6.6 mEq/L 4) Na+ 133 mEq/L

3 Watch out for that Potassium! Normal is 3.5-5.0 (memorize this!!!!) Hyperkalemia can lead to cardiac dysrhythmias.

36. A client who is going through alcohol detoxification states, "I see bugs crawling on the wall." Which is the best nursing response? 1) "I'll remove the bugs from the wall." 2) "You are confused because of your alcoholism." 3) "There are no bugs on the wall. I'll stay with you until you feel less anxious." 4) "You do not see any bugs on the wall."

3) "There are no bugs on the wall. I'll stay with you until you feel less anxious." This response presents objective reality and may help decrease the client's anxiety by the nurse's therapeutic offering of self.

51. A client with chronic alcoholism says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? 1) Carbamazepine (Tegretol) 2) Clonidine (Catapres) 3) Disulfiram (Antabuse) 4) Folic acid (Folvite)

3) Disulfiram (Antabuse) Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high enough. It is important that the client understands that all alcohol, oral or topical, and medications that contain alcohol are strictly prohibited when taking this drug.

50. A client diagnosed with chronic alcohol use disorder complains of feeling tremulous. The client's BP is now 170/110, P 116, R 30, T 97°F. The nurse anticipates which medication would give the client the most immediate relief from these symptoms? 1) Benztropine (Cogentin), 2 mg PO 2) Oxazepam (Serax), 30 mg PO 3) Lorazepam (Ativan), 1 mg IM 4) Meperidine (Demerol), 100 mg IM

3) Lorazepam (Ativan), 1 mg IM Ativan is frequently used to treat the symptoms of alcohol withdrawal. Because Ativan is ordered parenterally, this medication would give the client the most immediate relief of symptoms.

38. When teaching a client diagnosed with alcoholism about nutritional needs, which nutritional concept should the nurse emphasize? 1) Eat a high-protein, low-carbohydrate diet to promote lean body mass. 2) Increase sodium-rich foods to increase iodine levels. 3) Provide multivitamin supplements, including thiamine and folic acid. 4) Restrict fluid intake to decrease renal load.

3) Provide multivitamin supplements, including thiamine and folic acid. Vitamin B deficiencies contribute to the nervous system disorders seen in chronic alcohol abuse. Supplements of these vitamins are important to prevent complications. It is important that vitamin supplements include both thiamine (vitamin B1) and folic acid.

49. A client is diagnosed with stimulant use disorder: cocaine and antisocial personality disorder. The client eagerly participates in therapy and becomes charming and ingratiating to the primary nurse. Which best describes these client behaviors? 1) The client has not completed the cocaine withdrawal process. 2) The client is probably hiding something. 3) The client is exhibiting characteristics of antisocial personality disorder. 4) The client is exhibiting symptoms of cocaine dependence.

3) The client is exhibiting characteristics of antisocial personality disorder.

32. An impaired nurse is admitted to an inpatient substance abuse treatment facility. Which applies to his situation? 1) The nurse must relinquish his driver's license to the office of motor vehicles. 2) The nurse is mandated to comply with treatment and prescribed therapies. 3) The nurse is not mandated to meet specific requirements, because all civil rights are ensured. 4) The nurse must relinquish his registered nurse (RN) license to the state board of nursing.

3) The nurse is not mandated to meet specific requirements, because all civil rights are ensured. Although some variations occur from state to state, currently psychiatric clients maintain all of their civil rights. This nurse is not mandated by law to meet specific requirements, because all civil rights are ensured.

A support group of cancer survivors is discussing cancer-related fatigue (CRF). The survivor most likely to gain relief from CRF is the survivor who does which of the following? (SATA) 1. Takes naps during the day and evening 2. Drinks energy drinks daily 3. Exercises every other day 4. Eats a balanced diet

3, 4

A 41-year-old man who underwent a craniotomy for the removal of a brain tumor 6 months ago comes to the clinic for his monthly follow-up visit. In planning your assessment, you anticipate that the pt. may possibly experience which of the following late effects of surgery? (SATA) 1. Pain 2. Fatigue 3. Blurred vision 4. Difficulty breathing 5. Poor attention span

3, 5

Katie, a child in remission for leukemia, and her mother come to the pediatrician's office for a routine physical examination. The nurse asks Katie about whether she is having continued symptoms. Her mom says, " I don't know why you want all of this information about Katie's cancer treatment. The leukemia is gone." The best response from the nurse in support of the child and mother would be: 1. " The doctor likes to keep the records complete on all of her patients." 2. " Just because Katie is in remission does not mean that it will stay away." 3. " It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly." 4. " I understand your concern. If you don't want to provide the information, sign this release form."

3. " It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly."

A nurse in an oncology outpatient clinic has been seeing a woman and her husband since the woman was diagnosed with breast cancer. Sometimes the husband appears supportive, asking questions about his wife's care. At other times the husband seems easily distracted and uninterested. The nurse decides to reassess the psychosocial condition of the pt. and her husband. Which of the following questions best elicits needed psychosocial information? 1. " In what way does the pain you have affect you on a daily basis?" 2. " Describe to me what you eat in a typical day." 3. " Tell me how you think you and your husband are dealing with your cancer." 4. " Are the two of you having any relational difficulties because of your cancer?"

3. " Tell me how you think you and your husband are dealing with your cancer."

A nurse communicates with a diabetic patient during their regular check-up. The nurse finds that the patient is showing symptoms of Alzheimer's disease. Which response by the patient supports the nurse's diagnosis? 1. "I missed my walk last week." 2. "I regularly go for a walk, you can ask my daughter." 3. "I regularly meet Mr. Abraham Lincoln during my walk." 4. "I don't go for a walk, because it is very cold in the morning."

3. "I regularly meet Mr. Abraham Lincoln during my walk." Patients with Alzheimer's have progressive deterioration of memory. They forget to take medication and perform important self-care activities. They tend to hide the truth by creating stories like they go for a walk with Abraham Lincoln. This behavior is called confabulation. It is not the same as lying because patients do it unconsciously to maintain self-esteem. The statement that the patient is going for a regular walk which can be confirmed with the daughter indicates confidence. The statement that the patient missed the walk indicates that the patient remembers the period and also accepts the mistake. The statement that the patient doesn't go for a walk because of cold weather indicates that the patient accepts the mistake without any guilt.

Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBCs), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is: 1. 24 gauge 2. 22 gauge 3. 20 gauge 4. 18 gauge

3. 20 gauge

The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be: 1. 12 gtt/min 2. 22 gtt/min 3. 32 gtt/min 41-4 4. 42 gtt/min

3. 32 gtt/min 41-4

Which of the following clients is most at risk for fluid volume deficit? 1. 25-year-old male near-drowning victim 2. 56-year-old woman with salicylate poisoning 3. 45-year-old woman with second-degree burns over 20% of her body 4. 13-year-old boy with an oral temperature of 103.4° F

3. 45-year-old woman with second-degree burns over 20% of her body

Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: 1. A 6-month-old learning to drink from a cup 2. A 12-year-old who is moderately active in 80° F weather 3. A 42-year-old with severe diarrhea 4. A 90-year-old with frequent headaches

3. A 42-year-old with severe diarrhea

Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

3. A milkshake

The nurse is discontinuing a client's IV line in preparation for the client's discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first thing that the nurse should do is: 1. Notify the health care provider immediately 2. Apply pressure to the IV site 3. Apply a tourniquet high on the extremity 4. Ask another nurse to double-check the cannula

3. Apply a tourniquet high on the extremity

The nurse is preparing to replace a bag of IV fluids for a client receiving fluid therapy. When assessing the client, the nurse notes that the IV solution is not dripping. Which of the following should the nurse do to assess the patency of the site? 1. Lower IV container below level of IV site for presence of blood return. 2. Use a large-volume syringe to apply negative pressure to achieve a blood return. 3. Carefully adjust the roller clamp to see an increase in flow rate. 4. Massage the client's arm proximal to where the catheter is inserted

3. Carefully adjust the roller clamp to see an increase in flow rate.

A rapid infusion of citrated blood has been given to the client. The nurse observes for: 1. Diaphoresis 2. Anxiety 3. Chvostek's sign 4. Nausea and vomiting

3. Chvostek's sign

A nurse reviews the medical record of a 40-year-old pt. newly admitted to the medical nursing unit for evaluation of diabetes. As the nurse reviews the pt's medical history, she notices that the pt. had bladder surgery 3 years ago. Which of the following assessment questions is most appropriate for the nurse to ask to determine if the patient is a cancer survivor? 1. Determining if the pt. had additional surgeries recently 2. Assessing the pt's medication history 3. Determining if the surgery was cancer related 4. Assessing if the pt's parents had cancer

3. Determining if the surgery was cancer related

A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced: 1. Decreased muscle tone 2. Hypertension 3. Diarrhea 4. Fever

3. Diarrhea

A patient is brought to the emergency room after falling in the street a mile from home. There are no serious injuries. The patient's medical record states the patient has Alzheimer disease, and the patient asks the nurse call his or her spouse, who is long deceased. What should be the focus of care? 1. Family therapy for the patient's family members 2. Health promotion, instructing the patient on ways to be safe 3. Evaluation of the home situation for safety and level of care 4. Biological reasons for the ER visit and possible psychiatric care

3. Evaluation of the home situation for safety and level of care Because patients with Alzheimer disease are at risk for wandering and getting lost, this patient's living situation should be assessed for security; he or she may require full-time care. Because the patient has no serious injuries, biological needs have already been addressed. Telling the patient how to be safe will not be effective due to the nature of the disorder. Family therapy may be helpful, but this is not the priority goal.

The nurse is assessing a patient suspected of Alzheimer's disease (AD). What action by the patient does the nurse identify as a sign of agnosia? 1. Babbles and speaks incoherently when asked any question 2. Has problem in recalling what was served for breakfast an hour ago 3. Has problem in identifying familiar sounds like the ring of the telephone 4. Talks about how he or she convinced the President to pass a particular law

3. Has problem in identifying familiar sounds like the ring of the telephone When the patient is unable to identify the ring of the telephone, it means there is a loss of sensory ability to recognize familiar sounds. The nurse recognizes it as a feature of auditory agnosia. If the patient babbles and speaks incoherently, it means there is a loss of language ability. The nurse identifies this as a sign of aphasia. In AD, there is a gradual deterioration of recent and remote memory. If the patient is unable to recall what was served for breakfast an hour ago, it indicates impairment of recent memory. Patients with AD often confabulate in an unconscious attempt to maintain self-esteem. When the patient talks about how the President's decision was influenced by the patient, the nurse should recognize it as confabulation.

The nurse anticipates that the client with a fluid volume excess will manifest a(n): 1. Increased urine specific gravity 2. Decreased body weight 3. Increased blood pressure 4. Decreased pulse strength

3. Increased blood pressure

Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

3. Nausea and vomiting

The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurse's first action should be to: 1. Immediately discontinue the IV line and remove the cannula 2. Put cool compresses on the IV site to decrease the edema 3. Notify the health care provider of the situation 4. Put warm compresses on the IV site to decrease the pain

3. Notify the health care provider of the situation

Which risk factor for delirium is a direct result of external factors? 1. Fractures 2. Older age 3. Polypharmacy 4. Multiple comorbidities

3. Polypharmacy Delirium may occur as a result of polypharmacy, which can occur from a lack of continuity of care and communication, external factors. Older age and multiple conditions are internal factors. Fractures may be a result of an external cause but could also be a result of internal osteoporotic changes.

Every evening, several residents on the Alzheimer disease wing of a long-term care facility become excessively agitated. What is the term for this phenomenon? 1. Apraxia 2. Agraphia 3. Sundowning 4. Confabulation

3. Sundowning Sundowning is the term for the increase in agitation and decrease in mood in the later part of the day or night common among patients with Alzheimer disease. Confabulation describes the creation of vivid stories instead of actual memories. Agraphia refers to diminishment of reading and writing abilities. Apraxia is the loss of purposeful movement.

Which information indicates a client correctly understands the teaching about diet and cancer? 1 Cancer risks for older adults are based primarily on current diet. 2 Eating a diet high in garlic increases colorectal cancer risk. 3 Adoption of the Western diet has decreased the rate of some cancers. 4 Evidence exists that nutritional factors are related to cancer development.

4 Evidence exists that nutritional factors are related to cancer development.

The IV fluid should be used to prime tubing for administration of blood is: 1) D5 1/2 NS 2) D5 LR 3) 1/2 NS 4) NS

4 Only isotonic saline (0.9%) is recommended for use with blood components. Other isotonic electrolyte solutions that do not contain calcium may be used according to hospital policy. Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. For example, 5% dextrose in water will hemolyze red cells. Intravenous solutions containing calcium, such as Lactated Ringer's solution, can cause clots to form in blood. Prior to blood transfusion, completely flush incompatible intravenous solutions and drugs from the blood administration set with isotonic saline.

Which activity by the pregnant client will cause the nurse to intervene? 1 Quits smoking 2 Consumes a healthy diet 3 Maintains adequate weight gain Correct4 Places cell phone to abdomen so family can talk to the baby

4 Places cell phone to abdomen so family can talk to the baby

Which activity by the pregnant client will cause the nurse to intervene? 1 Quits smoking 2 Consumes a healthy diet 3 Maintains adequate weight gain 4 Places cell phone to abdomen so family can talk to the baby

4 Places cell phone to abdomen so family can talk to the baby

Which cancer should the nurse assess for in the client whose diet consists largely of salted foods? 1 Oral 2 Lung 3 Prostate 4 Stomach

4 Stomach

39. Which nursing intervention relates to rehabilitative care for a recovering alcoholic? 1) Providing a safe and supportive environment during alcohol withdrawal 2) Teaching about physical symptoms 3) Providing client and family education and assistance during treatment 4) Encouraging continued participation in AA

4) Encouraging continued participation in AA Because recovery is a long-term process, it is critical that the nurse encourage continuous participation in outpatient support systems such as AA.

34. Which symptom would the nurse expect to observe in a client experiencing opioid intoxication? 1) Insomnia 2) Abdominal cramps 3) Muscle aches 4) Impaired judgment

4) Impaired judgment Impaired judgment; initial euphoria followed by apathy; dysphoria; and psychomotor agitation or retardation are all symptoms of opioid intoxication.

47. On admission, a client experienced severe alcohol withdrawal symptoms. Four days later, the nurse notes a decrease in withdrawal symptoms. Which nursing intervention is most appropriate? 1) Withhold potentially addictive as needed (prn) medications. 2) Increase prn medications because potentially fatal complications can still occur. 3) Ask the doctor to prescribe a less addictive medication to reduce potential for dependence. 4) Monitor for withdrawal complications and administer medications on the basis of client symptoms.

4) Monitor for withdrawal complications and administer medications on the basis of client symptoms. The nurse must remain vigilant because withdrawal complications can occur days after initial withdrawal symptoms appear. Medication dosages for withdrawal should be based on an objective assessment of symptoms. This is usually done by the use of an assessment tool such as Clinical Institute Withdrawal Assessment (CIWA).

42. Which is the most serious symptom experienced during alcohol withdrawal? 1) Blackout 2) Acute withdrawal delirium 3) Hypotension 4) Seizure

4) Seizure During alcohol withdrawal, the central nervous system (CNS) rebounds from the effects of suppression caused by alcohol intake. This excitation of the CNS can lead to grand mal seizures and other complications, which are life threatening. This is the most serious complication of alcohol withdrawal syndrome.

53. A client is brought to the ED. The client is aggressive, has slurred speech, and exhibits impaired motor coordination. Blood alcohol level is 347 mg/dL. Among the physician's orders is thiamine. Which is the rationale for this intervention? 1) To prevent nutritional deficits 2) To prevent pancreatitis 3) To prevent alcoholic hepatitis 4) To prevent Wernicke's encephalopathy

4) To prevent Wernicke's encephalopathy Wernicke's encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

Mr. Stewart is a 62-year-old pt. diagnosed with prostate cancer who underwent surgical removal of the prostate 3 days ago. He lives with his wife at home. The nurse is planning to provide discharge instructions for the pt. What would be the most effective initial question to ask of the pt. and family in determining the approach to discharge instructions? 1. " Mr. Stewart, have you had surgery in the past?" 2. " The doctor has ordered you to go home with a urinary catheter. Tell me how you think you can manage this." 3. " Mrs. Stewart, do you find it difficult to look at your husband's incision? If so, tell me how you feel." 4. " Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

4. " Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

A nurse working in a medicine clinic knows that it is important to recognize cancer survivors who are most at risk for posttreatment symptoms. Which of the following pts. will likely be at greatest risk for posttreatment symptoms? 1. A 50-year-old mother of 3 who was diagnosed with late-stage breast cancer and has HTN 2. A 20-year-old male college student diagnosed with leukemia whose father had lung cancer 3. A 32-year-old Hispanic woman who has been diagnosed with local cervical cancer and receives Medicaid 4. A 72-year-old African American male who had colorectal cancer with surgery, radiation, and a second round of chemotherapy because of failure of initial treatment and has diabetes

4. A 72-year-old African American male who had colorectal cancer with surgery, radiation, and a second round of chemotherapy because of failure of initial treatment and has diabetes

The nurse recognizes which of the following clients is at the greatest risk for dehydration? 1. A 35-year-old client diagnosed with Crohn's disease 2. A 15-year-old client who is following a low-carbohydrate diet 3. A 2-year-old client diagnosed with an allergy to milk proteins 4. A 79-year-old client who has been diagnosed with advanced Alzheimer's disease

4. A 79-year-old client who has been diagnosed with advanced Alzheimer's disease

1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: 1. Rales 2. A bounding pulse 3. Engorged peripheral veins 4. An elevated hematocrit level

4. An elevated hematocrit level

Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

4. Decreased bowel sounds

A client has been hospitalized following a myocardial infarction. The client has an IV line running with multiple drips. The nurse assesses the client's medical record to determine the last time the IV tubing was changed, because the nurse knows that the Centers for Disease Control and Prevention (CDC) recommends that IV tubing be changed: 1. Every shift 2. Daily 3. Every 48 hours 4. Every 72 hours

4. Every 72 hours

A 66-year-old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted on the daily intake and output (I&O)? 1. IV fluids 2. Cream of mushroom soup 3. Gelatin 4. Mashed potatoes

4. Mashed potatoes

Arterial blood gas levels are obtained for the client. If the client's results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances? 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis

4. Metabolic alkalosis

A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

4. Move fluid into the cells

A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should: 1. Administer an antipyretic 2. Begin an infusion of epinephrine 3. Run normal saline through the blood tubing 4. Obtain and send a urine specimen to the laboratory

4. Obtain and send a urine specimen to the laboratory

For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis

The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the client's assessment? 1. Serum potassium 2. Serum sodium 3. Serum magnesium 4. Serum calcium

4. Serum calcium

To successfully assess if a pt. is experiencing cognitive changes as a result of cancer treatment or complications of treatment, which of the following questions by a nurse is likely most relevant? 1. Describe for me your medication schedule 2. How distressed are you feeling right now on a scale of 0 to 10? 3. Tell me about when you first noticed symptoms from your chemotherapy 4. Tell me what you notice differently in your ability to get work done at your office

4. Tell me what you notice differently in your ability to get work done at your office

Ben, a 31-year-old nursing student, is caring for Maria, a 45-year-old Latina woman who is receiving chemotherapy following surgery for breast cancer. Based on the evidence about cultural influences on cancer pts, Ben knows that which factor will likely influence this pt's ability to cope with her cancer? 1. Transportation resources to the oncology clinic 2. Whether the pt's physician is male or female 3. The stigma family members place on cancer 4. The level of social support available to the pt.

4. The level of social support available to the pt.

The term "perceptual disturbance" refers to difficulty accomplishing what task? 1. Formulating words appropriately. 2. Performing purposeful motor movements. 3. Changing one's way of thinking to accommodate new information. 4. The processing of information about one's internal and external environment.

4. The processing of information about one's internal and external environment. Perceptual disturbance refers to an impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way. Changing one's way of thinking to accommodate new information, performing purposeful motor movements, and formulating words appropriately fail to adequately describe the term perceptual disturbance.

