last fundamentals exam

A 17-year-old patient sustained facial fractures and a 6-inch laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her "looking this way." Which statement by the nurse is most appropriate? a) "Tell me what you mean by 'looking this way.'" b) "Okay, I'll restrict your visitors until your face heals." c) "Your friends and family love you no matter what." d) "You're young; your face will heal quickly."

ANS: A "Tell me what you mean . . ." encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assume that the patient is talking about her facial wounds. "I'll restrict your visitors . . ." assumes that the patient is speaking about her facial wounds when she might not be. The other options are examples of false reassurance and do not address the patient's concerns.

A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, "I hate this place; nobody knows how to take care of me or I'd be home by now." Which response by the nurse is best in this situation? a) "You seem angry; what's going on that makes you hate this place?" b) "I'm sorry that we aren't caring for you according to your expectations." c) "You were very sick; don't be angry; you're lucky to be alive." d) "You shouldn't be angry with us; we're trying to help you."

ANS: A "You seem angry; what's going on . . ." encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patient's anger by apologizing ("I'm sorry . . ."). Advising the patient "don't be angry" or "you shouldn't be angry" diminishes the patient's right to be angry.

The nurse completes the nutrition assessment for a 14-year-old female with a BMI of 15. What physical assessment finding might suggest bulimia nervosa? a) Loss of enamel on teeth b) Low level of interest in exercise c) Slightly elevated temperature d) Skin excoriation in skinfolds

ANS: A A BMI of less than 18.5 is considered underweight. Eating disorders are a concern for adolescents, girls more commonly than boys. Signs of anorexia nervosa may include dry, brittle hair and nails, generalized fatigue, constipation, low blood pressure, feeling cold with a lower than normal temperature, amenorrhea, and low BMI. Bulimia is self-induced vomiting (purging) after episodes of binging. In bulimia, the BMI might be low (less than 18.5), normal, or even high (greater than 25). Dental decay and erosion of tooth enamel occur with repeated purging. Most people with an eating disorder, especially those with bulimia nervosa, are preoccupied with exercise. Skin rash and excoriation in skin creases is more common in people with obesity.

The nurse caring for several patients on the intermediate care unit considers which of the following patients to be most at risk for developing an infection? A patient with a/an: a) Centrally venous catheter b) Indwelling urinary catheter c) Colostomy d) Nasoenteric feeding tube

ANS: A A central venous catheter is an invasive intravenous line that is advanced into the central circulation near the heart and may serve as a portal of entry for pathogens to enter a patient's body. Also a risk for infection, but to a lesser degree, an indwelling urinary catheterization may injure the fragile urethral mucosa, provide a direct pathway for pathogens into the bladder, and prevent the normal flushing of the urethra. As normal flora in the intestine that protect the body against infection, a nasoenteric tube into the gut as well as an ostomy (colostomy) are less likely to lead to infection.

Which of the following factors has the greatest positive effect on sleep quality? a) Sleeping hours in synchrony with one's circadian rhythm b) Sleeping in a quiet environment c) Spending additional time in stage III of the sleep cycle d) Napping frequently during the day hours

ANS: A A circadian rhythm is a biorhythm based on the day-night pattern in a 24-hour cycle. Sleep quality is best when the time at which the person goes to sleep and awakens is in synchrony with his circadian rhythm. Not all people require a quiet environment for sleep. Time spent in stage III of the sleep cycle is affected by the total time spent asleep. Napping on and off throughout the day might disrupt the natural circadian rhythm with uninterrupted periods of sleep that cycle through the various stages of the sleep cycle.

Which of the following is considered a "practice" (as opposed to a belief or value)? a) Always drinking water after exercise b) Thinking often about cleanliness c) Placing an emphasis on success d) Maintaining youth

ANS: A A practice is a set of behaviors that one follows, such as always drinking water after exercise. Being preoccupied with cleanliness, placing an emphasis on success, and maintaining youth are examples of values that are dominant in U.S. culture.

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? a) Acute b) Chronic c) Intractable d) Neuropathic

ANS: A Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.

Which statement is most reflective of Madeleine Leininger's theory of cultural care? a) The goal of her theory is to guide research that will assist nurses to provide culturally congruent care. b) The model for cultural competence stresses teamwork in providing culturally sensitive and competent care to improve outcomes for individuals, families, and communities. c) The model focuses on five components of cultural competence: Awareness, skills, knowledge, encounters, and desire. d) The theory focuses on increasing levels of one's consciousness to improve the possibilities to provide culturally competent care.