Client Needs: Physiological Integrity 19. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

A

Client Needs: Psychosocial Integrity 2. A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

A

Client Needs: Psychosocial Integrity 20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January c. June b. April d. September

A

Client Needs: Psychosocial Integrity 17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

A

b

A desirable short-term goal for the nursing diagnosis of defensive coping, related to biochemical changes as evidenced by aggressive verbal and physical behaviors, would be a. Sleeping soundly for 12 of the next 24 hours b. Making no attempts at self-harm within 12 hours of admission c. Willingly taking prescribed medication as offered by staff within 24 hours of admission d. Demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

A health teaching plan for a patient taking lithium should include instructions to a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

de

A manic patient showed progressive improvement with continued lithium therapy. After successful treatment, the patient is discharged from the hospital. What appropriate suggestions should the nurse make to the patient and his or her family during discharge? Select all that apply. a. Water pills or diuretics will help with lithium side effects. b. You can reduce the lithium dose if there is an excessive weight gain. c. Over-the-counter medications are safe if taken as instructed on the box. d. Schedule regular checkups to test the function of your thyroid and kidney. e. Contact the primary health care provider if there is any excessive vomiting.

ac

A manic patient under hospital supervision became aggressive and injured another patient. The primary health care provider advises that the patient be put in seclusion. What measures should the nurse take while secluding the patient? Select all that apply. a. Keep any instructions to the patient brief. b. Document the patient's behavior every hour. c. Assure the patient that the seclusion is temporary. d. Ensure that no one is with the patient during seclusion. e. Give detailed explanation for the seclusion to the patient.

c

A manic patient with rapid-cycling manic symptoms is treated with carbamazepine. Which adverse effect should the nurse report on chronic administration of the drug? a. Convulsions b. Severe hypotension c. Bone marrow suppression d. Changes in the electroencephalograph

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

b

A nurse caring for a manic patient observes that the patient has persistent gastrointestinal upset. The nurse assumes that the patient is showing advanced signs of lithium toxicity and tests the serum levels of lithium in the patient. What concentration of lithium does the nurse expect to find in the patient's blood serum? a. 0.5 mEq/L b. 1.8 mEq/L c. 2.5 mEq/L d. 3.4 mEq/L

be

A nurse in a pediatric clinic observes that a child has defensive and ineffective coping. Which action done by the child supports the nurse's assumption? Select all that apply. a. The child sleeps for long hours. b. The child has reduced concentration. c. The child consumes larger quantities of food. d. The child doesn't allow others to touch his belongings. e. The child presumes to possess supreme powers.

ace

A nurse is assisting a manic patient in dressing and maintaining basic hygiene tasks. Which nursing interventions are appropriate for the patient in a manic state? Select all that apply. a. Provide step-by-step instructions for dressing. b. Allow the patient to wear whatever he or she chooses. c. Provide simple clothes and hygiene tasks to the patient. d. Warn the patient that seclusion can be used to control behavior. e. Provide repeated reminders to finish tasks if necessary

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B When staff members are exhausted, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for long-term control.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? It will a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: D Some patients diagnosed with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin b. clonidine c. risperidone d. carbamazepine

a

A patient diagnosed with bipolar disorder has taken lithium for 1 year with good results. Today, the patient phones the nurse with these complaints. Which complaint should receive the nurse's priority attention? a. "I've had very bad diarrhea for 3 days." b. "I notice my hand trembling occasionally." c. "In the past 6 months, I have gained 8 pounds." d. "I have been putting a little extra salt on my food."

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication adherence.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Most patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B The patient's behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. Threatening the patient or assembling a show of force is likely to exacerbate the tension

A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, the nurse's first intervention is to a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

b

A patient experiencing mania has not slept for three days and states, "I am not tired. I have so much energy!" What is the best way for the nurse to assure the patient is getting adequate rest? a. Keep patient stimulated during daylight hours. b. Recommend frequent rest periods during the day. c. Suggest the patient remain awake during the day. d. Encourage hot tea at bedtime to promote relaxation

a

A patient is prescribed 300 mg lithium carbonate twice a day. The patient shows symptoms of exhaustion. Which category of drug would help to prevent exhaustion in the patient? a. Benzodiazepines b. Monoamine oxidase inhibitors c. Selective serotonin reuptake inhibitors d. Serotonin-norepinephrine reuptake inhibitors

d

A patient states, "I am possessed by my dead father." What is this kind of thought content called? a. Hallucination b. Loose association c. Tangential speech d. Grandiose delusion

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

a

A patient who is treated with lithium carbonate shows no improvement and often gets agitated and depressed. Which drug would the nurse expect the primary health care provider to prescribe to the patient? a. Valproate b. Phenytoin c. Gabapentin d. Phenobarbital

Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance? -A patient with a minimal urine output of 50 mL/hour -A patient with a minimal urine output of 10 mL/hour -A patient with a minimal urine output of 30ml/hour -A patient with a minimal urine output of 20 ml/hour

A patient with a minimal urine output of 20 ml/hour

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

cd

A patient with bipolar disorder takes lithium. After playing soccer on a hot summer day, the patient complains of nausea, vomiting, diarrhea, and thirst. The patient's hands begin to tremble and the gait becomes unsteady. What is the priority nursing intervention? Select all that apply. a. Administer an antiemetic medication to the patient. b. Collaborate with the health care provider regarding increasing the daily lithium dose. c. Instruct the patient not to take any more lithium until directed by the health care provider. d. Collaborate with the health care provider about drawing a serum lithium level immediately. e. Complete an abnormal involuntary movement scale (AIMS) evaluation on this patient immediately.

ANS: D The patient continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for patients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: C Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care? Select all that apply. A) Increasing oral fluids B) Placement of an oral airway at the bedside C) Monitoring for Chvostek's sign D) Implementing seizure precautions E) Hyperactive reflex assessment F) Observation for muscle weakness

A) Increasing oral fluids F) Observation for muscle weakness

What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? A) Using a lift sheet when repositioning the patient B) Positioning the patient so the heels do not touch the mattress C) Providing small, frequent meals rich in calcium and phosphorus D) Applying pressure for a full 5 minutes after intramuscular injections

A) Using a lift sheet when repositioning the patient

Client Needs: Psychosocial Integrity 3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

A, B, C

Patients with which conditions are at greatest risk for deficient fluid volume? Select all that apply. A. Fever of 103 B. Extensive burns C. Thyroid Crisis D. Water intoxication E. Continuous fistula drainage F. Diabetes Insipidus

A, B, C, E, F

A 50-year-old female confirms chronic alcohol intake. This practice places the patient at risk for cancer in which organs? (Select all that apply.) a. Larynx b. Esophagus c. Liver d. Lung e. Brain f. Breast

A, B, C, F Chronic alcohol consumption is a strong risk factor for colorectal cancer and cancer of the oral cavity, pharynx, hypopharynx, larynx, esophagus, liver, and breast. It is not associated with lung or brain cancer.

Client Needs: Psychosocial Integrity 2. A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F

A patient with hyponatremia would have which gastrointestinal findings upon assessment? Select all that apply. A. Hyperactive bowel sounds on auscultation B. Hard, dark-brown stools C. Hypoactive bowel sounds auscultation D. Frequent watery bowel movements E. Abdominal cramping F. Nausea

A,D,E,F

A 25-year-old female was diagnosed with cervical cancer. History reveals she had many sexual partners, which she indicates is too many to count. Which of the following is most likely to have caused her cancer? a. HPV-16 b. HPV-18 c. HPV-31 d. HPV-45

A. HPV-16, in most countries, accounts for 50% to 60% of cervical cancer cases. HPV-18 accounts for 10% to12% of cervical cancer cases. HPV-31 accounts for 4% to 5% of cervical cancer cases. HPV-45 accounts for 4% to 5% of cervical cancer cases.

A 65-year-old male was recently diagnosed with cancer. He is retired from construction work. Which of the following cancers is he likely to develop secondary to occupational hazards? a. Mesothelioma b. Bladder cancer c. Prostate cancer d. Bone cancer

A. One notable occupational factor is asbestos, which increases the risk of mesothelioma, lung cancer, and possibly others. The cancer secondary to occupational hazards is mesothelioma, not bladder cancer. The cancer secondary to occupational hazards is mesothelioma, not prostate cancer. The cancer secondary to occupational hazards is mesothelioma, not bone cancer.

Chromosome aberrations and mutations in cells that were not directly irradiated are referred to as: a. Bystander effects b. Lethal mutation c. Delayed reproductive death d. Genetic instability

A. The directly irradiated cells also can lead to genetic effects in so-called bystander cells or innocent cells. This is termed bystander effects. Lethal mutations occur when cells cannot reproduce, and this is not related to bystander effects. Lethal mutation and delayed reproductive death are similar phenomenon and are not related to bystander effects. Genetic instability is related to chromosomal instability.

A 25-year-old male nursing student recently learned how diet can alter the chances of developing cancer. He tries to minimize his risks of developing the disease by ordering his steak: a. Rare b. Medium c. Medium-well d. Well done

A. The nursing student should order the steak rare, as the most relevant carcinogens produced by cooking are found in well-done charbroiled beef. The nursing student should order the steak rare, not medium, as the most relevant carcinogens produced by cooking are found in well-done charbroiled beef. The nursing student should order the steak rare, not medium-well, as the most relevant carcinogens produced by cooking are found in well-done charbroiled beef. The nursing student should order the steak rare, not well-done, as the most relevant carcinogens produced by cooking are found in well-done charbroiled beef.

Which of the following compounds has been shown to increase the risk of cancer when used in combination with smoking? a. Alcohol b. Steroids c. Antihistamines d. Hypnotics

A. Tobacco use and alcohol use are known etiologic factors in head and neck cancers. It is alcohol, not steroids, and tobacco that have been identified as etiologic factors in cancer. It is alcohol, not antihistamines, and tobacco that have been identified as etiologic factors in cancer. It is alcohol, not hypnotics, and tobacco that have been identified as etiologic factors in cancer.

When a patient asks what types of cancers are associated with tobacco use, how should the nurse respond? a. Squamous and small cell adenocarcinomas b. Sarcoma and adenoma c. Melanoma and lymphoma d. Basal cell and lipoma

A. Tobacco use is associated with squamous and small cell adenocarcinomas. Tobacco use is associated with squamous and small cell adenocarcinomas, not sarcoma and adenoma. Tobacco use is associated with squamous and small cell adenocarcinomas, not melanoma and lymphoma. Tobacco use is associated with squamous and small cell adenocarcinomas, not basal cell and lipoma.

The nurse assesses a 76-year-old man with chronic myeloid leukemia receiving nilotinib (Tasigna). It is most important for the nurse to ask which question? A. "Have you had a fever?" B. "Have you lost any weight?" C. "Has diarrhea been a problem?" D. "Have you noticed any hair loss?"

A. "Have you had a fever?" An adverse effect of nilotinib is neutropenia. Infection is common in neutropenic patients and is the primary cause of death in cancer patients. Patients should report a temperature of 100.4o F or higher. Other adverse effects of nilotinib are thrombocytopenia, bleeding, nausea, fatigue, elevated lipase level, fever, rash, pruritus, diarrhea, and pneumonia.

Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend? A. A bland, low-fiber diet B. A high-protein, high-calorie diet C. A diet high in fresh fruits and vegetables D. A diet emphasizing whole and organic foods

A. A bland, low-fiber diet Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often benefit from a diet low in seasonings and roughage before the treatment. Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.

The laboratory reports that the cells from the patient's tumor biopsy are Grade II. What should the nurse know about this histologic grading? A. Cells are abnormal and moderately differentiated. B. Cells are very abnormal and poorly differentiated. C. Cells are immature, primitive, and undifferentiated. D. Cells differ slightly from normal cells and are well-differentiated.

A. Cells are abnormal and moderately differentiated. Grade II cells are more abnormal than Grade I and moderately differentiated. Grade I cells differ slightly from normal cells and are well-differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine.

A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. He insists that he is the real Santa Claus. Which of the following nursing interventions should the nurse implement when working with this patient? A. Consistently use the patient's name. B. Point out to the patient why he cannot be Santa Claus. C. Agree that he is Santa Claus so as not to upset him further. D. Provide medication as needed (PRN).

A. Consistently use the patient's name.

The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation (select all that apply)? A. Maintain hope. B. Exhibit a caring attitude. C. Plan realistic long-term goals. D. Give them antianxiety medications. E. Be available to listen to fears and concerns. F. Teach them about all the types of cancer that could be diagnosed.

A. Maintain hope. B. Exhibit a caring attitude. E. Be available to listen to fears and concerns. Maintaining hope, exhibiting a caring attitude, and being available to actively listen to fears and concerns would be the first nursing interventions to use as well as assessing factors affecting coping during the diagnostic period. Providing relief from distressing symptoms for the patient and teaching them about the diagnostic procedures would also be important. Realistic long-term goals and teaching about the type of cancer cannot be done until the cancer is diagnosed. Giving the family antianxiety medications would not be appropriate.

A 50-year-old female patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. What is the most appropriate intervention by the nurse? A. Provide canned food while expressing reasonable doubt. B. Agree with the patient's decision. C. Challenge the patient's delusion. D. Dismiss her fears and insecurities.

A. Provide canned food while expressing reasonable doubt.

The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements? Select all that apply. A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." C. The patient states, "I go to meetings once or twice a week but continue to drink." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately." F. The patient states, "I can quit whenever I want to."

A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately."

Kyle, a 23-year-old patient with schizophrenia, has been admitted to the psychiatric unit for one week. He has begun to take the first- generation antipsychotic haloperidol (Haldol). One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to turn towards you or to respond verbally. You obtain vital signs, which are as follows: BP 170/100, P 110, T 103. What are the priority nursing interventions? Select all that apply. a. Begin to wipe him with a washcloth wet with cold water or alcohol. b. Hold his medication, and contact his provider stat. c. Administer a medication such as benztropine IM to correct his dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Explain that he has anticholinergic toxicity, hold his meds, and give IM physostigmine. f. Hold his medication tonight, and consult his provider after completing medication rounds.

AB

Julia, a 28-year-old diagnosed with schizophrenia, is encouraged to attend groups but stays in her room instead. Staff and peers encourage her participation, but without success. Her hygiene is poor despite encouragement to shower and brush her teeth. She does not seem concerned that others wish she would behave differently. Which is the most likely explanation for Julia's failure to respond to others' efforts to help her behave in a more adaptive fashion? Select all that apply. a. She is displaying avolition. b. She is displaying anergia. c. She is displaying negativism. d. She is exhibiting paranoid delusions. e. She is being resistant or oppositional. f. She is apathetic due to her schizophrenia.

ABF

A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse's best action? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.

ANS A

A patient is not certain whether she and her family should participate in a genetic screening plan. She asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in males more frequently than in females. What is the nurse's best response? a. "The disease tends to show up in males because they do not have a second X chromosome to balance the expression of the gene." b. "One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the gene." c. "Females are known to have more effective DNA repair mechanisms than males, thus negating the damage caused by the recessive gene." d. "Expression of genes from the male's Y chromosome does not occur in females, so they are essentially immune to the effects of the gene."

ANS A

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep

ANS A

A cancer patient's susceptibility to the syndrome of inappropriate antidiuretic hormone (SIADH) can be suspected with which of the following laboratory results? a. Serum potassium of 5.2 mmol/L b. Serum sodium of 120 mmol/L c. Hematocrit of 40% d. Blood urea nitrogen (BUN) of 10 mg/dL

ANS B

A patient with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse's best action? a. Instruct the client to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

ANS B

The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

ANS B

What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? a. Risk for injury related to poor blood clotting b. Fatigue related to decreased cellular oxygenation c. Disturbed body image related to skin color changes d. Imbalanced nutrition, less than body requirements related to anorexia

ANS B

In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.

ANS D

The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

ANS D

While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age

ANS D

29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment

A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as A. a neologism B. clang association C. blocking D. a delusion

ANS: A A neologism is a newly coined word or misuse of an existing word that has meaning only for the client. None of the other options fit this description.

27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 214 (Box 12-5) | Page 221 TOP: Nursing Process: Implementation

9. A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers."

ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

18. Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.

ANS: A Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped.

16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

18. At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: a. codependence. b. assertiveness c. role reversal d. homeostasis.

ANS: A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

ANS: A Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

ANS: A Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

20. In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care.

39. A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

ANS: A Low self-esteem is present when a patient sees himself or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

Which of the following would be assessed as a negative symptom of schizophrenia? A. Anhedonia B. Hostility C. Agitation D. Hallucinations

ANS: A Negative symptoms refer to deficits that characterize schizophrenia. They include the crippling symptoms of affective blunting (lack of facial expression), anergia (lack of energy), anhedonia (inability to experience happiness), avolition (lack of motivation), poverty of content of speech, poverty of speech, and thought blocking

23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

33. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

ANS: A Patients who have ingested LSD respond well to being "talked down" by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

The most common course of schizophrenia is an initial episode followed by what course of events? A. Recurrent acute exacerbations and deterioration B. Recurrent acute exacerbations C. Continuous deterioration D. Complete recovery

ANS: A Schizophrenia is usually a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.

13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 210-211 | Page 215 (Box 12-6) | Page 222 (Case study and Nursing Care Plan 12-1) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

15. When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

28. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine - National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

ANS: A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

40. Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."

ANS: A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.

ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 (Table 12-1) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change.

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

22. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 201-202 | Page 204-205 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

38. A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

ANS: A Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

17.A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing

ANS: A A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can buy some aloe vera gel to use on the area." b. "I will expose the treatment area to a sun lamp daily." c. "I can use ice packs to relieve itching in the treatment area." d. "I will scrub the area with warm water to remove the scales."

ANS: A Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? a. "The cancer involves only the cervix." b. "The cancer cells look almost like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

10.The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3

ANS: A Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.)

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem

A 30-year-old male with HIV is diagnosed with Epstein-Barr virus. After 2 months, the virus is still active. Based upon the Epstein-Barr virus, which of the following cancers is most likely to develop in this patient? a. B-cell lymphoma b. Kaposi sarcoma c. T-cell leukemia d. T-cell lipoma

ANS: A Epstein-Barr virus is associated with B-cell lymphoma. Kaposi sarcoma is associated with HIV. Retroviruses are associated with leukemia. Lipomas are not associated with HIV.

4.The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial

ANS: A Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the immunologic response to tumor cells. b. IL-2 stimulates malignant cells in the resting phase to enter mitosis. c. IL-2 prevents the bone marrow depression caused by chemotherapy. d. IL-2 protects normal cells from the harmful effects of chemotherapy.

ANS: A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? a. Implement suicide precautions. b. Offer high-calorie snacks and fluids frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

ANS: A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

Which of the following indicates a nurse understands a proto-oncogene? A proto-oncogene is best defined as a(n) _____ gene. a. normal b. altered c. inactive d. tumor-suppressor

ANS: A In its normal, nonmutant state, an oncogene is referred to as a proto-oncogene. A proto-oncogene is not an altered gene, an inactive gene, or a tumor-suppressor gene.

27.The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

ANS: A Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375.

A 52-year-old male with hepatitis C recently developed hepatic cancer. Which of the following markers should be increased? a. Alpha-fetoprotein (AFP) b. Catecholamines c. Prostate-specific antigen d. Homovanillic acid

ANS: A Liver and germ cell tumors secrete a protein known as AFP, not catecholamines. Prostate tumors secrete prostate-specific antigen. Homovanillic acid is a catecholamine marker.

One of the biggest challenges facing current nursing practice is a. the number of aging Americans living with chronic disease. b. the number of patients entering into hospice programs. c. the number of cancer patients receiving supportive care. d. reduced length of stay in hospice care.

ANS: A Millions of Americans are living with one or more chronic debilitating diseases, and 7 out of 10 can expect to live with their diseases several years before dying. When coupled with the advancing age of the eight million baby boomers who now qualify for Medicare, this will soon create a huge demand on health care resources and community-based services.

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Temperature 100.2° F (37.9° C) c. Shivering and complaint of chills d. Generalized muscle aches and pains

ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications

6.The nurse is reviewing laboratory results. Which cation will the nurse observe is the mostabundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium

ANS: A Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominantly inside cells and in bone.

During history-taking, a patient tells the nurse that he is addicted to alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a. Stress reaction b. Delerium tremens c. Overdose d. Relapse

ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness. REF: Page 359 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.

The most prominent goal of palliative care is to a. integrate into chronic disease management sooner rather than later. b. enroll the patient into the Medicare Hospice Benefit. c. ensure that the patient has a 6-month prognosis. d. reserve this type of care until the patient is actively dying.

ANS: A The goal of palliative care is to integrate symptom management interventions earlier into the course of chronic disease sooner rather than later. This helps to promote optimal quality of life.

9.Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

ANS: A The infant should be seen first. An infant's proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60.

16.A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal

ANS: A The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance

18.The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

ANS: A The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L values are within normal range.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological dependency. B. The individual is experiencing physical dependency. C. The individual is experiencing substance dependency. D. The individual is experiencing social dependency.

ANS: A The nurse should use the term "psychological dependency" to best describe this client's situation. A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

34.The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

ANS: A The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O. Type O is considered the universal donor. A patient with a mastectomy should have the IV in the other arm. Potassium chloride should be diluted, and it is never given IV push.

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient swims a mile 3 days a week. b. The patient snacks frequently during the day. c. The patient showers everyday with a mild soap. d. The patient has a history of dental caries with amalgam fillings.

ANS: A The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. "Are you having difficulty hearing when I speak?" b. "How can I make this assessment interview easier for you?" c. "I notice you are frowning. Are you feeling annoyed with me?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"

ANS: A The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

What is the effect of telomere caps on cancer cells? a. Repeated divisions b. Clonal distinction c. Limited mitosis d. Mutation abilities

ANS: A The presence of telomere caps gives cancer cells the ability to divide over and over again, thus cancer cells have unlimited mitosis. Telomere caps do not give cells clonal distinction. Mutation capability is a characteristic of cancer cells, but this property is not related to telomeres.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

2.The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport

ANS: A The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration).

38.A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

ANS: A The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.

31.A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

ANS: A The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net fluid volume is equal.

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate? a. "Why don't we talk about the options you have for the care of your children?" b. "I'm sure you have friends that will take the children when you can't care for them." c. "For now you need to concentrate on getting well and not worrying about your children." d. "Many patients with cancer live for a long time, so there is still time to plan for your children."

ANS: A This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's friends will take the children, more assessment information is needed before making plans.

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution.

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

Currently what is understood to be the causation of schizophrenia? A. A combination of inherited and nongenetic factors B. Deficient amounts of the neurotransmitter dopamine C. Excessive amounts of the neurotransmitter serotonin D. Stress related and ineffective stress management skills

ANS: A Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme nongenetic factors (e.g., viral infection, birth injuries, nutritional factors) that can affect the genes governing the brain or directly injure the brain.

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 209-210 (Table 12-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

MULTIPLE RESPONSE 1. Brachytherapy is being used to treat cancer in a patient. What types of cancers respond well to brachytherapy? (select all that apply) a. Prostate b. Cervix c. Head d. Neck e. Lung

ANS: A, B, C, D Radiation sources can be temporarily placed into body cavities through a delivery method termed brachytherapy. Brachytherapy is useful in the treatment of cervical, prostate, and head and neck cancers. It is not used in the treatment of lung cancer. REF: p. 260

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "I need to review the side effects of the medications used in the withdrawal process." D. "I'll need to set boundaries to maintain a therapeutic relationship." E. "I need to take charge when dealing with clients diagnosed with substance disorders."

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients.

A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

Select all that apply. A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with anti-psychotic medications. The CCSE assesses cognitive function.

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: A, C, D, E The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.

2. A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention? Select all that apply. a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations. The nurse can participate in role playing and help the patient evaluate the usefulness of new strategies. The nurse can also provide valuable information about the physiologic changes that can be expected and the ways in which to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work done.

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.

In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use e. January birth date f. Physical abuse by the father

ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

44. Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

ANS: A, C, F Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.

43. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

ANS: A, C, F The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation

ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of A. acute dystonia B. tardive dyskinesia C. cholestastic jaundice D. psuedoparkinsonism

ANS: B An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia. This tool is not used to assess or monitor any of the other options.

25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

ANS: B Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse? A. Schedule the client to attend group therapy that includes those who have relapsed. B. Teach the client and family about behaviors associated with relapse. C. Remind the client of the need to return for periodic blood draws to minimize the risk for relapse. D. Help the client and family adapt to the stigma of chronic mental illness and periodic relapses.

ANS: B By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted. None of the other options are effective interventions when considering relapse prevention.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

ANS: B Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 206-207 | Page 212-213 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 206 (Table 12-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.

24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 218-219 (Table 12-5) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

37. A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

ANS: B Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 209-210 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

Nico, a 22-year-old patient, is diagnosed with schizophrenia. Which of the following symptoms would alert a provider to a possible diagnosis of schizophrenia in a 22-year-old male client? A. Excessive sleeping with disturbing dreams B. Hearing voices telling him to hurt his roommate C. Withdrawal from college because of failing grades D. Chaotic and dysfunctional relationships with his family and peers

ANS: B People diagnosed with schizophrenia all have at least one psychotic symptom such as hallucinations, delusional thinking, or disorganized speech. The other options do not describe schizophrenia but could be caused by a number of problems

1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 | Page 213-215 (Box 12-4)

19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d."The voices talk only at night when I'm trying to sleep."

ANS: B The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 207 | Page 212-213 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility.

35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

ANS: B The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 205-206 (Table 12-1) | Page 213-215 (Box 12-4)

3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 210 (Table 12-3) | Page 213 (Box 12-4)

27. An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances

ANS: B Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of "Call my doctor" if the patient's cognition and judgment are intact. If the patient responds, "I would stop eating" or "I would just wait and see what happened," the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a. document the other worker's assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker's impression by contacting the patient's significant other. d. discuss the worker's impression with the patient during the assessment interview.

ANS: B Assessment should include data obtained from both the primary and reliable secondary sources. The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.

The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight

ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.

7.The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

ANS: B Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L.

Palliative care used in the management of a patient with symptomatic chronic obstructive pulmonary disease (COPD) is an example of which of the following? a. Palliative care is used when the patient is beginning to die. b. Palliative care is used to help manage the symptoms that often accompany COPD. c. Hospice nurses must be involved to provide palliative care in a cancer patient. d. Patient must be enrolled into the Medicare Hospice Benefit to receive palliative care.

ANS: B Palliation is the relief or management of symptoms without providing a cure. To palliate is to reduce the severity of an actual or potential life-threatening condition or a chronic debilitating illness. Palliation is not equivalent to cure, but it is the reduction of undesirable effects resulting from the incurable disease or condition.

28.A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

ANS: B Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.

25.A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

ANS: B Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

ANS: B Prescriptive privileges are granted to master's-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. Note that this question was also offered for Chapter 1.

Which entry in the medical record best meets the requirement for problem-oriented charting? a. "A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV." c. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

ANS: B Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

"QSEN" refers to: a. Qualitative Standardized Excellence in Nursing b. Quality and Safety Education for Nurses c. Quantitative Effectiveness in Nursing d. Quick Standards Essential for Nurses

ANS: B QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

13.Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

ANS: B Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3-. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3- is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L is respiratory acidosis.

11.A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: B Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client's response to another drug.

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.

ANS: B The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.

The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer? a. Fresh fruit salad b. Roasted chicken c. Whole wheat toast d. Cream of potato soup

ANS: B To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided.

A 25-year-old male develops a tumor of the breast glandular tissue. What type of tumor will be documented on the chart? a. Carcinoma b. Adenocarcinoma c. Sarcoma d. Lymphoma

ANS: B Tumors that arise from or form ductal or glandular structures are named adenocarcinomas. Cancers arising in epithelial tissue are called carcinomas; mesenchymal tissue (including connective tissue, muscle, and bone) usually have the suffix sarcoma; lymphatic tissue are called lymphomas.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Cream cheese bagel d. Fresh strawberries and bananas

ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein.

Select all that apply. A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? a. Tell the patient that medication will help this type of thinking. b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. d. Tell the patient, "Your ideas are not realistic." e. Reassure the patient, "You are safe here."

ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the patient's statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient.

Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups

ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance. REF: Page 362 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, C, F The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, E The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

45. A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

ANS: B, E, F The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.

A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her son faces for extrapyramidal side effects (EPSs)? A. All antipsychotic medications have an equal chance of producing EPSs. B. Newer antipsychotic medications have a higher risk for EPSs. C. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. D. Advise the mother to ask the provider to change the medication to clozapine instead of risperidone.

ANS: C EPSs are typical of first-generation antipsychotics and include: acute dystonia, akathisia, and psuedoparkinsonism. Risperidone is a newer, atypical antipsychotic. All newer antipsychotic medications have a lower incidence of EPSs than older, traditional antipsychotics. The other responses are untrue. There is no reason to advise a medication change at this time.

30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.

ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

ANS: C Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 207 | Page 209-210 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome c. Pseudoparkinsonism b. Hepatocellular effects d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

15. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 206-207 | Page 212-213 (Box 12-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

ANS: C The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

27. Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

ANS: C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

A client diagnosed with disorganized schizophrenia would have greatest difficulty with the nursing intervention? A. Interacting with a neutral attitude B. Using concrete language C. Giving multistep directions D. Providing nutritional supplements

ANS: C The thought processes of the client with disorganized schizophrenia are severely disordered, and severe perceptual problems are present, making it extremely difficult for the client to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times. Ineffective organizational skills would not be a primary factor considering the other options.

7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

ANS: C This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine

ANS: C This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patient's symptoms.

A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. Which response should the nurse provide to this client statement? A. "You are safe here in the hospital; nothing bad will happen to you." B. "The voices are wrong about the hospital food. It is not contaminated." C. "I understand that the voices are very real to you, but I do not hear them." D. "Other people are eating the food, and nothing is happening to them."

ANS: C This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing. This is the only option that provides such support.

The nurse is planning long-term goals for a 17-year-old male client recently diagnosed with schizophrenia. Which statement should serve as the basis for the goal-setting process? A. If treated quickly following diagnosis, schizophrenia can be cured. B. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. C. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. D. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.

ANS: C Unfortunately, in most cases, schizophrenia does not respond fully to available treatments; it leaves residual symptoms and causes varying degrees of dysfunction or disability. The other options are all untrue of schizophrenia.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant, and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life.

A patient asks when adjuvant chemotherapy is used. How should the nurse respond? Adjuvant chemotherapy treatment is used: a. as the primary treatment. b. before radiation therapy. c. after surgical removal of a tumor. d. in cancer with little risk of metastasis.

ANS: C Adjuvant chemotherapy is given after surgical excision of a cancer with the goal of eliminating micrometastases. Adjuvant chemotherapy is not given as the primary treatment or before radiation therapy. Adjuvant chemotherapy is indicated in the treatment of individuals with metastasis. REF: p. 261

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate? a. "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b. "Yes, your parents may find out what you say, but it is important that they know about your problems." c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d. "It sounds as though you are not really ready to work on your problems and make changes."

ANS: C Adolescents are very concerned with confidentiality. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

22.The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

ANS: C An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. 35-year-old patient who has wet desquamation associated with abdominal radiation b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old patient who received neck radiation and has blood oozing from the neck d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.

A 30-year-old female is diagnosed with cancer. Testing reveals that the cancer cells have spread to local lymph nodes. A nurse realizes this cancer would be documented as stage: a. 1. b. 2. c. 3. d. 4.

ANS: C Cancer that has spread to regional structures, such as lymph nodes, is stage 3. Cancer confined to the organ of origin is stage 1. Cancer that is locally invasive is stage 2. Cancer that has spread to distant sites, such as a liver cancer spreading to lung or a prostate cancer spreading to bone, is stage 4.

A nurse is discussing preinvasive epithelial tumors of glandular or squamous cell origin. What is the nurse describing? a. Tumor in differentiation b. Dysplastic c. Cancer in situ d. Cancer beyond (meta) situ

ANS: C Early-stage growths that are localized to the epithelium and have not invaded are called cancer in situ. Cancer in situ is early-stage growth and not a tumor in differentiation but is more mature growth. Dysplastic cells do not define cancer in situ.

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics also may be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred.

Which genetic change causes alterations in only one or a few nucleotide bases? a. Insertions b. Deletions c. Point mutations d. Amplification mutations

ANS: C Genetic changes may occur by both mutational and epigenetic mechanisms. Mutation generally means an alteration in the DNA sequence affecting expression or function of a gene. Mutations include small-scale changes in DNA, such as point mutations, which are the alteration of one or a few nucleotide base pairs. The process involved with insertions, deletions, or amplification mutations is different.

26.The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.

ANS: C Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.

36.A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

ANS: C Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

ANS: C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"? a. Assessment b. Analysis c. Implementation d. Evaluation

ANS: C Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

Which information indicates a nurse understands characteristics of malignant tumors? a. Grows slowly b. Has a well-defined capsule c. Cells vary in size and shape d. Is well differentiated

ANS: C Malignant tumors have cells that vary in both size and shape, and they grow rapidly. They are poorly differentiated and not encapsulated.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease

29.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min

ANS: C Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min.

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: more than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

ANS: C Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt.

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

The nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's risk of lung cancer, which action by the nurse is best? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Discuss the risks associated with cigarettes during every patient encounter. d. Teach the patient about the use of annual chest x-rays for lung cancer screening.

ANS: C Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. A tumor must be at least 0.5 cm large before it is detectable by current screening methods and may already have metastasized by that time. Oncofetal antigens such as CEA may be used to monitor therapy or detect tumor reoccurrence, but are not helpful in screening for cancer. The seven warning signs of cancer are actually associated with fairly advanced disease

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions, but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patient's safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal. REF: Page 361 OBJ: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

Which statement indicates the patient has a correct understanding of metastasis? The most common route of metastasis is through the blood vessels and: a. lung tissue. b. body cavities. c. lymphatics. d. connective tissues.

ANS: C The most common route of metastasis is through the lymphatics, not lung tissue, body cavities, or connective tissues. REF: p. 253

Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

42.While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

ANS: C The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient.

The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement? a. "I go to meetings once a day and still drink." b. "My family and friends have been avoiding me lately." c. "I don't have a problem with alcohol. I can quit anytime I want to." d. "I know it will be hard to quit, but I am willing to try."

ANS: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them. REF: Page 360 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment

ANS: C The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? a. Add strained baby meats to foods such as casseroles. b. Teach the patient about foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add extra spice to enhance the flavor of foods that are served.

ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition

The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse's next priority? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating in self-help groups. c. Notify provider to obtain order for oxazepam and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychologic consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs. REF: Page 361 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

23.A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.

ANS: C Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.

A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient two ounces of a citrus fruit beverage during treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

3.The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

ANS: C Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inflammation or malnutrition. Concentration pressure is not a nursing term.

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) b. Ziprasidone (Geodon) c. Olanzapine (Zyprexa) d. Aripiprazole (Abilify)

ANS: D Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-219 (Table 12-5) TOP: Nursing Process: Planning

A client has reached the stable plateau phase of schizophrenia. What is the appropriate clinical planning focus for this client? A. Safety and crisis intervention B. Acute symptom stabilization C. Stress and vulnerability assessment D. Social, vocational, and self-care skills

ANS: D During the stable plateau phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community. All the other options are appropriate planning focuses for the acute phase of schizophrenia.

2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.

ANS: D Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.

34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.

ANS: D Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

29. Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse.

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 211-215 (Box 12-6) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

41. Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia

ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid abuse.

31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 207-209 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

25. A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

11. A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial

ANS: D Minimizing one's drinking is a form of denial of alcoholism. The patient's own description indicates that "social drinking" is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system.

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)

ANS: D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."

ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary.

31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "pentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

ANS: D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.

ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

12. A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"

ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." The nurse's best response would be: A. "You are having problems with your speech. You need to try harder to be clear." B. "You are confused. I will take you to your room to rest a while." C. "I will get you a prn medication for agitation." D. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

ANS: D The guidelines that are useful in communicating with a patient with disorganized or bizarre speech are to place the difficulty in understanding on yourself, not the patient, and look for themes that may be helpful in interpreting what the patient wants to say. Telling the patient he needs to try harder to be clearer is unrealistic since the patient would be unable do this. The other options are not useful in communicating with this patient and attempting to find common themes.

8. A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

21. Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiologic stability.

ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

30. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 204 | Page 212-213 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

32. An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.

ANS: D The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

23. A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

29. A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be: A. "You are safe here. This is a locked unit, and no one can get in." B. "I do not believe I understand the word volmers. Tell me more about them." C. Why do you think someone or something is going to harm you?" D. "It must be frightening to think something is going to harm you."

ANS: D This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option A gives global reassurance. Option B encourages elaboration about the delusion. Option C asks for information that the client will likely be unable to answer.

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205 | Page 213-214 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

14. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 211 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Tumor growth will be controlled by the removal of malignant tissue. d. Tumor size will decrease and this will improve the effects of other therapy.

ANS: D A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.

33.A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

ANS: D A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended.

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider? a. Poor oral intake b. Frequent loose stools c. Complaints of nausea and vomiting d. Increase in carcinoembryonic antigen (CEA)

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. The other patient findings are common adverse effects of chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply the ordered anesthetic gel to oral lesions before meals.

ANS: D Because the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient.

Which information should the nurse include when teaching about angiogenic factors? In cancer, angiogenic factors stimulate: a. release of growth factors. b. tumor regression. c. apoptosis. d. new blood vessel growth.

ANS: D Cancers can secrete multiple factors that stimulate new blood vessel growth called angiogenesis, not release of growth factors or tumor regression. Apoptosis is cell death. REF: pp. 245-246

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Complaints of nausea and anorexia c. Oral temperature of 100.6° F (38.1° C) d. Crackles heard at the lower scapular border

ANS: D Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2.

40.The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

ANS: D Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances.

What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

Nursing behaviors associated with the implementation phase of nursing process are concerned with: a. participating in mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

ANS: D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

Palliative care does everything except a. promote comfort. b. reduce disease exacerbations. c. decrease acute care hospital admissions. d. promote a cure for chronic disease.

ANS: D Palliation is the reduction of symptoms without elimination of the cause. Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure.

Today most patients are living for several years before dying with multiple chronic conditions, such as COPD, congestive heart failure, diabetes, and obesity. These concomitant diseases contribute to multiple symptoms that interfere with the patient's quality of life. What type of care would you consider for this patient? a. End-of-life care b. Supportive care c. Comfort care d. Palliative care

ANS: D Palliative care provides optimal symptom management in the setting of multiple chronic conditions. The relief and management of these symptoms help to promote improved quality of life for the patient and help to maintain physical functioning.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior chest.

ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer and/or are receiving chemotherapy

A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. Behavior which is most consistent with this stage of relapse would include a. expressing feelings of anxiety. b. expressing feelings of being overwhelmed. c. bizarre behaviors and speech. d. presence of hallucinations.

ANS: D Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Examine interventions for possible revision of the target date.

ANS: D Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

32.A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.

ANS: D The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued.

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Mucositis d. Hematuria

ANS: D The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy.

A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient's friend? a. "Does he take amphetamines or uppers?" b. "Has he ever used LSD?" c. "Have you two been out of the country in the last 2 days?" d. "Is he using any opioids such as heroin?"

ANS: D The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated. REF: Page 364 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care? a. Compromised family coping related to disruption in lifestyle b. Impaired home maintenance related to perceived role changes c. Risk for caregiver role strain related to burdens of caregiving responsibilities d. Dysfunctional family processes related to effect of illness on family members

ANS: D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.

A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

ANS: D The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit of 30% b. Platelets of 95,000/µL c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/µL

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

Which client statement indicates a knowledge deficit related to substance abuse? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

37.A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.

ANS: D The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautions

ANS: D The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." Patient will: a. show improved use of language. b. demonstrate improved social skills. c. become more independent in decision making. d. select and participate in one group activity per day.

ANS: D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone. b. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.

ANS: D The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room or incision required.

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

ANS: D The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. "I can always trust my family." b. "It seems like I always have bad luck." c. "You never know who will turn against you." d. "I hear evil voices that tell me to do bad things."

ANS: D The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patient's chief symptom.

A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

41.Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

ANS: D This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.

The nurse is caring for a 32-year-old woman diagnosed with schizophrenia. The woman tells the nurse, "The news on TV last night was all about me." This is an example of what kind of thought content? a. Thought insertion b. Thought broadcasting c. Magical thinking d. Ideas of reference

ANS: D Thought insertion is a belief that others are placing thoughts in one's mind. Thought broadcasting is a belief that others can read one's thoughts. Magical thinking is a belief that one's thoughts can make an event happen. Ideas of reference refers to a person's belief that external events, like the evening news, have a direct personal reference to oneself.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that "chemo-brain" is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short- or long-term. There is no urgent need to report common chemotherapy side effects to the provider.

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a. Record the patient's answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the patient's rights. d. Obtain important information from the family member.

ANS: D When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question.

3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply) a. administration of naloxone (Narcan). b. vitamin B12 and folate supplements. c. restoring nutritional integrity. d. management of heart rate. e. environmental safety.

ANS: D, E Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

3. While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

ANS: D, E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Too brief to be of value d. Excessively wordy e. Meets standards

ANS: E This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

1.A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient's intake. Record your answer as a whole number. _____ mL

ANS:460The patient's fluid intake is 250 mL of feeding, 60 mL of water (30 mL before and after), and 150 blood: . Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, soup), drinks (e.g., water, coffee, juice), or receives through nasogastric or jejunostomy feeding tubes. IV fluids (continuous infusions and intermittent IV piggybacks) and blood components also are sources of intake. Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes.DIF:Apply (application)REF:949 | 951 | 955OBJ:Describe how to measure and record fluid intake and output

Which type of dementia has a clear genetic link? Alcohol-induced dementia Multi-infarct dementia Creutzfeldt-Jakob disease Alzheimer's disease

Alzheimer's disease Family members of people with Alzheimer's disease have a higher risk of developing the disease than does the general population.REF: 436

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? 1. risk of dehydration 2. risk of kidney damage 3. risk of stroke 4. risk of bleeding

Answer: 1 Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality. Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.

The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing? 1. intracellular fluid deficit 2. intracellular fluid overload 3. extracellular fluid deficit 4. interstitial fluid deficit

Answer: 1 Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.

A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following? 1. the body's natural compensatory mechanisms 2. pharmacological effects of a diuretic 3. effects of rapidly infused intravenous fluids 4. cardiac failure

Answer: 1 Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart. Rationale 2: A diuretic would cause further fluid loss, & is contraindicated. Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output. Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate? 1. Risk for Imbalanced Fluid Volume 2. Excess Fluid Volume 3. Imbalanced Nutrition 4. Ineffective Tissue Perfusion

Answer: 1 Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium. Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition does not apply. Rationale 4: Ineffective Tissue Perfusion does not apply

A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's primary healthcare provider with which of the following 24-hour urine output volumes? 1. 600 mL 2. 750 mL 3. 1000 mL 4. 1200 mL

Answer: 1 Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).