ANS: A Although Madeleine Leininger does not use the specific term "cultural competence," her theory fits with that concept. The goal of her theory is to guide research that will assist nurses to provide culturally congruent care using her three modes of nursing care actions and decisions. The Purnell model for cultural competence stresses teamwork in providing culturally sensitive and competent care and the Purnell model identifies several levels of consciousness in achieving cultural competence. The Campinha-Bacote model identifies the mnemonic ASKED (awareness, skills, knowledge, encounters, and desire).

The nurse has just administered a subcutaneous insulin injection to her diabetic patient. What is the next immediate action by the nurse? a) Dispose of the needle/syringe uncapped into a disposable sharps container. b) Recap the syringe with needle and dispose into a sharps container. c) Dispose the needle/syringe into a biohazard bag inside the patient's room. d) Separate the needle and syringe and place them into a sharps container.

ANS: A Always place disposable needles, syringes, and other sharp items such as broken glass in a special disposable, sharps container immediately after their use. Never recap or handle any contaminated needle. Biohazard bags are used for contaminated items and equipment related to body fluids that are not to be placed in regular trash containers.

The nurse caring for a patient admitted with severe depression identifies a nursing diagnosis of Hopelessness on the care plan. Which outcome is appropriate for this diagnosis? a) Displays stabilization and control of mood b) Sleeps 6 to 8 hours per night with report of feeling rested c) Does not engage in risky, self-injurious behavior d) Eats a well-balanced diet to prevent weight change

ANS: A An outcome for the nursing diagnosis Hopelessness is "displays stabilization and control of mood." "Sleeps 6 to 8 hours per night and reports feeling rested" and "eats a well-balanced diet to prevent weight change" are example of outcomes for the diagnosis Depressed Mood. "Does not engage in risky, self-injurious behavior" is an outcome for the nursing diagnosis Risk for Suicide.

What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome? a) Promotes fluid retention by increasing the reabsorption of water by kidney tubules b) Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle c) Increases the use of fats and proteins for energy and conserves glucose for use by the brain d) Promotes fluid excretion by causing the kidneys to reabsorb more sodium

ANS: A Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.

The nurse is caring for a patient newly diagnosed with narcolepsy. What is the priority teaching point the nurse would share with the patient? a) Do not drive or operate heavy equipment. b) Men are more likely to be diagnosed than women. c) There is no treatment; symptoms must be managed. d) Getting more sleep will correct narcolepsy.

ANS: A For safety reasons, it is important to advise patients with a sleep disorder to avoid driving or operating heavy equipment until their condition is stabilized. Men and women are equally likely to be diagnosed with narcolepsy. Narcolepsy is treated with central nervous system stimulants that control the symptoms. Although pseudo-narcolepsy may result from inadequate sleep, more sleep will not correct narcolepsy.

An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about whether he should consent to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient? a) Decisional Conflict b) Death Anxiety c) Powerlessness d) Ineffective Denial

ANS: A Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is uncertain about whether he should take the surgical risk. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is suffering from Death Anxiety at this time. Powerlessness is a perceived lack of control over a current situation; this patient is trying to exert some control over his care. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge.

How should the nurse classify pain that a patient with lung cancer is experiencing? a) Radiating b) Deep somatic c) Visceral d) Referred

ANS: A Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. Deep somatic pain is localized and can be described as achy or tender. Cutaneous pain occurs in the superficial layers of the skin or subcutaneous tissue. Radiating pain starts at the source and extends to other locations. Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Visceral pain is not well localized and can be described as tight, pressure, or crampy pain.

The nurse caring for a patient with unresolved anger. For which associated complication should the nurse assess? a) Depression b) Hypochondriasis c) Somatization d) Malingering

ANS: A Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger.

Which food provides the body with no usable glucose? a) Wheat germ b) Apple c) White bread d) White rice

ANS: A Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and white rice all contain carbohydrates, which provide usable glucose.

You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation? a) Epinephrine b) Corticotrophin-releasing hormone c) Aldosterone d) Antidiuretic hormone

ANS: A During the shock phase of the general adaptation syndrome, epinephrine prepares the body to react in an emergency situation by increasing heart rate and blood pressure. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.

A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? a) Caution the patient against combining acetaminophen with alcohol. b) Explain that acetaminophen increases the risk for bleeding. c) Advise taking acetaminophen with meals to prevent gastric irritation. d) Explain that physical dependence may occur with long-term oral use.

ANS: A Even in recommended doses, acetaminophen can cause hepatoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. NSAIDs, not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence.

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate nutritional goal for this patient? The patient will increase his consumption of: a) Bananas, peaches, molasses, and potatoes b) Eggs, baking soda, and baking powder c) Wheat bran, chocolate, eggs, and sardines d) Egg yolks, nuts, and sardines

ANS: A Foods rich in potassium include bananas, peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powder have high sodium content. Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium.

A 13-year-old patient is admitted to the hospital. There is no medical restriction on visitation. To help maintain the patient's social identity while hospitalized, it is most important for the nurse to encourage visits by: a) Peers b) Grandparents c) Siblings d) Parents

ANS: A Peers are more important than family in maintaining social identity in this age group.

Which outcome is most realistic and appropriate in planning care for any newly diagnosed client with anxiety? a) Plans coping strategies for anxious situations b) Discusses the reasons for episodes with significant others c) Establishes two new social relationships d) Verbalizes that he is episode free

ANS: A Identifying the source of the client's anxiety will allow him to recognize the conflict and use his conscious, rational mind to deal with it by identifying and planning strategies for anxiety-producing situations. Expecting the client to be episode free is not realistic, and may put unrealistic expectations on the client. For newly diagnosed clients, establishing two new social relationships, given the energy required for trust to develop, may not be attainable. Discussing the reasons for episodes with significant others is not necessarily realistic or appropriate. The client may experience symptoms as a result of trauma and may have associated feelings of shame.

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? a) Stimulate the patient. b) Prepare to administer naloxone (Narcan). c) Administer a dose of pain medication. d) Notify the physician immediately.

ANS: A If the patient's score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patient's respiratory rate is less than 8 breaths/min; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated.

An elderly patient admitted from a skilled nursing residence to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of Dehydration. Which of the following should lead the nurse to suspect that dementia, rather than depression or dehydration, is the source of the symptoms? a) Rambles, speaks incoherently, answers questions inappropriately b) Speaks slowly with delayed response to questions, but responds appropriately c) Awakens early in the day yet sleeps almost constantly during the day d) Sometimes has difficulty concentrating on details of the present situation

ANS: A In dementia, a patient's language is disoriented, rambling, and incoherent; and the patient responds to questions inappropriately or with "near misses." Speaking slowly and being slow to respond to verbal stimuli are signs of depression; in depression, the patient usually answers questions appropriately. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragmented and the person awakens often during the night. Difficulty concentrating on details is a thinking pattern seen more often in depression; in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment.

To discuss a client's sexual health needs in a comfortable and competent manner, it is most important for a nurse to be able to: a) Recognize and set aside personal biases or experiences related to sexuality b) Perform an accurate and comprehensive physical assessment c) Collect an accurate and comprehensive sexual history d) Acquire theoretical knowledge of sexual health concerns

ANS: A In many cultures, people have been socialized to avoid talking openly about sexuality. As a nurse, you will find that you must discuss a variety of issues that are vital for a client's optimal wellness. Some of these discussions may include sexual concerns, dysfunctions, infections, or behaviors. As you reflect on the issues of human sexuality, you will be challenged to confront your own biases related to sexuality and to set those aside as you work with your clients. Although theoretical knowledge is important, you will be able to use it fully only if you can identify and set aside your own biases.

The nursing student tells her instructor, "My patient is Jewish and when I tried to teach her about her antihypertensive medication she said, 'I'd rather eat chicken soup than take those medications.'" What is the most appropriate response by the instructor? a) "This is common folk medicine among some Jewish people. You can talk to her about taking her medications and eating chicken soup." b) "There is no scientific evidence to support chicken soup as a substitute for antihypertensive medications. Maybe you should do some research on this." c) "The patient can make her own choices and decisions, and there is nothing we can do about this." d) "You can tell the patient she can eat her soup, but she needs to understand that she has to take her medications first."

ANS: A It is not uncommon for any group, including those of the Jewish faith, to practice folk medicine and use folklore remedies. Chicken soup is a folk medicine, although it certainly may have some health value unrelated to hypertension. Folk medicine is defined as the belief and practice that the members of a group follow when they are ill as opposed to more conventional (biomedical or professional) standards. In this item, the most appropriate response by the instructor is to ask the student to talk to her patient about using both, as neither will interfere with the other and the patient most likely needs the antihypertensive medications. Asking the student to complete some research may be appropriate at another time, but this response will not assist the student in working with her patient. A patient can make his or her own choices and decisions but it is more appropriate to talk to the patient, provide some teaching, and gain insight before just "throwing in the towel."