An elderly postoperative pt is demonstrating lethargy, confusion, & a resp rate of 8 per minute. The nurse sees that the last dose of pain medication administered via a pt controlled anesthesia (PCA) pump was within 30 minutes. Which of the following acid-base disorders might this pt be experiencing? 1. respiratory acidosis 2. metabolic acidosis 3. respiratory alkalosis 4. metabolic alkalosis

Answer: 1 Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. Rationale 2: The pt condition being described is respiratory not metabolic in nature. Rationale 3: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. Rationale 4: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. The pt condition being described is respiratory not metabolic in nature.

An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia? 1. hypotension, warmth, & sweating 2. nausea & vomiting 3. hyperreflexia 4. excessive urination

Answer: 1 Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating. Rationale 2: Lower levels of magnesium are associated with nausea & vomiting. Rationale 3: Lower levels of magnesium are associated & hyperreflexia. Rationale 4: Urinary changes are not noted.

A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem? 1. corticosteroid 2. thiazide diuretic 3. narcotic 4. muscle relaxer

Answer: 1 Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics. Rationale 2: Excessive sodium is lost with the use of thiazide diuretics. Rationale 3: Narcotics do not typically affect electrolyte balance. Rationale 4: Muscle relaxants do not typically affect electrolyte balance.

A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an imbalance of which of the following electrolytes? 1. calcium 2. sodium 3. potassium 4. chloride

Answer: 1 Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves & muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, & the ionized serum calcium level falls.

A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? 1. hyperkalemia 2. hypokalemia 3. hypercalcemia 4. hypocalcemia

Answer: 1 Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes. Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics. Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.

A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt? 1. Digoxin toxicity may occur. 2. A higher dose of digoxin (Lanoxin) may be needed. 3. A diuretic may be needed. 4. Fluid volume deficit may occur.

Answer: 1 Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure. Rationale 2: More digoxin is not needed. Rationale 3: A diuretic may cause further fluid loss. Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.

The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure? 1. The pt breathes rapidly to eliminate carbon dioxide. 2. The pt will retain bicarbonate in excess of normal. 3. The pH will decrease from the present value. 4. The pt's oxygen saturation level will improve.

Answer: 1 Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis. Rationale 2: Because compensation must be performed by the system other than the affected system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value. Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.

When caring for a group of pts, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis? 1. bulimia 2. dialysis 3. venous stasis ulcer 4. COPD

Answer: 1 Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A pt with bulimia may engage in vomiting or indiscriminate use of diuretics. Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic acidosis. Rationale 3: A venous stasis ulcer does not result in an acid-base disorder. Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? 1. seizure 2. infection 3. neutropenic 4. high-risk fall

Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included. Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia. Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia. Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.

An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do? 1. Wear support hose. 2. Keep legs in a dependent position. 3. Avoid wearing shoes while in the home. 4. Try to sleep without extra pillows.

Answer: 1 Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, & resting in a recliner or bed with extra pillows. Rationale 2: The pt should elevate the legs. Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them. Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.

When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? 1. The kidneys retain bicarbonate. 2. The kidneys excrete bicarbonate. 3. The lungs will retain carbon dioxide. 4. The lungs will excrete carbon dioxide.

Answer: 1 Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis

The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide.

Answer: 1 Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution. Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia. Rationale 3: Kayexalate is used in pts with hyperkalemia. Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.

When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt? 1. other electrolyte disturbances 2. hypertension 3. visual disturbances 4. drug toxicity

Answer: 1 Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension. Rationale 3: Visual disturbances do not occur with hypocalcemia. Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.

The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate which initial intervention to correct this problem? 1. Encourage the pt to breathe in & out slowly into a paper bag. 2. Immediately administer oxygen via a mask & monitor oxygen saturation. 3. Prepare to start an intravenous fluid bolus using isotonic fluids. 4. Anticipate the administration of intravenous sodium bicarbonate.

Answer: 1 Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels to normal, correcting the cause of the problem. Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given. Intravenous fluids would not be the initial intervention. Rationale 3: Not enough information is given to determine the need for intravenous fluids. Rationale 4: Bicarbonate would be contraindicated as the pH is already high.

A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care? 1. Request a dietitian consult for selecting foods high in phosphorous. 2. Provide aluminum hydroxide antacids as prescribed. 3. Instruct pt to avoid poultry, peanuts, & seeds. 4. Instruct to avoid the intake of sodium phosphate.

Answer: 1 Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause & promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans & peas, eggs, fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains. Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet. Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.

The pt who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this pt? Select all that apply. 1. bananas 2. seafood 3. white rice 4. lean red meat 5. chocolate

Answer: 1,2,5 Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this pt should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, & chocolate. White rice & lean red meat are not included.

The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood pH? Select all that apply. 1. renal 2. cardiac 3. buffers 4. respiratory

Answer: 1,3,4 Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system. Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the body's pH. Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system. Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.

An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? 1. hypernatremia 2. hyponatremia 3. fluid volume excess 4. hyperkalemia

Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia. Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level. Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit. Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.

The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are very deep. The metabolic disorder this pt might be demonstrating is which of the following? 1. hypernatremia 2. increasing carbon dioxide in the blood 3. hypertension 4. pain

Answer: 2 Rationale 1: Hypernatremia is associated with profuse sweating & diarrhea. Rationale 2: Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain. As a result, both the rate & depth of respiration increase. The increased rate & depth of lung ventilation eliminates carbon dioxide from the body, & carbonic acid levels fall, which brings the pH to a more normal range. Rationale 3: The respiratory rate in a pt exhibiting hypertension is not altered. Rationale 4: Pain may be manifested in rapid, shallow respirations.

A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered 1. directly into the venous access line. 2. mixed in the prescribed intravenous fluid. 3. via a rectal suppository. 4. via intramuscular injection.

Answer: 2 Rationale 1: Never administer undiluted potassium directly into a vein. Rationale 2: The intravenous route is the recommended route for diluted potassium. Rationale 3: The nurse should administer diluted potassium into the pt's intravenous line. Rationale 4: The nurse should administer diluted potassium into the pt's intravenous line.

A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is 1. to sustain respiratory function. 2. to help regulate acid-base balance. 3. to keep a vein open. 4. to encourage urine output.

Answer: 2 Rationale 1: Potassium does not sustain respiratory function. Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity. Rationale 3: Intravenous fluids are used to keep venous access not potassium. Rationale 4: Urinary output is impacted by fluid intake not potassium.

A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances? 1. hypokalemia 2. hypernatremia 3. carbon dioxide 4. magnesium

Answer: 2 Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels. Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt. Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.

The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this pt? Select all that apply. 1. tachycardia 2. weakness 3. dysrhythmias 4. Kussmaul's respirations 5. cold, clammy skin

Answer: 2,3,4 Rationale: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations. Rationale: These ABG results, coupled with the pt's recent diagnosis of diabetes mellitus & history of vomiting would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.

The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply. 1. Administer the dose IV push over 3 minutes. 2. Monitor the injection site for redness. 3. Add the ordered dose to the IV hanging. 4. Use an infusion controller for the IV. 5. Monitor fluid intake & output.

Answer: 2,4,5

The blood gases of a pt with an acid-base disorder show a blood pH outside of normal limits. The nurse realizes that this pt is 1. fully compensated. 2. demonstrating anaerobic metabolism. 3. partially compensated. 4. in need of intravenous fluids

Answer: 3 Rationale 1: If the pH is restored to within normal limits, the disorder is said to be fully compensated. Rationale 2: Anaerobic metabolism results when the body's cells become hypoxic. Rationale 3: If the pH is restored to within normal limits, the disorder is said to be fully compensated. When these changes are reflected in arterial blood gas (ABG) values but the pH remains outside normal limits, the disorder is said to be partially compensated. Rationale 4: Although the pt may be in need of intravenous fluids, this is not the most correct or definitive answer.

An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated? 1. Ask the physician for an order to begin intravenous fluid replacement. 2. Ask the physician to order a chest x-ray. 3. Assess the urine for osmolality. 4. Ask the physician for an order for a brain scan.

Answer: 3 Rationale 1: It is inappropriate to seek an IV at this stage. Rationale 2: There is no indication the pt is experiencing pulmonary complications thus a cheat x-ray is not indicated. Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration & hyperosmolality. The nurse should check the pt's urine for osmolality as a 1st step in determining hydration status before other detailed & invasive testing is done. Rationale 4: There is no data to support the need for a brain scan.

A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt? 1. poor skin turgor 2. decreased urine output 3. distended neck veins 4. concentrated hemoglobin & hematocrit levels

Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit. Rationale 2: Decreased urine output is associated with fluid volume deficit. Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema. Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.

A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing? 1. pulmonary edema 2. atrial dysrhythmias 3. cerebral bleeding 4. stress fractures

Answer: 3 Rationale 1: Pulmonary edema is not associated with dehydration. Rationale 2: Atrial dysrhythmias are not a factor for this pt. Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding. Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this pt? 1. Assist the pt to maintain a standing position for several minutes. 2. This pt should be on bed rest. 3. Assist the pt to move into different positions in stages. 4. Contact physical therapy to provide a walker.

Answer: 3 Rationale 1: The pt should avoid prolonged standing. Rationale 2: Bed rest can promote skin breakdown. Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include assisting & teaching the pt how to move from one position to another in stages. Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in this situation.

A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this pt? 1. Drink one glass of red wine per day. 2. Avoid the sun. 3. Milk & milk-based products will ensure an adequate calcium intake. 4. Red meat is the protein source of choice.

Answer: 3 Rationale 1: This pt should avoid alcohol. Rationale 2: This pt can benefit from sun exposure. Rationale 3: This pt is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk & milk-based products. Rationale 4: Protein monitoring is not indicated.

A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this pt is demonstrating is which of the following? 1. respiratory acidosis 2. metabolic acidosis 3. respiratory alkalosis 4. metabolic alkalosis

Answer: 4 Rationale 1& 2: Respiratory acidosis & metabolic acidosis are both consistent with pH less than 7.35. Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 & a PaCO2 of less than 35 mmHG. It is caused by respiratory related conditions. Rationale 4: Arterial blood gases (ABGs) show a pH greater than 7.45 & bicarbonate level greater than 26 mEq/L when the pt is in metabolic alkalosis.

An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding these symptoms? 1. "Have you stopped taking your digoxin medication?" 2. "When was the last time you had a bowel movement?" 3. "Were you doing any unusual physical activity?" 4. "Are you using a salt substitute?"

Answer: 4 Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this question. Rationale 2: The pt's bowel habits are not of concern at this time. Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with physical exertion. Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be used. Advise pts who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.

A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous fluids will most likely be which of the following? 1. dextrose 5% & water 2. dextrose 5% & ? normal saline 3. dextrose 5% & ? normal saline 4. normal saline

Answer: 4 Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the hypercalcemia. Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.

The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder? 1. calcium 2. magnesium 3. phosphorous 4. potassium

Answer: 4 Rationale 1: This pt will be less likely to develop a calcium imbalance. Rationale 2: This pt will be less likely to develop a magnesium imbalance. Rationale 3: This pt will be less likely to develop a phosphorous imbalance. Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? A. Onset of action is from 1 to 3 weeks or longer. B. They tend to be more effective for men. C. Recent memory impairment is commonly observed. D. They often cause the client to have diurnal variation.

Answer: A A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. None of the other options provide correct information regarding antidepressant medications

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? A. "Let's look at what you just said, that you can 'never do anything right.'" B. "Tell me what things you think you are not able to do correctly." C. "Is this part of the reason you think no one likes you?" D. "That is the most unrealistic thing I have ever heard."

Answer: A Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate. None of the other options examines the underlying cause of the feeling

What statement about the comorbidity of depression is accurate? A. Depression most often exists in an individual as a single entity. B. Depression is commonly seen in individuals with medical disorders. C. Substance abuse and depression are seldom seen as comorbid disorders. D. Depression may coexist with other disorders but is rarely seen with schizophrenia.

Answer: B Depression commonly accompanies medical disorders. The other options are false statements.

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" The nurse's response is based on what fact concerning hostility? A. The client is getting better and is able to be assertive. B. The client may be at high risk for self-harm. C. The client is probably experiencing transference. D. The client may be angry at someone else and projecting that anger to staff.

Answer: B Overt hostility is highly correlated with suicide; therefore the patient may be considered high risk, and appropriate precautions should be taken. The other responses are incorrect with no evidence to support them

Which statement would best show acceptance of a depressed, mute client? A. "I will be spending time with you each day to try to improve your mood." B. "I would like to sit with you for 15 minutes now and again this afternoon." C. "Each day we will spend time together to talk about things that are bothering you." D. "It is important for you to share your thoughts with someone who can help you evaluate your thinking."

Answer: B Spending time with the client without making demands is a good way to show acceptance. While not inappropriate, the other options are less accepting

What is the major reason for hospitalization of the depressed patient? A. Inability to go to work B. Suicidal Ideation C. Loss of appetite D. Psychomotor agitation

Answer: B Suicidal thoughts are a major reason for hospitalization for patients with major depression. It is imperative to intervene with such patients to keep them safe from self-harm. The other options describe symptoms of major depression but aren't by themselves the major reason for hospitalization

When the clinician mentions that a client has anhedonia, the nurse can expect that the client will demonstrate what behavior? A. Poor retention of recent events B. A weight loss from anorexia C. No pleasure from previously enjoyed activities D. Difficulty with tasks requiring fine motor skills

Answer: C Anhedonia is the only term that suggests the lack of ability to experience pleasure.

Beck's cognitive theory suggests that the etiology of depression is related to what factor? A. Sleep abnormalities B. Serotonin circuit dysfunction C. Negative processing of information D. Belief that one has no control over outcomes

Answer: C Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self-deprecating view of oneself; (2) a pessimistic view of the world; and (3) the belief that negative reinforcement will continue. None of the other options are related to this theory.

Assessment of the thought processes of a client diagnosed with depression is most likely to reveal what characteristic? A. Good memory and concentration B. Delusions of persecution C. Self-deprecatory ideation D. Sexual preoccupation

Answer: C Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world. This characteristic is not associated with any of the other options.

A 38-year-old patient is admitted with major depression. Which statement made by the patient alerts the nurse to a common accompaniment to depression? A. "I still pray and read my Bible every day." B. "My mother wants to move in with me, but I want to independent." C. "I still feel bad about my sister dying of cancer. I should have done more for her!" D. "I've heard others say that depression is a sign of weakness."

Answer: C Guilt is a common accompaniment to depression. A person may ruminate over present or past failings. Praying and reading the Bible describes a coping mechanism; the other responses do not describe a common accompaniment to depression.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? A. Self-blame B. Catatonia C. Learned helplessness D. Discounting positive attributes

Answer: C Learned helplessness results in depression when the client feels no control over the outcome of a situation. None of the other options demonstrate these feelings

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with which term? A. Senile dementia B. Hypertensive crisis C. Psychomotor agitation D. Central serotonin syndrome

Answer: C These behaviors describe the psychomotor agitation sometimes seen in clients with the agitated type of depression. None of the other options are associated so directly with these behaviors.

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? A. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." B. "I will not take any over-the-counter medication while on the fluoxetine." C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." D. "I will report increased thirst and urination to my provider."

Answer: C This describes symptoms of serotonin syndrome, a life-threatening complication of SRRI medication. The other options are incorrect because the patient should be wearing sunscreen to avoid sunburn, may take over-the-counter medications if sanctioned by the provider, and would not have been educated to report increased thirst and urination as a side effect of fluoxetine.

Which response by a 15-year-old boy demonstrates a common symptom observed in patients diagnosed with major depressive disorder? A. "I'm so restless. I can't seem to sit still." B. "I spend most of my time studying. I have to get into a good college." C. "I'm not trying to diet, but I've lost about 5 pounds in the past 5 months." D. "I go to sleep around 11 pm but I'm always up by 3 am."

Answer: D

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? A. Amtriptyline is very expensive, so the patient may have to buy fewer at a time. B. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness. C. The health care provider wants to see whether any side effects occur within the first week of administration D. Amtriptyline is lethal in overdose.

Answer: D Amitriptyline is a tricyclic antidepressant (TCA); these drugs are known to be lethal in smaller doses than other antidepressants. Because the patient had a plan of overdose, the best course of action is to give a small prescription requiring her to visit her provider's office more often for monitoring of suicidal ideation and plan. Tricyclics are not known to be expensive. Antidepressant therapy usually takes several weeks to produce full results, so the patient would not be evaluated after only 1 week. Side effects are always a consideration but not the most important consideration with TCAs.

Dysthymia cannot be diagnosed unless it has existed for what period of time? A. At least 3 months B. At least 6 months C. At least 1 year D. At least 2 years

Answer: D Dysthymia is persistent depressive disorder and is a chronic condition that by definition has to have existed for longer than 2 years in adults and 1 year in children and adolescents.

Client Needs: Physiological Integrity 10. A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

B

Client Needs: Physiological Integrity 29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

B

Client Needs: Physiological Integrity 13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

B

Client Needs: Physiological Integrity 14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

B

Client Needs: Physiological Integrity 23. During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat c. Affect labile; mood euphoric b. Affect flat; mood depressed d. Affect and mood are incongruent.

B

Client Needs: Psychosocial Integrity 3. A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." c. "I like the shirt you are wearing." b. "You're wearing a new shirt." d. "You must be feeling better today."

B

Client Needs: Psychosocial Integrity 7. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a. dysthymia. c. euphoria. b. anhedonia. d. anergia.

B

Mark, a 32-year-old patient with schizophrenia, is found in a closet with an empty 2-liter bottle of cola taken from the staff refrigerator. The bottle had been full. The patient has also been drinking more from the hallway water cooler and taking drinks from his peers' dinner trays. Recently, staff has noticed an increase in auditory hallucinations and the onset of confusion. Which response is most appropriate? a. Place Mark on every-15-minute checks to identify any further deterioration. b. Restrict his access to fluids, and evaluate for water intoxication via daily weights. c. Attempt to distract the patient from excess fluid intake and other bizarre behavior. d. Request an increase in antipsychotic medication, owing to the worsening of his psychosis.

B

When an aide asks why carcinomas rarely occur in childhood, how should the nurse respond? (Select all that apply.) a. Carcinomas cannot develop in an immunosuppressed environment. b. Carcinomas need a long time from exposure to occurrence. c. Carcinomas are due to environmental exposures. d. Carcinomas occur primarily in secondary sexual organs. e. Carcinomas are mesodermal.

B, C Carcinomas rarely occur in children because these cancers most commonly result from environmental carcinogens and require a long period from exposure to the appearance of the carcinoma.

Which factors affect the amount and distribution of body fluids?Select all that apply. A. Race B. Age C. Gender D. Height E. Body Fat F. Weight

B, C, E, F

The nurse is caring for a patient with a severe hypocalcemia. What safety measures does the nurse put in place for this patient? Select all that apply. A. Encourage the patient to use a cane when ambulating B. Turn on a bed alarm when the patient is in bed. C. Obtain an order for Ambient to ensure the patient sleeps at night. D. Place the patient on a low bed. E. Ensure the top side rails are up when the patient is in bed. F. Raise all four side rails.

B, D, E

The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for the patient, what does the nurse expect to find on assessment? A. No changes, because respiratory system is not involved. B. Increased respiratory rate, because the body perceives hypovolemia as hypoxia C. Hypoventilation, because the respiratory system is trying to compensate for low ph D. Normal respiratory rate, but a decrease oxygen saturation.

B.

A water test recently revealed arsenic levels above 200 g/L. Which of the following cancers would be most likely to develop in those who consistently drank the water? a. Liver b. Skin c. Colon d. Kidney

B. Evidence indicates an increased risk of bladder, skin, and lung cancers following consumption of water with high levels of arsenic. Evidence indicates an increased risk of bladder, skin, and lung cancers, not liver, following consumption of water with high levels of arsenic. Evidence indicates an increased risk of bladder, skin, and lung cancers, not colon, following consumption of water with high levels of arsenic. Evidence indicates an increased risk of bladder, skin, and lung cancers, not kidneys, following consumption of water with high levels of arsenic.

A patient asks why indoor pollution is worse than outdoor pollution. How should the nurse respond? Indoor pollution is considered worse than outdoor pollution because of cigarette smoke and: a. Fireplace wood smoke b. Radon c. Benzene d. Chlorine

B. Indoor pollution is related to cigarette smoke and radon. Indoor pollution is related to cigarette smoke and radon, not fireplace smoke. Indoor pollution is related to cigarette smoke and radon, not benzene. Indoor pollution is related to cigarette smoke and radon, not chlorine.

When an oncologist is teaching about how radiation induces genomic instability, which of the following should the oncologist discuss? a. Increasing hypersensitivity b. Facilitating new mutations c. Promoting cell death d. Enhancing mitosis

B. Radiation induces genomic instability because it facilitates new mutations. Radiation does not promote hypersensitivity. Radiation may promote cell death, but this is not its role in inducing genomic instability. Radiation does not enhance mitosis but halts it.