The nurse is caring for a patient with a significant history of hypertension and cardiovascular disease. The nurse would be most interested in the findings of which laboratory results? a) Low-density lipoproteins (LDL) and high-density lipoproteins (HDL) b) Fatty acids such as alpha-linolenic acid (omega-3) c) B-complex vitamins d) Vitamin K

ANS: A Low-density lipoproteins (LDLs) transport cholesterol to body cells. Diets high in saturated fats increase LDL circulation in the bloodstream and may result in fatty deposits on vessel walls, causing cardiovascular disease. As a result, LDL is often known as the "bad cholesterol." High-density lipoproteins (HDLs) remove cholesterol from the bloodstream, returning it to the liver, where it is used to produce bile; thus, a high HDL is considered protective against cardiovascular disease. It is often known as the "good cholesterol." Vitamin K is involved in blood clotting. B-complex vitamins' primary function is cellular metabolism. Linolenic acid (omega-3) helps to protect against heart disease but does not indicate cardiovascular disease.

The nurse is caring for a patient with a history of depression and hypertension. The patient states, "Sometimes I just don't believe in using all the medications the doctor orders for me, so I use a lot of over-the-counter herbal medications." What is the most appropriate response by the nurse? a) "Yes, there are many good herbal therapies, but you'll want to let your doctor know about these therapies in addition to the medications he has ordered for you." b) "Some over-the-counter medications work very well for depression; however, you cannot take them without your doctor's permission." c) "You shouldn't be treating yourself, as you don't know how these medications work with your depression." d) "I think it's a great idea! If they make you feel better, then continue doing what you're doing."

ANS: A Many people use herbal therapies to relieve symptoms of anxiety and depression. Patients may self-treat, or herbal therapies may be prescribed by complementary and alternative modalities (CAM) practitioners. The nurse should assess for CAM use to be sure the method is not contraindicated and that the patient has informed the primary care provider about their use. While CAM can be effective, many of these modalities such as ginkgo biloba, ginseng, and kava have side effects, cause adverse reactions, and are contraindicated with other medications. The nurse should neither approve nor disapprove of the patient's actions, but should make clear that the physician should be informed about all medications, including over-the-counter ones.

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct?" a) "The virus mutates too rapidly to develop a vaccine." b) "Vaccines are developed only for very serious illnesses." c) "Researchers are focusing efforts on an HIV vaccine." d) "The virus for the common cold has not been identified."

ANS: A More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold.

The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? a) Distraction b) Guided imagery c) Sequential muscle relaxation d) Hypnosis

ANS: A Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state.

The nurse is checking the gastric aspirate for the patient receiving tube feedings. She notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3. Which action should she take? a) Stop the feeding immediately; then notify the prescribing provider. b) Hold the tube feeding for 2 hours; continue if residual is less than 200 mL. c) Flush tube with 30 mL of sterile water; resume tube feeding at prescribed rate. d) Administer a promotility agent as prescribed; resume feeding in 1 hour.

ANS: A Normal gastric fluid should be clear, green, and acidic (pH 5.0). If the gastric aspirate is pale yellow and cloudy with a pH of 7.3 (alkaline), the nurse must stop the tube feeding immediately and notify the prescriber of the feedings. This finding might indicate the feeding tube has migrated to the lungs, which could lead to aspiration pneumonia and become a medical emergency. Holding the feeding for 2 hours and continuing after that could lead to aspiration pneumonia because the quality of the fluid indicates the placement of the tube is in the lungs. Flushing the tube and resuming feedings when the feeding tube is in the lungs could lead to a medical emergency. A promotility agent (e.g., metoclopramide) would be given if the patient has gastric residual volume (GRV) of 250 mL or more for two consecutive checks. However, if the GVR is more than 500 mL, the nurse would stop the feeding and reassess the patient.

The patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which of the following best describes this type of infection? a) Nosocomial b) Healthcare associated c) Multidrug-resistant organisms (MDRO) d) Unavoidable occurrence

ANS: A Nosocomial infections refer specifically to hospital-acquired infections. Healthcare-associated infections (HAIs) refer to infections associated with healthcare given in any setting (hospitals, long-term care facilities); however, nosocomial is more specific. A multi-drug-resistant organism (MDRO) is a bacterium that is resistant to many antibiotics. Examples of MDROs include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Indwelling urinary catheters are needed in many circumstances, and might be unavoidable in that sense. However, the infection itself is not unavoidable because it can be prevented in most instances with meticulous nursing care. Therefore "unavoidable occurrence" is an incorrect option.