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. "Restrict oral fluids for 24 hours and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."

B. "Have someone bring you to the clinic immediately."

The nurse is teaching a wellness class to a group of women at their workplace. The nurse knows that which woman is at highest risk for developing cancer? A. A woman who obtains regular cancer screenings and consumes a high-fiber diet B. A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years C. A woman who exercises five times every week and does not consume alcoholic beverages D. A woman who limits fat consumption and has regular mammography and Pap screenings

B. A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years Cancer prevention and early detection are associated with the following behaviors: limited alcohol use; regular physical activity; maintaining a normal body weight; obtaining regular cancer screenings; avoiding cigarette smoking and other tobacco use; using sunscreen with SPF 15 or higher; and practicing healthy dietary habits (e.g., reduced fat and increased fruits and vegetables).

While watching television, a 28-year-old male patient appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which of the following nursing interventions would be appropriate in dealing with this patient? Select all that apply. A. In a firm voice, tell the patient to stop this behavior. B. Acknowledge the presence of the hallucinations. C. Instruct other team members to ignore the patient's behavior. D. Reassure the patient that he is not in any danger. E. Give simple commands in a calm voice.

B. Acknowledge the presence of the hallucinations. D. Reassure the patient that he is not in any danger. E. Give simple commands in a calm voice.

What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development? A. Teach the patient to exercise daily. B. Teach the patient promoting factors to avoid. C. Tell the patient to have the cancer surgically removed now. D. Teach the patient which vitamins will improve the immune system.

B. Teach the patient promoting factors to avoid. The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of cancer development. Daily exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible without a critical mass of cells, and this advice would not be the nurse's role.

A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? Select all that apply. A. The patient states, "I don't think my body will recover from the drinking." B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected by family life." D. The patient states, "I am glad that I did not drag others into my drinking." E. The patient states, "I have been attending one meeting a day."

B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected by family life." E. The patient states, "I have been attending one meeting a day."

The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? A. Ask the patient if the site hurts. B. Turn off the chemotherapy infusion. C. Call the ordering health care provider. D. Administer sterile saline to the reddened area.

B. Turn off the chemotherapy infusion. Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation the infusion should first be stopped. Then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline.

Client Needs: Psychosocial Integrity 18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

C

Client Needs: Safe, Effective Care Environment 6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

C

Jordan is a 21-year-old who was recently diagnosed with schizophrenia. He has had to drop out of college as the positive symptoms of his disease have made it impossible for him to pursue his dream of being an architect. He presents to the emergency department with flat affect, depressed mood, and having auditory hallucinations telling him he is "no good to anyone anymore." Which of the following statement is true regarding depression and schizophrenia? a. Anxiety and substance abuse are comorbid with schizophrenia, but not depression or dysphoria. b. It is important to assess for depression in patients with schizophrenia, but suicide rarely occurs in this population of clients. c. Assessing for depression and suicidal ideation in patients with schizophrenia is important since almost half of people with schizophrenia will attempt suicide. d. The medications that will be given to control the positive symptoms of schizophrenia, such as auditory hallucinations, will alleviate any depressive symptoms a patient may have.

C

A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? A) "Your cancer is widespread and requires more than the usual amount of radiation treatment." B) "The cost of larger doses of radiation for a shorter period of time is justified by the results." C) "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." D) "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."

C) "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time."

Which of the following findings during a female breast examination should the nurse report as suspicious for breast cancer? A) Multiple nodules of round, lumpy, tender tissue in both breasts B) A single soft, mobile, lobular nodule that is nontender C) A poorly defined, firm lump that is nontender and nonmovable D) A single soft lump that is well-defined and tender

C) A poorly defined, firm lump that is nontender and nonmovable

Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C, D, E

The role of physical activity in the prevention of colon cancer is identified by which of the following? a. It increases fluid loss leading to thirst and increased fluid intake, hydrating the colon. b. It increases blood supply thereby increasing oxygen to the colon. c. It increases gut motility thereby decreasing the time the bowel is exposed to mutagens. d. It increases the secretion of hydrochloric acid thereby killing mutants.

C. Physical activity increases gut motility thereby decreasing exposure to mutagens. Physical activity increases fluid loss, but this does not prevent mutagens. Physical activity increases blood supply to the colon, but this does not prevent mutagens. Physical activity does not increase hydrochloric acid.

The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says he still has pain in his leg and it is getting worse. What assessment question should the nurse ask the patient to determine treatment measures for this patient's pain? A. "Where is the pain?" B. "Is the pain getting worse?" C. "What does the pain feel like?" D. "Do you use medications to relieve the pain?"

C. "What does the pain feel like?" The unlicensed assistive personnel (UAP) told the nurse the location of the patient's pain and the worsening of pain (pattern). Asking about the quality of the pain will help in planning further treatment. The nurse should already know if the patient is using medication to relieve the pain or can check the patient's medication administration record to see if analgesics have been administered. The intensity of pain using a pain scale should also be assessed.

The female patient is having whole brain radiation for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? A. "When your hair grows back it will be patchy." B. "Don't use your curling iron and that will slow down the loss." C. "You can get a wig now to match your hair so you will not look different." D. "You should contact "Look Good, Feel Better" to figure out what to do about this."

C. "You can get a wig now to match your hair so you will not look different." Hair loss with radiation is usually permanent. The best response by the nurse is to suggest getting a wig before she loses her hair so she will not look or feel so different. When hair grows back after chemotherapy, it is frequently a different color or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss but will not answer the patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is avoiding the patient's immediate concern.

Which cellular dysfunction in the process of cancer development allows defective cell proliferation? A. Proto-oncogenes B. Cell differentiation C. Dynamic equilibrium D. Activation of oncogenes

C. Dynamic equilibrium Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal cell degeneration or death or when the body has a physiologic need for more cells. Cell differentiation is the orderly process that progresses a cell from a state of immaturity to a state of differentiated maturity. Mutations that alter the expression of proto-oncogenes can activate them to function as oncogenes, which are tumor-inducing genes and alter their differentiation.

A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? A. It is in situ. B. It has metastasized. C. It has spread locally. D. It has spread extensively.

C. It has spread locally. Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes metastasis.

A 64-year-old male patient who is receiving radiation to the head and neck as treatment for an invasive malignant tumor complains of mouth sores and pain. Which intervention should the nurse add to this patient's plan of care? A. Weigh the patient every month to monitor for weight loss. B. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide. C. Provide high-protein and high-calorie, soft foods every 2 hours. D. Apply palifermin (Kepivance) liberally to the affected oral mucosa.

C. Provide high-protein and high-calorie, soft foods every 2 hours. A patient with stomatitis should have soft, nonirritating foods offered frequently. The diet should be high in protein and high in calories. Saline or water should be used to cleanse the mouth (not hydrogen peroxide). Palifermin is administered intravenously as a growth factor to stimulate cells on the surface layer of the mouth to grow. Patients should be weighed at least twice each week to monitor for weight loss.

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: a. insert a nasogastric tube (NG) as ordered. b. administer acetaminophen as ordered. c. instruct the client to breathe into a paper bag. d. administer antibiotics as ordered.

C. instruct the client to breathe into a paper bag

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a. clonazepam b. risperidone c. lamotrigine d. aripiprazole

37. Paula is attending an education class on addictive disorders. She suspects that her husband may be abusing opiates since he has been taking pills given to him by his brother and she knows the brother had been taking oxycodone for back pain. She asks the nurse how to interpret her husband's behaviors. Which of the following observations by Paula are consistent with opioid intoxication? Select all that apply. 1) "Sometimes he seems euphoric and other times he acts like he doesn't care about anything." 2) "Last night he went out without a coat on and it was 15 degrees outside." 3) "While we were talking at dinner his speech was rapid and he seemed hyperalert to everything in the environment." 4) "He's been having trouble remembering things." 5) "Sometimes it looks like his pupils are very small."

Correct 1: One manifestation of opioid intoxication is an initial period of euphoria followed by apathy, which is indicated by her statement that "sometimes he acts like he doesn't care about anything." Correct 2: Going outside without a coat in subfreezing weather could be inferred as impaired judgment, which is consistent with opioid intoxication. Feedback 3: Rapid speech and hypervigilance are more consistent with stimulant intoxication. In opioid intoxication one would expect to see mental cloudiness. Correct 4: Impairment in attention and memory is consistent with opioid intoxication. Correct 5: Paula is describing pupillary constriction, which is consistent with opioid intoxication.

40. Which issues influence an individual's predisposition to substance-related disorders? Select all that apply. 1) Genetic history 2) Fixation at the oral stage of psychosexual development 3) Punitive ego 4) Personality traits 5) Behavior modeling

Correct 1: Research has indicated that an apparent hereditary factor is involved in the development of substance-use disorders. This is especially evident with alcoholism. Correct 2: Theories of psychosexual development state that anxiety in people fixated at the oral stage may be reduced by their consumption of substances such as alcohol. Feedback 3: A psychodynamic approach to the etiology of substance abuse focuses on a punitive superego, not ego. According to psychodynamic theory, individuals with punitive superegos turn to alcohol to diminish unconscious anxiety. Correct 4: Certain personality traits, such as low self-esteem, depression, and passivity, are thought to increase a tendency toward addictive behavior. Correct 5: Studies have shown that children and adolescents are more likely to use substances if they have parents who provide a model for substance use.

41. Paul, a 65-year-old Caucasian, is being seen at the health clinic for hypertension and has a history of alcohol use disorder. Which of the following observations by the nurse are consistent with physical complications associated with chronic alcohol use disorders? Select all that apply. 1) His skin is yellow. ) He has a butterfly-shaped rash on his cheeks and nose. 3) His abdomen is distended. 4) He is coughing up blood. 5) He complains of acute pain in his left eye.

Correct 1: Yellowish skin is evidence of jaundice, which is secondary to cirrhosis of the liver. Cirrhosis of the liver is a common manifestation of end-stage alcoholic liver disease. Feedback 2: Although facial flushing is a common manifestation in chronic alcohol use disorders, a distinctly butterfly-shaped rash may be indicative of other autoimmune conditions such as lupus erythematosis. Further assessment is warranted. Correct 3: Abdominal distention can be a manifestation of alcoholic hepatitis, cirrhosis of the liver, and pancreatitis, all of which are complications of alcohol use disorder. Further assessment is warranted. Correct 4: Coughing up blood may be evidence of several complications of alcoholism, including esophageal varices, which can culminate in potentially fatal hemorrhage. Further assessment is warranted to evaluate for these as well as other potential causes of coughing up blood. Feedback 5: A complaint of pain or pressure in or behind one's eyes is not directly associated with alcoholism but suggests a potentially emergent concern that requires further assessment.

An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes that this pt is at risk for developing 1. dehydration. 2. over-hydration. 3. fecal incontinence. 4. a stroke.

Correct Answer: 1 Rationale 1: Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or who are confused, depressed, tube-fed, on bed rest, or taking medications (such as sedatives, tranquilizers, diuretics, & laxatives), are at greatest risk for fluid volume imbalance. Rationale 2: There is inadequate evidence to support the risk of over-hydration. Rationale 3: There is inadequate evidence to support the risk of fecal incontinence. Rationale 4: There is inadequate evidence to support the risk of a stroke.

Which pts are at risk for the development of hypercalcemia? Select all that apply. 1. the pt with a malignancy 2. the pt taking lithium 3. the pt who uses sunscreen to excess 4. the pt with hyperparathyroidism 5. the pt who overuses antacids

Correct Answer: 1,2,4,5 Rationale 1: Pts with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy. Rationale 2: Lithium & overuse of antacids can result in hypercalcemia. Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys. Rationale 3: The pt who uses sunscreen to excess is more likely to have a vitamin D deficiency which would result in hypocalcemia. Rationale 4: Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys. Rationale 5: Lithium & overuse of antacids can result in hypercalcemia.

A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for which of the following electrolyte imbalances? 1. hypercalcemia 2. hypophosphatemia 3. hypernatremia 4. hypermagnesemia

Correct Answer: 2 Rationale 1: Pts who experience burns are not at an increased risk for developing increased blood calcium levels. Rationale 2: Causes of hypophosphatemia include stress responses & extensive burns. Rationale 3: Pts who experience burns are not at an increased risk for developing increased blood sodium levels. Rationale 4: Pts who experience burns are not at an increased risk for developing increased blood magnesium levels.

Chapter 14: Depressive Disorders MULTIPLE CHOICE 1. A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

D

Client Needs: Physiological Integrity 26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed c. Smiling inappropriately b. Staring at the nurse d. Eyes pointed downward

D

Client Needs: Physiological Integrity 9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth c. Nasal congestion b. Blurred vision d. Urinary retention

D

Client Needs: Physiological Integrity 15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

D

Client Needs: Psychosocial Integrity 11. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. c. interest and pleasure. b. over-involvement. d. ineffectiveness and frustration.

D

Client Needs: Psychosocial Integrity 22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice c. Hot tea b. Orange juice d. Milk

D

Client Needs: Psychosocial Integrity 24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

D

Which statement indicates the patient has a good understanding of cancer risk factors? The most important environmental risk factor for cancer is exposure to: a. Ultraviolet (UV) radiation b. Radon c. Estrogen d. Cigarette smoke

D. Cigarette smoking is carcinogenic and remains the most important cause of cancer. UV radiation is an important risk factor, but cigarette smoking remains the most important cause of cancer. Radon plays a role as a risk factor for cancer, but cigarette smoking remains the most important cause of cancer. Estrogen plays a role in the risk factors of cancer, but cigarette smoking remains the most important cause of cancer.

When an oncologist is discussing the degree to which an organisms development is contingent on its environment, which of the following is the oncologist explaining? a. Transgenerational inheritance b. Epigenetics c. Histone modification d. Developmental plasticity

D. Developmental plasticity is the degree to which an organisms development is contingent on its environment. Transgenerational inheritance is the heritable transmission to future generations of environmentally caused phenotypes. Epigenetics is the role of genes in development and disease. Histone modifications are changes in genetic acetylation.

Which of the following patients would be at greatest risk for basal cell carcinoma? a. Dark complexion, light eyes, underweight b. Light complexion, dark eyes, overweight c. Medium complexion, light eyes, smoker d. Light complexion, light eyes, fair hair

D. Individuals at risk for basal cell carcinoma are light complected and have light eyes and fair hair. Individuals at risk for basal cell carcinoma are light complected and have light eyes and fair hair. Individuals at risk for basal cell carcinoma are light complected and have light eyes and fair hair. Individuals at risk for basal cell carcinoma are light complected and have light eyes and fair hair.

A nurse recalls physical activity was shown to reduce the risk of which of the following types of cancer? a. Prostate b. Lung c. Bone d. Colon

D. Physical activity reduces the risk for breast and colon cancers. Physical activity reduces the risk for breast and colon cancers, but not prostate. Physical activity reduces the risk for breast and colon cancers, but not lung. Physical activity reduces the risk for breast and colon cancers, but not bone.

The nurse is caring for an 18-year-old female patient with acute lymphocytic leukemia who is scheduled to receive hematopoietic stem cell transplantation (HSCT). Which statement, if made by the patient, indicates a correct understanding of the procedure? A. "After the transplant I will feel better and can go home in 5 to 7 days." B. "I understand the transplant procedure has no dangerous side effects." C. "My brother will be a 100% match for the cells used during the transplant." D. "Before the transplant I will have chemotherapy and possibly full body radiation."

D. "Before the transplant I will have chemotherapy and possibly full body radiation." Hematopoietic stem cell transplantation (HSCT) requires eradication of diseased or cancer cells. This is accomplished by administering higher-than-usual dosages of chemotherapy with or without radiation therapy. A relative such as a brother would not be a perfect match with human leukocyte antigens; only identical twins are an exact match. HSCT is an intensive procedure with adverse effects and possible death. HSCT recipients can expect a 2- to 4-week hospitalization after the transplant.

Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? A. Firm-bristle toothbrush B. Hydrogen peroxide rinse C. Alcohol-based mouthwash D. 1 tsp salt in 1 L water mouth rinse

D. 1 tsp salt in 1 L water mouth rinse A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash are not used because they would damage the oral tissue.

The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be most appropriate for the nurse to use to increase the patient's nutritional intake? A. Increase intake of liquids at mealtime to stimulate the appetite. B. Serve three large meals per day plus snacks between each meal. C. Avoid the use of liquid protein supplements to encourage eating at mealtime. D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be helpful.

The patient has been diagnosed with non-small cell lung cancer. Which type of targeted therapy will most likely be used for this patient to suppress cell proliferation and promote programmed tumor cell death? A. Proteasome inhibitors B. BCR-ABL tyrosine kinase inhibitors C. CD20 monoclonal antibodies (MoAb) D. Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TK)

D. Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TK) Targeted therapies are more selective for specific molecular targets. Thus they are able to kill cancer cells with less damage to normal cells than with chemotherapy. Epidermal growth factor receptor (EGFR) is a transmembrane molecule that works through activation of intracellular tyrosine kinase (TK) to suppress cell proliferation and promote apoptosis of non-small cell lung cancer and some colorectal, head and neck, and metastatic breast cancers. Proteasome inhibitors promote accumulation of proteins that promote tumor cell death for multiple myeloma. BCR-ABL tyrosine kinase inhibitors target specific oncogenes for chronic myeloid leukemia and some GI stromal tumors. CD20 monoclonal antibodies (MoAb) bind with CD20 antigen causing cytotoxicity in non-Hodgkin's lymphoma and chronic lymphocytic leukemia.

A 70-year-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? A. Weight gain of 2 lb B. Urine specific gravity of 1.015 C. Blood urea nitrogen of 20 mg/dL D. Serum sodium level of 118 mEq/L

D. Serum sodium level of 118 mEq/L Lung cancer cells are able to manufacture and release antidiuretic hormone (ADH) with resultant water retention and hyponatremia. Hyponatremia (serum sodium levels less than 135 mEq/L) may lead to central nervous system symptoms such as confusion, seizures, coma, and death. A weight gain may be due to fluid retention. The urine specific gravity and blood urea nitrogen are normal.

The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? A. The medications the patient is taking B. The nutritional supplements that will help the patient C. How much time is needed to provide the patient's care D. The time the nurse spends at what distance from the patient

D. The time the nurse spends at what distance from the patient The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.

Elaine is a 62-year-old patient who is recovering from a urinary tract infection during which she was hospitalized with delirium. She is following up with her primary care provider 4 weeks after being discharged. Based on research regarding possible postdelirium complications, what are important areas for the provider to assess at this time? Sleeping habits Sexual functioning Symptoms of posttraumatic stress Depression and level of cognition

Depression and level of cognition Although delirium is usually a short-term condition, it may have long-term consequences. In patients with preexisting cognitive impairment, there is an acceleration of cognitive decline. Although there are reports of long-term cognitive impairment (in the absence of preexisting cognitive impairment) and functional decline following delirium, results of studies have been inconsistent. An association also exists with depression after delirium. Although a holistic examination would assess sleep, this is not the area that research has found to be problematic. A holistic examination would include sexual functioning, but it is not the priority at this time. Posttraumatic stress symptoms have been seen in younger patients who experienced delirium while hospitalized.Cognitive Level: Analyze (Analysis)Nursing Process: AssessmentNCLEX: Psychosocial IntegrityText page: 432

Fill in the blank. The period during which a cancer pt. goes into remission following the basic, rigorous course of chemotherapy and enters a phase of watchful waiting is called ___________

Extended survival

46. Pamela has sought treatment for ongoing substance use disorder. She asks the nurse what treatment options are available to help her combat this problem. Which of these options would be accurate for the nurse to include in patient education? Select all that apply. 1) ECT 2) Self-help groups 3) Deterrent therapy 4) Substitution pharmacotherapy 5) Vitamin supplements

Feedback 1: ECT is primarily indicated for the treatment of depression. There is no evidence of its benefit in preventing relapse in substance use disorders. Correct 2: Self-help groups such as Alcoholics Anonymous are commonly recommended as a treatment option for substance use disorders. Correct 3: Deterrent therapy, such as Antabuse to deter alcohol use, is a recognized option for some substance use disorders. Correct 4: Substitution therapy, such as methadone for heroin users, is a recognized option for some substance use disorders. Feedback 5: Vitamin supplements are beneficial in reversing nutritional deficiencies in alcoholism and other substance use disorders but do not combat the problem of substance use disorder itself.

44. Janice is a nurse whose husband is in rehab for alcohol use disorder. While attending a family group, Janice makes several statements about their relationship. Which of these statements would suggest Janice is exhibiting codependent behavior? Select all that apply. 1) "My husband has to accept responsibility for his behavior and the consequences of his drinking." 2) "I know I shouldn't go out drinking with him, but I'm afraid he'll leave me if I don't." 3) "My father was the same way and I learned its better just to keep your mouth shut so you don't get hit." 4) "If he didn't have me monitoring his every move he'd probably be dead already." 5) "I need to make sure I'm protecting myself and my children."

Feedback 1: This statement is an example of healthy boundaries rather than codependent behavior. Correct 2: People-pleasing, fear of abandonment, and neediness, as evidenced in this statement, are all characteristic codependent behaviors. Correct 3: The sense of helplessness and a history of abuse or neglect as a child are consistent with codependency. Correct 4: This statement suggests an unrealistic need to be in control and may also suggest that Janice's self-worth is rooted in her need to be needed. Both of these are evidence of codependency. Feedback 5: Janice's expression of concern for her own safety and her clear identification of her responsibilities as a parent are examples of healthy rather than codependent behaviors.

What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? (Select all that apply.) -Hematocrit level of greater than 47% -BUN: serum creatinine ratio of greater than 12.1 -Urine specific gravity of 1.027 -Urine osmolality of greater than 450 mOsm/kg -Urine positive for blood

Hematocrit level of greater than 47% Urine specific gravity of 1.027 Urine osmolality of greater than 450 mOsm/kg

Based on current research, which of the following patients is most likely to develop dementia? Karen, who works as an office manager in a high-stress environment Milo, who is a former boxer and is now a trainer Lilly, who works in a factory where asbestos is found Justin, who is a bartender in a dark underground club/bar

Milo, who is a former boxer and is now a trainer Brain injury and trauma are associated with a greater risk of developing Alzheimer's disease and other dementias. People who suffer repeated head trauma, such as boxers and football players, may be at greater risk. The other options do not specifically represent known risk.Cognitive Level: Apply (Application)Nursing Process: DiagnosisNCLEX: Psychosocial IntegrityText page: 438

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

NS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 210 (Table 12-3) | Page 219-220 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

The calcium concentration in the blood is regulated by which mechanism? -Parathyroid hormone (PTH) -Thyroid hormone (TH) -Adrenal gland -Androgens

Parathyroid hormone (PTH)

Claire is a student nurse working with Carl, an 82-year-old patient with dementia. She finds herself frustrated at times by not knowing how best to care for or communicate with Carl. Which of the following statements she could make to Carl illustrates best care practice? Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day." Positive regard implies respect. It is the ability to view another person as being worthy of caring about and as someone who has strengths. The attitude of unconditional positive regard is the nurse's single most effective tool in caring for people with dementia. It induces people to cooperate with care and increases family members' satisfaction with care. Although the patient may not be able to verbalize plans for his day, this response conveys belief that the patient has something to offer and treats him with respect. It also shows that the nurse wants to care for the patient and conveys commitment to the relationship. Limit-setting may be necessary at times; however it is not the most effective care tool. The other responses are nontherapeutic.Cognitive Level: Apply (Application)Nursing Process: ImplementationNCLEX: Psychosocial IntegrityText page: 442

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? -Sodium -Potassium -Calcium -Magnesium

Sodium

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

The exact cause of bipolar disorder has not been determined; however, for most patients a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

b

The nurse can expect a patient demonstrating typical manic behavior to be attired in clothing that is a. Ill-fitted and ragged b. Colorful and outlandish c. Dark-colored and modest d. Compulsively neat and clean

c

The nurse cares for a patient in the acute phase of bipolar disorder who has mania. This patient annoys other patients, loudly engages in power struggles with staff, and gives orders to the housekeeping employees about how to clean. Which nursing diagnosis is most applicable? a. Defensive coping b. Ineffective coping c. Impaired social interaction d. Impaired verbal communication

c

The nurse is reviewing the medical records of several patients receiving therapy for manic disorders. Which medication has a rare, potentially life-threatening rash? a. Lithium b. Valproate c. Lamotrigine d. Carbamazepine

cdef

The nurse is teaching a patient and the patient's family about lithium therapy. Which instructions will the nurse include? Select all that apply. a. "Restrict the sodium in your diet." b. "Take lithium on an empty stomach." c. "Take lithium with meals to avoid an upset stomach." d. "Lithium is a mood stabilizer that helps prevent relapse." e. "Maintain a consistent fluid intake of 1,500-3,000 mL/day." f. "You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating."

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It is most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

The plan of care for a patient in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: B Evidence of genetic transmission is supported by lifetime prevalence statistics. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

This nursing diagnosis applies to a patient experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.

Trousseau's sign

Which event would a client with early stage 4 Alzheimer's disease have greatest difficulty remembering? His or her high school graduation The births of his or her children The story of a teenage escapade What he or she ate for breakfast

What he or she ate for breakfast Initially, recent memory is impaired, and remote memory remains intact.REF: 440; Table 23-3

bcd

What information regarding lithium carbonate is true? Select all that apply. a. It is effective for patients with a history of rapid cycling. b. It demonstrates effectiveness in the treatment of bipolar I. c. Indefinite maintenance dosing is required for many patients. d. Manic behaviors generally show improvement in 10 to 21 days. e. Associated hypersexual behavior is well managed with the medication.

abcd

What intervention will help minimize staff-splitting by a manic patient? Select all that apply. a. Set reasonable limits on patient behavior. b. Regularly self-reflect for possible countertransference. c. Consistently reenforce consequences for inappropriate behavior. d. Schedule frequent staff meetings to discuss problematic behavior. e. Identify one staff member who will work exclusively with the patient

bc

What should the nurse monitor in bipolar disorder patients who have been administered divalproex sodium? Select all that apply. a. Skin rashes b. Liver function c. Platelet count d. Blood pressure

a

When a hyperactive manic patient expresses the intent to strike another patient, the initial nursing intervention would be to a. Set verbal limits b. Initiate physical confrontation c. Question the patient's motive d. Prepare the patient for seclusion

ANS:B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

a

Which action should the nurse take when managing a hospitalized patient experiencing acute mania? a. Encouraging frequent naps b. Advising the patient to avoid frequent toilet visits c. Giving the patient well-cooked three-course meals d. Allowing the patient to dress and groom unassisted

d

Which antianxiety medication should be prescribed to patients with acute mania? a. Citalopram (Celexa) b. Propranolol (Inderal) c. Labetalol (Normodyne) d. Clonazepam (Klonopin)

a

Which behavior is important to include for the patient and the family to recognize possible signs of impending mania? a. Decreased sleep b. Increased appetite c. Decreased social interaction d. Increased attention to body functions

acdef

Which behaviors describe the symptoms of the manic phase of bipolar disorder? Select all that apply. a. Distractibility b. Low self-esteem c. Racing thoughts d. Excessive energy e. Pressured speech f. Purposeless movement g. Fatigue and increased sleep h. Withdrawal from environment

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

c

Which food should be incorporated in the diet of patients with bipolar disorder that would also help in mood regulation? a. Cereals b. Chocolates c. Cod liver oil d. Milk products

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

Which nursing diagnosis would most likely apply to a patient diagnosed with major depressive disorder as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

c

Which patient is the best candidate for electroconvulsive therapy (ECT)? a. Patient with mania controlled on lithium therapy b. Patient with schizophrenia refusing medications c. Patient with bipolar depression displaying catatonia d. Patient with an altered level of consciousness (LOC)

acde

Which patient statement supports the diagnosis of mania? Select all that apply. a. "I really don't need much sleep; two hours a night is enough." b. "I really enjoy cooking and eating all sorts of expensive foods." c. "My mother says this outfit is way too sexy but I like it and wear it all the time." d. "I've telephoned everyone I know and talked for hours; my husband will be mad." e. "My family is really upset with me but it's just because they're jealous of all I do."

d

Which patients can be safely prescribed lithium therapy to treat bipolar disorder? a. Patients with renal diseases b. Patients with thyroid disorder c. Patients with myasthenia gravis d. Patients with erectile dysfunction

c

Which principle should the nurse use when communicating with a patient experiencing an elated mood and euphoria? a. Use abstract concepts. b. Give detailed explanations. c. Use a calm, firm approach. d. Encourage frequent self-disclosure.

a

Which room placement would be best for a patient experiencing a manic episode? a. A single room near the nurses' station b. A single room near the unit activities area c. A shared room with a patient with dementia d. A shared room away from the unit entrance

c

Which side effects of lithium can be expected at therapeutic levels? a. Nausea and thirst b. Ataxia and hypotension c. Fine hand tremor and polyuria d. Coarse hand tremor and gastrointestinal upset

abd

Which statement concerning seclusion should be included in the patient's medical record? Select all that apply. a. Patient placed in seclusion at 1330. b. Patient was threatening to "kill anyone who comes near me." c. Attempts to deescalate patient's agitation were unsuccessful. d. Patient's vital signs are monitored and recorded every 15 minutes. e. Staff discussed future interventions to help minimize patient's potential for aggression.

abde

Which statement regarding bipolar I is true? Select all that apply. a. The median age for onset is 18 years. b. The disorder tends to begin with a depressive episode. c. The disorder is more common among women than men. d. Severe postpartum depression increases the risk for developing the disorder. e. The episodes tend to increase in number and severity during the course of the illness.

ANS: A, B, D, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the patient is at risk to omit medications

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.) a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Supervise medication administration. e. Monitor the patient's sleep patterns.

d

Which symptom may be seen in patients with bipolar II disorder (hypomania)? a. Hallucinations b. Disturbed thoughts c. Impaired social functioning d. Hyperactivity and high energy

A newborn male is born with heart failure. Three weeks later he receives a heart transplant. Which of the following is he at the highest risk for developing? a. Leukemia b. Liver cancer c. Pancreatic cancer d. Burkitt lymphoma

a Organ transplant places the child at risk for leukemia.

A nurse is preparing to teach the most common malignancy in children. Which malignancy should the nurse discuss? a. Leukemia b. Neuroblastoma c. Wilms tumor d. Retinoblastoma

a The most common malignancy in children is leukemia, accounting for one third. Tumors of the nervous system are the second most common. Wilms tumor is less frequently occurring. Retinoblastoma is less frequently occurring.

A 3-year-old female was diagnosed with Wilms tumor. This disease is a tumor of the: a. Kidney b. Brain c. Bone marrow d. Liver

a Wilms tumor is a tumor found in the kidney.

8. The nurse is caring for a patient who is undergoing chemotherapy and radiation for cancer. The patient asks the nurse about the value of cancer screening when therapy is over. What is the nurse's best response? a. "It should be done on an ongoing schedule." b. "It is not something that should be discussed right now." c. "It probably will not be needed since the cancer has been cured." d. "It usually is not done but can be done if the patient wants peace of mind."

a. "It should be done on an ongoing schedule." Because survivors are at increased risk for developing a second cancer and/or chronic illness, it is important to educate them about lifestyle behaviors and the importance of participating in ongoing cancer screening and early detection practices. Lifelong cancer screening provides the opportunity to identify new cancers in early stages. Cancer screening should be discussed and should be done even if the cancer is cured.

2. A nurse is providing follow-up care for cancer survivors. Which condition should the nurse most monitor for in these patients? a. Cancer b. Infection c. Weight gain d. Low blood pressure

a. Cancer Cancer survivors are at increased risk for cancer (either a recurrence of the cancer for which they were treated or a second cancer). The increased risk for developing a second cancer is the result of cancer treatment, genetic factors or other susceptibility, or an interaction between treatment and susceptibility. Infection, weight gain, and low blood pressure are not common conditions for cancer survivors.

5. A nurse is taking a history on a patient with cancer. Which assessment is priority? a. Fatigue b. Vision c. Dehydration d. Blood pressure

a. Fatigue Cancer-related fatigue (CRF) and associated sleep disturbances are among the most frequent and distressing complaints of people with cancer. Vision, dehydration, and blood pressure are not frequent side effects of cancer.

7. The nurse is caring for a young woman with breast cancer. The stress between the woman and spouse is obvious, as is anxiety among the children. What is the nurse's best action in this situation? a. Help find or develop an educational program for the patient and spouse. b. Encourage the patient to agree with the spouse. c. Support the spouse, and explain that the spouse knows what is best. d. Take the children away and recommend foster care.

a. Help find or develop an educational program for the patient and spouse. It is a nurse's responsibility to educate (develop an educational program) cancer survivors and their families about the effects of cancer and cancer treatment. Spouses often do not know what to do to support the survivor, and they struggle with how to help; therefore, agreeing even if disagreeing does not help and the spouse does not always know what is best. Foster care is not necessary at this time.

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. "Converses without interrupting; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

a. "Converses without interrupting; clothing matches; participates in activities."

3. To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply. a. Alcohol use disorder b. Major depressive disorder c. Stomach cancer d. Polydipsia e. Metabolic syndrome

a. Alcohol use disorder b. Major depressive disorder d. Polydipsia e. Metabolic syndrome

3. Which nursing interventions best demonstrate an understanding of the Quality and Safety Education in Nursing (QSEN) competences? Select all that apply. a. Asking the patient what he or she expects from the treatment he or she is receiving b. Seeking recertification for cardiopulmonary resuscitation (CPR) c. Accessing the internet to monitor social media related to opinions on healthcare d. Consulting with a dietician to discuss a patient's cultural food preferences and restrictions e. Reviewing the literature regarding the best way to monitor the patient for a fluid imbalance

a. Asking the patient what he or she expects from the treatment he or she is receiving b. Seeking recertification for cardiopulmonary resuscitation (CPR) d. Consulting with a dietician to discuss a patient's cultural food preferences and restrictions e. Reviewing the literature regarding the best way to monitor the patient for a fluid imbalance

. A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack."

10. Amadi is a 40-year-old African national being treated in a psychiatric outpatient setting due to a court order. Amadi's medical record is limited in scope, so where can Renata, his registered nurse, obtain more data on Amadi's condition within legal parameters? Select all that apply. a. Emergency department records b. Police records related to the offense resulting in the court order for treatment c. Calling his family in Africa for details about Amadi's mental health d. Past medical records in the current facility

a. Emergency department records b. Police records related to the offense resulting in the court order for treatment d. Past medical records in the current facility

1. What is the purpose of the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply. a. Ensuring that an individual's health information is protected b. Providing third-party players with access to patient's medical records c. Facilitating the movement of a patient's medical information to the interested parties d. Guaranteeing that all those in need of healthcare coverage have options to obtain it e. Allowing healthcare providers to obtain personal health to provide high-quality healthcare.

a. Ensuring that an individual's health information is protected e. Allowing healthcare providers to obtain personal health to provide high-quality healthcare.

9. Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply. a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol. c. Administer a medication such as benztropine IM to correct this dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today.

a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol.

8. A nurse identified a nursing diagnosis of self-mutilation for a female diagnosed with borderline personality disorder. The patient has multiple self-inflicted cuts on her forearms and inner thighs. What is the most important patient outcome for this nursing diagnosis? a. Identify triggers to self-mutilation b. Demonstrate a decrease in frequency and intensity of cutting c. Describe strategies in increase socialization on the unit d. Describe two strategies to increase self-care

a. Identify triggers to self-mutilation

A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.

a. Infuse 5% dextrose in water at 125 ml/hr.

A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.

a. Infuse 5% dextrose in water at 125 ml/hr. Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

a. Labile and euphoric

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Notify the patient's health care provider. b. Give the prescribed PRN lorazepam (Ativan). c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Encourage the patient to take deep, slow breaths.

a. Notify the patient's health care provider. The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Ativan administration will slow the respiratory rate and increase the level of acidosis.

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patient's sleep patterns

a. Provide structure b. Limit credit card access e. Monitor the patient's sleep patterns

Which nursing intervention has priority during the acute phase of a client's manic episode? a. Providing fluids frequently to promote hydration b. Monitoring the amount of sleep the client achieves c. Identifying triggers for exacerbation of manic behavior d. Including family in regular counseling and therapy sessions

a. Providing fluids frequently to promote hydration During the acute phase of mania, physical needs often take priority and demand nursing interventions. Therefore deficient fluid volume is the priority. While the remaining options are appropriate they lack the potential effect on physical health that fluid deficiency has.DIF: Cognitive Level: Analysis (Analyzing)REF: Page 240TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking? a. Restrict patient's oral free water intake. b. Avoid use of electrolyte-containing drinks. c. Infuse a solution of 5% dextrose in 0.45% saline. d. Administer vasopressin (antidiuretic hormone, [ADH]).

a. Restrict patient's oral free water intake. To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the patient's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further.

When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking? a. Restrict patients oral free water intake. b. Avoid use of electrolyte-containing drinks. c. Infuse a solution of 5% dextrose in 0.45% saline. d. Administer vasopressin (antidiuretic hormone, [ADH]).

a. Restrict patients oral free water intake.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury

2. Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia? a. Screening a group of males between the ages of 15 and 25 for early symptoms. b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use issues. c. Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective. d. Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention.

a. Screening a group of males between the ages of 15 and 25 for early symptoms.

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

a. Test for skin tenting. b. Measure rate and character of pulse. f. Observe for flatness of neck veins when supine.

The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 ml over the last hour. c. Oral fluid intake is 100 ml for the last 8 hours. d. There is prolonged skin tenting over the sternum.

a. The blood pressure is 90/40 mm Hg.

The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about a. daily alcohol intake. b. intake of dietary protein. c. multivitamin/mineral use. d. use of over-the-counter (OTC) laxatives.

a. daily alcohol intake. Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium level.

a pt diagnosed with bipolar disorder lives in the community and is showing early signs of mania. the pt says " i need to go visit my daughter but she lives across the country. i put some requests on the internet to get a ride. im sure someone will take me" whats the nurses best response a. im concerned about ur safety when meeting or riding with strangers b. have u asked friends and family to donate money for ur airfare c. u are not likely to get a ride. lets consider some other strategies d, have u asked ur daughter if she wants u to come for a visit

a. im concerned about ur safety when meeting or riding with strangers

When teaching a patient with renal failure about a low phosphate diet, the nurse will include information to restrict a. ingestion of dairy products. b. the amount of high-fat foods. c. the quantity of fruits and juices. d. intake of green, leafy vegetables.

a. ingestion of dairy products. Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. lung sounds. b. urinary output. c. peripheral pulses. d. peripheral edema.

a. lung sounds. Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet.

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication. ANS: A

a. meals.

A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis

a. metabolic acidosis.

A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

a. metabolic acidosis. he pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. oral digoxin (Lanoxin) 0.25 mg daily. b. ibuprofen (Motrin) 400 mg every 6 hours. c. metoprolol (Lopressor) 12.5 mg orally daily. d. lantus insulin 24 U subcutaneously every evening.

a. oral digoxin (Lanoxin) 0.25 mg daily. Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.

The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

a. several factors, including genetics, are implicated.

a community mental health nurse counsels a group of pts about the upcoming flu season. what instruction does the nurse provide for pts who are prescribed lithium a. stop taking ur med and contact me if u have n/v/d b. " remember that lithium reduces ur immunity so u are more vulnerable to catching the flu c. the flu is contagious . isolate urself if u get the flu so that u avoid exposing others to it d. b/c u take lithium u may have flu symptoms that are not typically experienced by others

a. stop taking ur med and contact me if u have n/v/d

. A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

a. within therapeutic limits

The nurse caring for a client with Alzheimer's disease can anticipate that the family will need information about therapy with antihypertensives. benzodiazepines. immunosuppressants. acetylcholinesterase inhibitors.

acetylcholinesterase inhibitors. Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.REF: Page 447

The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess nightly agitation. lethargy. depression. mania.

agitation. Sundowning involves increased disorientation and agitation occurring at night.REF: Page 442

A client diagnosed with Alzheimer's disease looks confused when the phone rings and cannot recall many common household objects by name, such as a pencil or glass. The nurse can document this loss of function as apraxia. agnosia. aphasia. anhedonia.

agnosia. Agnosia is loss of the ability to recognize familiar objects.REF: 438

Rosa, a 78-year-old patient with Alzheimer's disease, picks up her glasses from the bedside table but does not recognize what they are or their purpose. She is experiencing: apraxia. agnosia. aphasia. agraphia.

agnosia. Agnosia is the loss of sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.Cognitive Level: Remember (Knowledge)Nursing Process: AssessmentNCLEX: Psychosocial IntegrityText page: 438

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

alcoholism

10. The nurse is caring for a patient with known coronary artery disease who has recently been diagnosed with lung cancer. What should the nurse do? a. Focus the assessment solely on the cancer diagnosis since it is the newer diagnosis. b. Ask questions about cardiac symptoms and their relationship to the cancer. c. Ignore symptom management and focus on palliative care. d. Say nothing because cancer survivors dislike prying.

b. Ask questions about cardiac symptoms and their relationship to the cancer. The nurse needs to consider not only the effects of cancer and its treatment but also how it will affect any other medical condition. For example, if a patient also has heart disease, how will the fatigue related to chemotherapy affect this individual? The nurse must focus on both, not just the cancer diagnosis. Nurses do not ignore symptom management; given the symptoms that a patient identifies, the nurse will explore each one to gain a complete picture of the patient's health status. Saying nothing is inappropriate; patients will appreciate the nurse's sensitivity and interest in their well-being.

2. A nurse is working in a cancer facility that follows the Institute of Medicine's (IOM) recommendations for essential components of survivorship care. Which recommendations will be the nurse's focus? (Select all that apply.) a. Cessation of noncancer follow-up and care b. Prevention and detection of new and recurrent cancers c. Intervention for consequences of cancer and its treatment d. Coordination between specialists and primary care providers e. Surveillance for cancer spread, recurrence, or second cancers

b. Prevention and detection of new and recurrent cancers c. Intervention for consequences of cancer and its treatment d. Coordination between specialists and primary care providers e. Surveillance for cancer spread, recurrence, or second cancers The Institute of Medicine (IOM) recommends four essential components of survivorship care: (1) Prevention and detection of new cancers and recurrent cancer; (2) surveillance for cancer spread, recurrence, or second cancers; (3) intervention for consequences of cancer and its treatment (e.g., medical problems, symptoms, psychological distress); and (4) coordination between specialists and primary care providers. The patient should continue with noncancer follow-up and care.

1. A cancer survivor patient has anxiety and depression. Which therapies should the nurse include in the plan of care? (Select all that apply.) a. Keep information to a minimum with health care providers. b. Teach the use of problem-oriented coping processes. c. Encourage the use of social support systems. d. Use cognitive behavioral interventions. e. Schedule exercise when convenient.

b. Teach the use of problem-oriented coping processes. c. Encourage the use of social support systems. d. Use cognitive behavioral interventions. Patients who use problem-oriented, active, and emotionally expressive coping processes also manage stress well. Survivors who have social and emotional support systems and maintain open communication with their treatment providers will also likely have less psychological distress. Interventions to treat anxiety and depression in cancer survivors include education, routine (not when convenient) exercise, adequate sleep, and reassurance that anxiety and depression are commonly seen in cancer survivors.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response. a. "A high proportion of patients diagnosed with bipolar disorders are found among creative writers." b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder." c. "Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses." d. "More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds."

b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder."

Lithium is prescribed for a client admitted with a diagnosis of bipolar disorder. Which other therapy is also initially prescribed to temporarily help manage the client's symptoms? a. Antimanic medication b. Antipsychotic medication c. Electroconvulsive therapy (ECT) d. Cognitive behavioral therapy (CBT)

b. Antipsychotic medication Antipsychotic agents may be needed because of their sedating and mood-stabilizing properties, especially during initial treatment until antimanic medications, such as lithium, take effect. While the remaining options are appropriate, they do not support the antimanic medication therapy initially.DIF: Cognitive Level: Application (Applying)REF: Page 241TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

7. During an interview with a non-English-speaking middle-aged woman recently diagnosed with major depression, the patient's husband states, "She is happy now and doing very well." The patient, however, sits motionless, looking at the floor, and wringing her hands. A professional interpreter would provide better information due to the fact that a family member in the interpreter role may: Select all that apply. a. Be too close to accurately capture the meaning of the patient's mood. b. Censor the patient's thoughts or words. c. Avoid interpretation. d. Leave out unsavory details.

b. Censor the patient's thoughts or words.

A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Disturbed thought processes c. Sleep deprivation

A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? a. Serum sodium level of 138 mEq/L (138 mmol/L) b. Gradually decreasing level of consciousness (LOC) c. Oral temperature of 100.1° F with bibasilar lung crackles d. Weight gain of 2 pounds (1 kg) above the admission weight

b. Gradually decreasing level of consciousness (LOC) The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

. A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches.

Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a liter of IV fluid.

b. Infuse the KCl at a rate of 20 mEq/hour.

Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a liter of IV fluid.

b. Infuse the KCl at a rate of 20 mEq/hour. Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

A patient experiencing acute mania waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes." Select the nurse's most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

b. Invite the patient to sit with the nurse and look at new fashion magazines.

Which of these actions can the nurse who is caring for a critically ill patient with multiple intravenous (IV) lines delegate to an experienced LPN? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

b. Monitor the IV sites for redness, swelling, or tenderness An experienced LPN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

b. Neutral walls with pale, simple accessories

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer

b. Positive Chvostek sign in patient with acute pancreatitis

A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changes

b. Provide a subdued environment

A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mEq/L. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

b. Serum calcium is 18 mEq/L. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life-threatening.

. When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patient's behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

b. Set limits on the patient's behavior as necessary

The following data are obtained by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

b. The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland

b. Tumor that secretes excessive antidiuretic hormone (ADH)

Which action will the nurse include in the plan of care for a patient who has a central venous access device (CVAD)? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Have the patient turn the head toward the CAVD during injection cap changes.

b. Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the patient should turn away from the CVAD during cap changes.

9. Medical records are considered legal documents. Proper documentation needs to reflect patient condition along with changes. It should also be based on professional standards designated by the state board of nursing, regulatory agencies, and reimbursement requirements. Proper documentation can be enhanced by: a. Only using objective data b. Using the nursing process as a guide c. Using language the specific patient can understand d. Avoiding legal jargon

b. Using the nursing process as a guide

The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes

b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign

A patient develops mania after discontinuing done. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

b. bring hyperactivity under rapid control

When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is a. skin turgor. b. daily weight. c. presence of edema. d. hourly urine output.

b. daily weight. Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.

b. edema.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.

b. edema. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.

b. if the oral mucosa feels dry. An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.

A 16-year-old male with aspirations of becoming a bodybuilder spends 3 hours a day in the gym. Five years later he develops hepatocellular carcinoma. Which of the following is the most likely cause of the cancer? a. Immunosuppressive agents b. Cytotoxic agents c. Anabolic steroids d. A viral infection

c A history of anabolic steroids places the patient at risk for hepatocellular carcinoma.

While planning care for children with cancer, which information should the nurse remember? Most childhood cancers originate from the: a. Placenta b. Environment c. Mesodermal germ layer d. Neural tube

c Most childhood cancers originate from the mesodermal germ layer that gives rise to connective tissue, bone, cartilage, muscle, blood, blood vessels, gonads, kidney, and the lymphatic system.

A couple brings their child to his primary care provider for a checkup. The child has Down syndrome, and the couple is concerned about other diseases that could afflict the child. The primary care provider explains that young children with Down syndrome are at higher risk for developing: a. Nephroblastoma b. Rhabdomyosarcoma c. Leukemia d. Retinoblastoma

c One of the more recognized syndromes is the association of trisomy 21, Down syndrome, and with an increased susceptibility to acute leukemia.

The most common tissue type of cancer occurring after adolescence is: a. Sarcoma b. Squamous cell c. Carcinoma d. Neuromas

c The most common tissue type after adolescence is carcinoma.

4. Which disadvantage is inherent to the problem-oriented charting system (SOAPIE)? a. Does not support a universal organizational system b. Commonly allows for the inclusion of subjective information c. Documentation is not listed in chronological order d. Does not support the nursing process as a format

c. Documentation is not listed in chronological order

A patient receiving isoosmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dl (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dl (1.55 mmol/L)

c. Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

c. Oliguric renal disease

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood

c. Poor judgment and hyperactivity

A patient with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first? a. Notify the patient's health care provider. b. Withhold the next scheduled dose of Maalox. c. Review the magnesium level on the patient's chart. d. Check the chart for the most recent potassium level.

c. Review the magnesium level on the patient's chart. The patient has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The Maalox should be held, but more immediate action is needed to correct the patient's decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.

Which teaching focused intervention will have the greatest impact on reducing the risk of relapsing for a client diagnosed with bipolar disorder? a. Symptom recognition b. Stress management skills c. Role of family as support d. Available social resources

c. Role of family as support Patient and family teaching takes many forms and is most important in encouraging compliance with the medication regimen and reducing the risk of relapse. While appropriate the remaining options are less focused on minimizing relapse and more on managing the disorder.DIF: Cognitive Level: Application (Applying)REF: Page 241TOP: Nursing Process: ImplementMSC: NCLEX: Psychosocial Integrity

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder? a. Educating the client to the policies upon admission to the unit b. Instructing the client that intrusive behaviors are not appropriate c. Setting and maintaining consistent unit policies that are enforced by all staff d. Ensuring that the client's medication therapy is administered in a timely manner

c. Setting and maintaining consistent unit policies that are enforced by all staff It is fundamentally important that nurses and all staff need to use consistent limit-setting strategies using a neutral tone when a patient displays intrusive interpersonal behaviors and intervene quickly with impulsive and aggressive behaviors to best assure effective client care and milieu management. While appropriate, none of the remaining options are the foundation of bipolar disorder care.DIF: Cognitive Level: Application (Applying)REF: Page 241TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

A patient who has an infusion of 50% dextrose prescribed asks the nurse why a peripherally inserted central catheter must be inserted. Which explanation by the nurse is correct?a. The prescribed infusion can be given much more rapidly when the patient has a central line. b. There is a decreased risk for infection when 50% dextrose is infused through a central line. c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d. The required blood glucose monitoring is more accurate when samples are obtained from a central line.

c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

c. carbamazepine (Tegretol)

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

c. clear the room of all other patients.

a patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed med. the pt says "i will use my whole check next month to buy lottery tickets. winning will solve my money problems" select nurse best action a. educate the pt about the low odds of winning the lottery b. present reality by saying to the pt "that is not good use of ur money" c. confer with the treatment team about appointing a legal guardian for the pt d. tell the pt, "if u buy lottery tickets ur money will run out before the end of the mo"

c. confer with the treatment team about appointing a legal guardian for the pt

A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. increased total urinary output. b. elevation of serum hematocrit. c. decreased serum sodium level. d. rapid and unexpected weight loss

c. decreased serum sodium level.

A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. increased total urinary output. b. elevation of serum hematocrit. c. decreased serum sodium level. d. rapid and unexpected weight loss

c. decreased serum sodium level. SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.

c. self-control of distorted thinking.

A child was recently diagnosed with cancer. The diagnosis suggests it is an embryonic tumor. Which of the following characterizes this type of cancer? a. Commonly occurring b. Often seen in adults c. Composed of mature, differentiated cells d. Usually manifested around age 5

d These types of cancers usually manifest around age 5. These types of cancers are not commonly occurring. These types of cancers are not commonly seen in adults. These types of cancers are composed of undifferentiated cells.

11. The patient has lung cancer and voices concerns about cancer treatments affecting sexuality. What is the nurse's best reply? a. "That is something to ask the health care provider." b. "Chemotherapy will work in the lungs and should have no effect on sexuality." c. "How cancer treatment affects sexuality depends on how active you are and your age." d. "Sexual changes are common with cancer therapy. Let me get someone who can answer your questions."

d. "Sexual changes are common with cancer therapy. Let me get someone who can answer your questions." Cancer therapies have the potential to cause fatigue, apathy, nausea, vomiting, malaise, and sleep disturbances, all of which interfere with a patient's sexual functioning. It helps if the nurse can develop a comfort level in acknowledging with patients that sexual changes are common at any age level. When patients begin to discuss their sexuality, be familiar with the expert resources in your institution (e.g., psychologist, social worker) available for patient referral. The issue should not be pushed onto the health care provider.

1. A nurse is working on a cancer unit. The unit uses the National Coalition for Cancer Survivorship definition for a cancer survivor. Which definition will the nurse use? a. Been cancer free for 5 years after diagnosis b. Been cancer free for 3 years after diagnosis c. Had cancer and is declared cancer free d. Had cancer and extends until death

d. Had cancer and extends until death Cancer survivorship begins at the time of cancer diagnosis, includes treatment, and extends to the rest of the person's life. Being cancer free for any length of time does not relate to the definition of a cancer survivor put forth by the National Coalition for Cancer Survivorship.

3. A nurse is assessing a cancer survivor for chemotherapy-induced peripheral neurotoxicity (CPIN). Which assessment finding is consistent with CPIN? a. Hearing loss b. Devastating depression c. Extreme loss of motor functioning d. Numbness and tingling in hands and feet

d. Numbness and tingling in hands and feet Chemotherapy-induced peripheral neurotoxicity (CPIN) refers to peripheral nerve damage resulting from the effects of certain chemotherapeutic agents. Damage to large sensory nerves causes feelings of numbness and tingling in the hands and feet. Motor function may also be affected, but usually to a lesser degree than sensory function. Hearing loss and depression are not signs and symptoms of CPIN.

9. The nurse is caring for a patient diagnosed with cancer. The family of the patient asks the nurse for resources about the cancer. What should the nurse do? a. Refer family members to the health care provider. b. Inform them that few options are available. c. Maintain confidentiality by keeping silent. d. Provide the family with the information.

d. Provide the family with the information. The nurse's role is to tell patients and families about the different resources available so they can make informed choices. The physician is a resource, but the nurse can educate and help as well. There are numerous organizations that provide resources to cancer survivors. The nurse must maintain patient confidentiality, not resource confidentiality.

4. A cancer survivor is in the intensive care unit (ICU). Some of the patient's family is from out of town and would like to see the patient even though it is not "official" visiting hours. The patient is anxious to see family members. The nurse allows the family to visit. What is the rationale for the nurse's actions? a. The nurse disagrees with the established time for visiting. b. The nurse realizes that the patient is dying. c. The nurse feels there is no real reason to have limited visiting hours. d. The nurse believes that the visit will help relieve psychological stress.

d. The nurse believes that the visit will help relieve psychological stress. Survivors who have social and emotional support systems are likely to have less psychological distress. Relationships are critical for cancer survivors. The nurse does not necessarily have problems with the standard visiting hours. Not enough information is provided to indicate that the patient is near death, and not all patients in the ICU are dying.

12. The nurse is caring for a patient who has successfully undergone cancer therapy and will be discharged home soon. The patient is concerned about going home and not knowing what to do. Which information is the most valuable for the nurse to share with the patient? a. The nurse will develop a plan of care that will tell exactly what needs to be done. b. If any issues arise, call the health care provider and follow the instructions. c. Proper cancer treatment has been provided, and nothing else is required. d. There is a team that will provide support and care that may be needed.

d. There is a team that will provide support and care that may be needed. When a survivor is released from an oncologist, the internist and other health care providers provide and coordinate care based on knowledge of prior cancer history and treatment. To meet the health care needs of cancer survivors, it is essential for a "survivorship care plan" to be written by the principal provider (not the nurse) who coordinates the patient's oncology treatment. Depending upon the issue, there may be several health care providers who may be a better choice. Proper cancer treatment will include a follow-up plan or "survivorship care plan." The nurse will still advise the patient to call the health care provider if there are issues and to follow the instructions given, but acknowledging the team approach that is used and available support is most valuable to the patient at the time of discharge.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

d. "I will drink apple juice instead of orange juice for breakfast." Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

6. A 13-year-old boy is undergoing a mental health assessment. The nurse practitioner assures him that his medical records are protected and private. The nurse recognizes that this promise cannot be kept when the youth divulges: a. "I lost my virginity last year." b. "I am angry with my parents most of the time." c. "I have thoughts of being in love with boys." d. "My parents do not know that I hit my grandpa."

d. "My parents do not know that I hit my grandpa."

5. Which standardized rating scale will the nurse specifically include in the assessment of a newly admitted patient diagnosed with major depressive disorder? a. Mini-Mental State Examination (MMSE) b. Body Attitude Test c. Global Assessment of Functioning Scale (GAF) d. Beck Inventory

d. Beck Inventory

Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

d. Congestive heart failure

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

d. Consider the need to check the lithium level. The patient may not be swallowing medications.

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness

d. Decreased level of consciousness

A postoperative patient who is receiving nasogastric suction is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suctions for a few hours. b. Notify the health care provider about the ABG results. c. Teach the patient about the need to take slow, deep breaths. d. Give the patient the PRN morphine sulfate 4 mg intravenously.

d. Give the patient the PRN morphine sulfate 4 mg intravenously. The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. I will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple juice instead of orange juice for breakfast.

d. I will drink apple juice instead of orange juice for breakfast.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

5. Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia

d. Paranoia

4. A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations.

d. She should experience a reduction in hallucinations.

The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

d. There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

8. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that: a. Medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill.

d. They are not actually ill.

6. Gilbert, age 19, is described by his parents as a "moody child" with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered: a. Favorable with medication b. In the relapse stage c. Improvable with psychosocial interventions d. To have a less positive outcome

d. To have a less positive outcome

A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

d. arrange for one-on-one supervision.

A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes. b. frequent loose stools. c. facial muscle spasms. d. generalized weakness.

d. generalized weakness Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes. b. frequent loose stools. c. facial muscle spasms. d. generalized weakness.

d. generalized weakness.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis .b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis. The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

a patient was diagnosed with bipolar disorder many yrs ago. the pt tells the nurse "when i have a manic episode, theres always a feeling of gloom behind it and i know i will soon be totally depressed" nurses best response? a. most pts diagnosed with bipolar disorder report the same types of feelings b. feelings of gloom associated with depression result from serotonin dysregulation c. if u take ur med as it is prescribed u will not have those experiences d. ur comment indicates u have an understanding and insight about ur disorder

d. ur comment indicates u have an understanding and insight about ur disorder

When preparing educational materials for the family of a client diagnosed with progressive dementia, the nurse will include information related to local: (select all that apply): day care centers legal professionals home health services family support groups professional counseling

day care centers home health services family support groups professional counseling Most importantly, families need to know where to get help. Help includes professional counseling and education regarding the process and progression of the disease. Families especially need to know about and be referred to community-based groups that can help shoulder this tremendous burden (e.g., day care centers, senior citizen groups, organizations providing home visits and respite care, and family support groups). While legal professionals may be of interest to the family, client and family education does not include such services.REF: Page 446

The family members of a client with stage 1 Alzheimer's disease have jobs and cannot provide adequate supervision for the client. A reasonable alternative for the nurse to explore with them would be day care. acute care hospitalization. long-term institutionalization. group home residency.

day care. Day care is a good option for clients with early-stage Alzheimer's disease. It provides supervision, a protected environment, and supportive interactions.REF: Page 442

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temp, and reported "dry mouth." The nurse suspects the client is experiencing which condition?

dehydration

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning she is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with delirium. dementia. amnesic disorder. selective inattention.

delirium. Delirium is characterized by a disturbance of consciousness, a change in cognition (such as impaired attention span), and a fluctuating level of consciousness that develop over a short period of time.REF: Page 432

Dementia in an older adult is often a misdiagnosis for depression. cerebral emboli. normal effects of aging. poor nutritional status.

depression. Depression in an older adult is frequently confused with dementia.REF: Page 438

A client with delirium strikes out at a staff member. The nurse can most correctly hypothesize that this behavior is related to anger. fear. an unmet physical need. the need for social interaction.

fear. Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious clients who are fearful may strike out at others, seemingly without provocation.REF: 435

Trudy is a 72-year-old patient hospitalized with pneumonia and experiencing delirium. She points to her IV pole and screams, "Get him out of here! He's going to hurt me!" You recognize that what Trudy is experiencing is a(n): hallucination. delusion. illusion. confabulation.

illusion. ILLUSIONS are errors in perception of sensory stimuli. The stimulus is a real object in the environment; however, it is misinterpreted and often becomes the object of the patient's projected fear. HALLUCINATIONS are false sensory stimuli. For example, individuals experiencing delirium may become terrified when they "see" giant spiders crawling over the bedclothes or "feel" bugs crawling on or under their bodies. A DELUSION is described as thinking or believing something that is not true and is seen more often in schizophrenia. For example, a patient may firmly believe that government agencies can read and are monitoring his or her thoughts or that neighbors can see him or her through walls. CONFABULATION is the creation of stories or answers in place of actual memories to maintain self-esteem.Cognitive Level: Understand (Comprehension)Nursing Process: AssessmentNCLEX: Psychosocial IntegrityText page: 434

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

potassium

The term "perceptual disturbance" refers to difficulty processing information about one's internal and external environment. changing one's way of thinking to accommodate new information. performing purposeful motor movements. formulating words appropriately.

processing information about one's internal and external environment. Perceptual distortion refers to impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way.REF: 433

A nursing diagnosis appropriate for a client with Alzheimer's disease, regardless of the stage, would be risk for injury. acute confusion. imbalanced nutrition. impaired environmental interpretation syndrome.

risk for injury. Memory loss, agnosia, poor judgment, and the other symptoms of Alzheimer's disease contribute to placing the client at risk for injuries such as burns and falling down stairs.REF: 435

A client diagnosed with Alzheimer's disease has become more forgetful and has difficulty performing familiar tasks like bathing and dressing. The nurse would assess the client as being in the stage of Alzheimer's disease labeled stage 1, mild. stage 2, moderate. stage 3, moderate-severe. stage 4, end.

stage 3, moderate-severe. Moderate-severe Alzheimer's disease requires a high level of supervision because of the severe memory loss the client is experiencing. Wandering and inability to meet self-care needs become problematic.REF: Page 440 (Table 23-3)

A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. When the client is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." The best reply for the nurse would be "That will be fine. I'll have you sign our hospital release form." "Because we do not have a copy of durable power of attorney, we cannot release them to you." "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." "I would like to have your mother wear them. It will help her to be less confused."

"I would like to have your mother wear them. It will help her to be less confused." Clients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids.REF: Page 433

Which of the following statements best describes electrolytes in extracellular and intracellular fluid? 1) There is a greater concentration of sodium in extracellular fluid and a greater concentration of potassium in intracellular fluid. 2) There is equal movement of sodium and potassium between intracellular and extracellular fluids. 3) There is a greater concentration of potassium in extracellular fluid and a greater concentration of sodium in intracellular fluid. 4) None of the above

1

The major cation regulating extracellular osmolality is: 1) Sodium 2) Potassium 3) Chloride 4) Magnesium

1 Cations are positively charged and anions are negatively charged. Sodium, potassium, and magnesium are all cations. Chloride is an anion. Sodium plays the most important part in regulating osmolality between and within the fluid compartments

Which dietary condition shows consistent evidence for increasing the risk of colorectal cancer in clients? 1 Obesity 2 Increased calcium 3 Beta-carotene deficiency 4 Lycopene-containing foods

1 Obesity

Which of the following statements about IV fluid replacement therapy for an infant with dehydration is true? 1) The infusion rate may be higher during the first 1-3 hours 2) The 1st half of the 24 hour total will be infused over 10 hours. 3) The infant is NPO for the first 48 hours. 4) Undiluted juices and cola may be given during IV replacement therapy.

1 Rehydration rates of infusion may be higher in the initial 1 to 3 hours than what is normally needed and then the rate will be slowed down to avoid fluid overload. If the dehydrated infant can drink fluids that can be an alternative way to provide fluids. Depending on the cause of dehydration, usually electrolyte solutions are used such as pedialyte or "New Oral Rehydration Solutions" as suggested by the World Health Organization for outbreaks of cholera and rotovirus rather than juice or cola.

A 15-year-old girl, the unrestrained passenger, in the front seat of a pickup truck was thrown from the vehicle when it hit a guard rail. She is admitted to the ER where she is evaluated by the ER physician. STAT lab work has been ordered and a student nurse asks why the doctor wants to have electrolytes done, "She's so young, and besides what abnormal labs could she have this early?" The best response would be: 1) "It is very possible that she will have an elevated potassium." 2) "We don't need to worry about what it will show; we'll just get it done." 3) "It is likely she will have an increased calcium due to her broken wrist." 4) "Electrolyte studies will indicate whether or not she had been drinking."

1 Severe trauma or tissue damage can release potassium into the extracellular compartment leading to a subsequent increase in serum potassium and the dangers that can cause. Blood alcohol level will indicate if she has been drinking. Even if she has fractured bones, her calcium level will probably not be affected at this point.

Caring for a pt. with caner is unique because of the effects of the disease and associated treatment. An understanding of a pt's symptom experience is critical and best revealed by a nurse asking which of the following questions? (SATA) 1. " What symptoms do you think you are having as a result of your cancer?" 2. " Describe for me how the symptoms affect you in your daily life." 3. " Let's focus on your pain. Tell me how it affects you." 4. " Can you describe for me how your family provides care for your symptoms?"

1, 2, 3

A 62-year-old pt. is being admitted to a surgical unit for a total hip replacement. The nurse reviews his medical record and learns that the pt. has a history of impaired liver function and paresthesias in his feet. After assessing the pt's medical history further, the nurse is not sure what caused the liver impairment or paresthesia. To clarify, an appropriate question to ask the pt. is which of the following? 1. " Have you been treated for cancer in the past?" 2. " What is the nature of your liver problem?" 3. " Has the doctor discussed with you whether your liver problems will affect your recovery from surgery?" 4. " How long have you had the numbness and tingling in your feet?"

1. " Have you been treated for cancer in the past?"

A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is: 1. 0.45% normal saline (NS) 2. 10% dextrose 3. 5% dextrose in lactated Ringer's 4. Dextrose 5% in 1/2 NS

1. 0.45% normal saline (NS)

Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply.) 1. 50-year-old with hypertension 2. 36-year-old with schizophrenia 3. 40-year-old with a fractured femur 4. 15-month-old with diarrhea for 2 days 5. 76-year-old with advanced Alzheimer's disease 6. 25-year-old with partial-thickness burns over 40% of the body

1. 50-year-old with hypertension 3. 40-year-old with a fractured femur 4. 15-month-old with diarrhea for 2 days 5. 76-year-old with advanced Alzheimer's disease 6. 25-year-old with partial-thickness burns over 40% of the body

Mr. Wallace is a 34-year-old who is a 5-year survivor of Hodgkin's disease. He continues to have symptoms related to his chemotherapy treatment. Mr. Wallace is a computer expert and enjoys Internet discussion groups. What is the best resource a nurse can recommend to help him access a survivorship care plan? 1. Association of Cancer Online Resources 2. National Coalition for Cancer Survivorship 3. National Cancer Society 4. National Cancer Institute

1. Association of Cancer Online Resources

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body's regulators to the function it provides. a.Increases excretion of sodium and water b.Reduces excretion of sodium and water c.Reduces excretion of water d.Major buffer in the extracellular fluid e.Vasoconstricts and stimulates aldosterone release 1.Antidiuretic hormone 2.Angiotensin II 3.Aldosterone 4.Atrial natriuretic peptide 5.Bicarbonate

1. C 2. E 3. B 4. A 5. D

Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

1. Dry, sticky tongue

A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

1. Expand the volume of fluid in the vascular system

A client experiencing diabetic ketoacidosis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Red, flushed skin 2. Verbally aggressive 3. Complaints of dry mouth 4. Crackles in both lung fields 5. Oral temperature of 102.8° F 6. Requiring frequent linen changes

1. Red, flushed skin 2. Verbally aggressive 3. Complaints of dry mouth 5. Oral temperature of 102.8° F 6. Requiring frequent linen changes

A 75-year-old patient is hospitalized with sudden onset confusion and disorientation. The patient wanders and becomes agitated without any apparent stimulus. What is the highest priority nursing diagnosis? 1. Risk for injury 2. Acute confusion 3. Impaired memory 4. Self-care deficit, bathing, or hygiene

1. Risk for injury Risk for injury; acute confusion; impaired memory; and self-care deficit, bathing, or hygiene are diagnoses likely to apply in this situation; however, safety is the nurse's highest priority.

A patient diagnosed with delirium strikes out physically at a staff member. What is the most likely cause of this behavior? 1. State of fear 2. Physical illness 3. An unmet physical need 4. The need for social interaction

1. State of fear Patients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious patients who are fearful may strike out at others, seemingly without provocation. Physical illness, an unmet physical need, or the need for social interaction generally are not associated with such aggressive behavior.

Which medication is aimed at preventing the breakdown of acetylcholine? Select all that apply. 1. Tacrine 2. Donepezil 3. Rivastigmine 4. Memantine 5. Galantamine

1. Tacrine 2. Donepezil 3. Rivastigmine 5. Galantamine Because a deficiency of acetylcholine has been linked to Alzheimer's disease, medications aimed at preventing its breakdown (cholinesterase inhibitors) have been developed, including tacrine hydrochloride, donepezil, rivastigmine, and galantamine. Memantine normalizes levels of glutamate, a neurotransmitter that may contribute to neurodegeneration.

Which behavior is associated with typical age-related cognitive changes? Select all that apply. 1. Taking 30 minutes to find one's misplaced car keys. 2. Having the electricity turned off for lack of payment. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation.

1. Taking 30 minutes to find one's misplaced car keys. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation. Typical age-related cognitive changes include occasional examples of memory lapse, poor judgment, and omissions. The more serious, atypical changes involve complete, constant, or chronic issues with memory and cognition.

A nurse was assigned to select patients with Alzheimer's disease for a clinical trial of a new drug from a geriatric population. Based on what appropriate symptoms does the nurse select the patients? Select all that apply. 1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. 3. The patient reports forgetting to pay the electric bills. 4. The patient reports frequently losing things and tracing them later. 5. The patient sometimes forgets which word to use during a conversation.

1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. Geriatric patients normally have minor age-related deflects in memory. The nurse should be able to differentiate between the normal age-related changes and signs of Alzheimer's disease. Patients with Alzheimer's disease have difficulty in conversation and poor judgment and decision making. Other symptoms include inability to manage a budget, losing track of the date or the season, misplacing things and being unable to trace them. Normal age-related changes include forgetting which word to use and losing things frequently. Missing monthly payments and making a bad decision once in a while is a normal behavior and does not indicate Alzheimer's disease.

A patient with Parkinson's disease reports that bugs are crawling on his bed. The nurse checks the bed and finds peanuts on the bed. What does the nurse conclude from the patient's behavior? 1. The patient has impaired environmental interpretation syndrome. 2. The patient has delusions. 3. The patient has developed an allergy to peanuts. 4. The patient has a skin disorder.

1. The patient has impaired environmental interpretation syndrome. Patients with Parkinson's disease have confusion and dementia, and have impaired environmental interpretation syndrome. It is characterized by hallucinations and illusions. The patients tend to mistake benign objects for objects which are sinister and frightening. The patients may have tactile hallucinations, but not suffer from delusions. An allergy to peanuts or developing a skin disorder are unlikely causes of the patient's complaint, as these disorders are accompanied by other symptoms as well.

A Chinese-American patient has been diagnosed with dementia. What should the nurse keep in mind when addressing the needs of the family caregivers? Select all that apply. 1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 4. They perceive caregiving as burdensome. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease.

1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease. Chinese-Americans depict dementia as fate or wrongdoing rather than a disease. They are less likely to seek help from others. Filial piety and family harmony are important, which emphasizes honor and devotion to parents. They feel obligated to sacrifice individual needs and wants. As the disease progresses, dementia is viewed as a mental illness with associated stigma and resulting in feelings of humiliation. Chinese-Americans do not perceive their caregiving role as burdensome. They believe that memory loss in early dementia is a part of the normal aging process. It is not viewed as a mental illness.

A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.) 1. Water vapor that is lost through the skin that is burned 2. Plasma and interstitial fluids that are lost as burn exudate 3. Blood leakage via damaged capillaries in the dermis 4. Respiratory acidosis resulting from altered respiratory function 5. Plasma that leaves the intravascular space and becomes trapped in blisters 6. Sodium and water shift that out of the vessels because of increased permeability

1. Water vapor that is lost through the skin that is burned 2. Plasma and interstitial fluids that are lost as burn exudate 3. Blood leakage via damaged capillaries in the dermis 5. Plasma that leaves the intravascular space and becomes trapped in blisters 6. Sodium and water shift that out of the vessels because of increased permeability

A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results? 1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L 2. pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L 3. pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L 4. pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/

1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? -115 mEq/L -130 mEq/L -145 mEq/L -160 mEq/L

115 mEq/L

Which of the following is the normal level of potassium in the blood? 1) 1.5 to 4.0 2) 3.5 - 5.0 3) 5.0-7.5 4) none of the above

2

A patient has been admitted with a potassium of 5.8 mEq/L; the nurse anticipates which of the following action? 1) Administration of glucose IV and insulin sub-q. 2) Administration of glucose / insulin / diuretics IV. 3) Administration of IV potassium diluted in normal saline. 4) Administration of synthetic aldosterone.

2 Normal Potassium range is between 3.5 to 5.0 mEq/L. Increased potassium can lead to serious cardiac arrhythmias and actions must be taken to eliminate excess potassium. In non-emergency situations, hyperkalemia can be treated with a low potassium diet. Insulin injections are used to treat hyperkalemia in emergency situations. It provokes the uptake of potassium ions by cells, decreasing potassium ion concentration in the blood. Kayexalate is a resin given orally or rectally that can help bind potassium in the intestines for excretion by the feces.

Two-thirds of total body fluid is located in which compartment? 1) Interstitial 2) Intracellular 3) Intravascular 4) Extracellular

2 Approximately 70% of body fluid is intracellular and 30% is extracellular. In order for the cells of the body to function normally, this balance must be maintained.

During the administration of IV fluids, which of the following findings should prompt further action? 1) Increased urinary output. 2) Crackles heard during pulmonary assessment. 3) Lack of thirst. 4) Abdominal cramping.

2 Crackles heard upon respiratory assessment could indicate fluid retention or overload (pulmonary edema).The physician needs to be notified of this development.

For the patient in hemorrhagic (hypovolemic) shock, the most important nursing action is to: 1) Administer replacement electrolytes orally or by IV. 2) Administer adequate fluid / blood volume IV. 3) Place the patient on cardiac monitor to observe for signs of electrolyte abnormalities. 4) Monitor urinary output as a measure of fluid status.

2 Fluid replacement is most important to maintain function of the cells for the patient in hypovolemic shock. The patient should be maintained NPO in case surgery, including anesthesia, is required. Remember ABCs. Fluid replacement is part of C.

A patient is being discharged following an acute myocardial infarction and subsequent heart failure. His discharge medications include: Lasix 40 mg daily, Lanoxin 0.25 mg daily, and the ACE inhibitor, Capoten (captopril) 50 mg TID. Prior to sending him home, the nurse should call the physician regarding: 1) The time of day the medications are to be taken. 2) The lack of a potassium supplement order. 3) The lack of fluid restriction order. 4) The lack of chloride and magnesium supplement orders.

2 He is on a diuretic (Lasix) and this would alert the nurse to the idea that he should have a potassium replacement ordered. However, the Capoten is potassium sparing and could increase serum potassium levels. So it would be best to check with the MD about these orders and if supplementation is needed!

A client has high intake of red meat. Which factor will increase the client's risk for cancer development? 1 Increased fiber 2 Higher levels of heme iron 3 Lower levels of coenzyme Q10 4 Decreased single-stranded DNA virus

2 Higher levels of heme iron

A nurse is describing the effects of obesity on cancer. Which information should the nurse share? 1 Obesity leads to decreased proinflammatory cytokines. 2 Obesity causes excessive levels of altered adipokines. 3 Aromatase activity, from obesity, is decreased in adipose tissue dysfunction. 4 Hypoinsulinemia, from obesity, contributes to a tumor-permissive environment.

2 Obesity causes excessive levels of altered adipokines.

35. Which would the nurse consider a priority intervention when planning care for a medically unstable client diagnosed with alcohol use disorder? 1) Simplifying the environment 2) Addressing physical needs 3) Providing opportunities for success experiences 4) Establishing a trusting interpersonal relationship

2) Addressing physical needs Physical problems must be addressed prior to meeting any psychosocial needs of a client who is medically unstable. According to Maslow's hierarchy of needs, physiological needs should be prioritized over all other needs.

48. A client who is unable to control binge drinking requires increased amounts of alcohol to achieve the same level of intoxication. The client is experiencing marital strife and legal problems. The client's behaviors meet the criteria for which DSM-5 diagnostic category? 1) Dual diagnosis 2) Alcohol use disorder 3) Neurocognitive disorder 4) Alcohol intoxication

2) Alcohol use disorder This client has developed tolerance, cannot control alcohol intake, and has continued use despite persistent problems related to drinking. These symptoms meet the criteria for the diagnosis of alcohol use disorder in the DSM-5.

33. Which client and family teaching is most important regarding the cause of substance addiction? 1) An individual's social and cultural environment can be implicated in the cause of substance addiction. 2) Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction. 3) Evidence of a genetic link accounts for most cases of substance addiction. 4) Reinforcing properties of the substance encourage progression from use to addiction.

2) Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction.

43. The nurse is assessing a client who is a substance abuser. The client states, "I use every day, but it rarely interferes with my work." The nurse determines that the client is using which defense mechanism? 1) Projection 2) Denial 3) Reaction formation 4) Displacement

2) Denial Denial is characterized by avoidance of disagreeable realities and unconscious refusal to acknowledge a thought, feeling, need, or desire. By stating that alcohol use rarely interferes with his or her work, the client is denying a substance abuse problem.

45. Which primary factor is critical in maintaining abstinence for the client diagnosed with alcohol use disorder? 1) Attendance at Alcoholics Anonymous (AA) meetings 2) Personal commitment to change 3) Family involvement 4) Compliance with pharmacological therapy

2) Personal commitment to change The first step in the recovery process necessitates that the client accept ownership of the problem and establish a behavioral change commitment to continued abstinence.

A female patient is brought to the hospital by her daughter, who visited the patient this morning and found her to be confused and disoriented. When the patient is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." What would be the best response from the nurse? 1. "That will be fine. I'll have you sign our hospital release form." 2. "I would like to have your mother wear them. It will help her to be less confused." 3. "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." 4. "Because we do not have a copy of durable power of attorney, we cannot release them to you."

2. "I would like to have your mother wear them. It will help her to be less confused." Patients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids.

Which of the following clients is at greatest risk for insensible water loss? 1. A 37-year-old with a superficial burn to the left hand 2. A 15-year-old experiencing an asthmatic attack 3. A 50-year-old with type 2 diabetes 4. A 73-year-old with a history of pneumonia

2. A 15-year-old experiencing an asthmatic attack

Which nursing intervention would be most appropriate for an older individual suspected of being at risk for the development of the unique symptoms of delirium? 1. Assuring that the individual is ambulated sufficiently. 2. Assessing orientation to person, place, and time every two hours. 3. Cutting the individual's food into small pieces to avoid the risk of choking. 4. Assuring that the individual is dressed warmly to avoid the risk of hypothermia.

2. Assessing orientation to person, place, and time every two hours. Delirium reduces awareness of the environment that involves sensory misperceptions and disordered thought (disturbed attention, memory, thinking, and orientation) and also disturbances of psychomotor activity and the sleep-wake cycle. These disturbances develop rapidly (over hours to days). Frequent assessment of an individual at risk for developing delirium for orientation would be most appropriate. Assuring ambulation, cutting food into small pieces, and assuring warm clothing are appropriate but not needs unique to an individual at risk for developing delirium.

A client experiencing acute congestive heart failure (CHF) is likely to present with which of the following clinical signs? (Select all that apply.) 1. Flat neck veins 2. Bilateral crackles 3. +2 ankle edema bilaterally 4. Urine output of 790 mL in 24 hours 5. History of a 5-pound weight gain in 3 days 6. Systemic blood pressure 15 mm Hg above usual baseline

2. Bilateral crackles 3. +2 ankle edema bilaterally 5. History of a 5-pound weight gain in 3 days 6. Systemic blood pressure 15 mm Hg above usual baseline

A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Tingling fingers 2. Difficult to arouse 3. Warm, flushed skin 4. Tremors in the hands 5. Reporting a "terrible headache" 6. Repeatedly asking "Where am I?

2. Difficult to arouse 3. Warm, flushed skin 4. Tremors in the hands 5. Reporting a "terrible headache" 6. Repeatedly asking "Where am I?

An elderly patient is diagnosed with Alzheimer's disease. What characteristic features may be seen in this patient? Select all that apply. 1.Speaks rapidly, inappropriately, and incoherently 2. Forgets familiar words or the location of everyday objects 3 . Becomes moody or withdrawn, especially in challenging situations 4. Shows altered awareness and is unable to focus, or sustain attention 5. Has increasing and frequent trouble controlling bladder and bowels

2. Forgets familiar words or the location of everyday objects 3. Becomes moody or withdrawn, especially in challenging situations 5. Has increasing and frequent trouble controlling bladder and bowels Alzheimer's disease is characterized by progressive deterioration of cognitive functioning, including forgetting familiar words or the location of everyday objects. The patient becomes moody or withdrawn, especially in socially or mentally challenging situations. The patient also has increasing and frequent trouble controlling their bladder and bowels. Delirium is an acute cognitive disturbance where the patient's speech is rapid, inappropriate, incoherent, and rambling. There is an alteration in consciousness levels. This manifests as altered awareness and inability to focus, sustain, and shift attention.

A patient's family expresses concern that the patient is developing Alzheimer disease. The patient is now 65 and was once a professional wrestler. How might this history affect the diagnosis? 1. This history will not affect the diagnosis. 2. History of head trauma is a risk factor for dementia. 3. The patient is too young to have Alzheimer disease. 4. As an athlete, the patient is less likely to have Alzheimer disease.

2. History of head trauma is a risk factor for dementia. If the patient was a professional athlete in a contact sport, there may be a history of head injury, which will affect the diagnosis. The patient's history can indeed affect the diagnosis. Although most patients who are diagnosed with Alzheimer disease are 75 or older, it is not impossible for younger patients to show signs of the disease. Other than the risk of head trauma, athletes are no more or less likely to develop the disease.

Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

2. Increased anxiety

The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is: 1. 0.45% saline 2. Lactated Ringer's 3. 5% dextrose in normal saline 4. 5% dextrose in lactated Ringer's

2. Lactated Ringer's

Which is a drawback of early cholinesterase inhibitors? 1. Constipation 2. Liver toxicity 3. Only useful in mild dementia 4. Increased acetylcholine levels

2. Liver toxicity Earlier forms of cholinesterase inhibitors, such as tacrine, caused liver toxicity, causing them to be withdrawn from the US market in 2012. Increasing availability of acetylcholine is a benefit for patients with dementia. These drugs are not beneficial for people with mild dementia. The side effects include nausea, vomiting, and diarrhea, not constipation.

A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The child's rectal temperature is 101.1° F. The nurse knows the child is probably dehydrated and should do which of the following first? 1. Give the child some juice to drink. 2. Prepare to start an IV. 3. Get an order for an antipyretic. 4. Sponge the child to bring down the fever.

2. Prepare to start an IV.