To provide the most analgesic effect, a medication should bind with and block the pain impulse especially at which of the following opioid receptor sites? a) Mu b) Delta c) Kappa d) Sigma

ANS: A Opiate receptors include mu, delta, kappa, and sigma receptors; however, mu receptors are most effective in relieving pain.

What are patterns of waking behavior that appear during sleep known as? a) Parasomnias b) Dyssomnias c) Insomnia d) Hypersomnia

ANS: A Parasomnias are patterns of waking behavior that appear during sleep. Sleepwalking, sleep talking, and bruxism are parasomnias.

What is the primary reason the nurse incorporates pain assessment as a part of vital signs measurement? a) Asking about pain may prompt patients to report pain more readily. b) Frequent pain assessment is required by the state's nurse practice act. c) Pain is a vital sign much like blood pressure and heart rate. d) Pain assessment indicates the nurse cares about the patient.

ANS: A Patients often internalize their pain experience. Therefore, a regular pain assessment helps the nurse and patient to communicate and better collaborate on the goals of pain therapy and ways to achieve better pain relief. The nurse practice act does not specify timing of interventions. Pain is not a vital sign; instead, pain assessment might be performed regularly, just like a vital sign assessment, for more effective pain management. Although asking how the patient feels and to rate the intensity and describe the quality of pain is an indication of caring, the goal of pain assessment is to optimize pain management.

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? a) Anticoagulant therapy b) Diabetes mellitus c) Hypertension d) Embolectomy

ANS: A Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm.

The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients? a) Iron b) Vitamin A c) Protein d) Vitamin C

ANS: A Patients with iron deficiency may have spoon-shaped, brittle nails. Other abnormal nail findings include dull nails with transverse ridge (protein deficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneath nails (protein or caloric deficiency).

Which of the following explanations by the nurse would be the best description of personal identity? a) A continually evolving sense of individuality and uniqueness b) The same as demographic data c) A person's genetic and cultural heritage d) Individual information guarded to avoid identity theft

ANS: A Personal identity is a person's view of himself as a unique human being, different and separate from all others. Identity develops over time, beginning in childhood when a child identifies with his parents, and then later with teachers, peers, and others, and once developed is relatively constant and consistent. Personal identity can be influenced by culture and learned through socialization.

At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful? a) Decreased blood pressure b) Decreased peripheral skin temperature c) Increased heart rate d) Increased respiratory rate

ANS: A Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate.

Should a bioterrorism event occur, what factor is most important in minimizing the effects of such an event? a) Rapidly recognize unusual disease patterns and detect the presence of unusual infectious diseases. b) Communicate any extraordinary events to the organization's safety officer. c) Report any suspicious findings to the Centers for Disease Control and Prevention. d) Institute a community-wide education program for standard precautions and handwashing.

ANS: A Should a biological event occur, either as a result of bioterrorism or a naturally occurring epidemic, a key factor in minimizing its effects is the ability to quickly recognize unusual disease patterns and detect the presence of infectious diseases. This is the best answer to minimize effects of an event. However, the healthcare worker would also follow a reporting process of notifying the safety officer of the facility along with the CDC.

A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? a) Sodium b) Potassium c) Phosphorus d) Magnesium

ANS: A Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures. Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia. Phosphorus excess leads to tetany and seizures. Magnesium excess causes weakness, nausea, and malaise.

The primary focus of your interventions for a 6-year-old child who sleepwalks would be to: a) Maintain patient safety during episodes of somnambulation b) Administer and teach about medications to suppress stage III sleep c) Encourage the child to verbalize feelings regarding sleep pattern d) Provide a quiet environment for nighttime sleep

ANS: A Sleepwalking places the patient at Risk for Injury because of his lack of awareness of the surroundings. The nurse's primary intervention would be to protect the patient from injury (e.g., falls) while sleepwalking, also called somnambulation. Because the child is only 6 years old, administering and teaching about medications and having him verbalize feelings would not be useful. Providing a quiet environment would likely be ineffective and certainly not the focus of interventions.

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? a) Folic acid b) Calcium c) Protein d) Vitamin D

ANS: A The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needs also increase during pregnancy; however, their consumption does not prevent neural tube defects. Vitamin D consumption does not prevent neural tube defects.

Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain? a) Selective serotonin reuptake inhibitor b) Selective norepinephrine reuptake inhibitor c) Opioid analgesic d) Anti-emetic

ANS: A The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, such as atomoxetine (Strattera), are commonly used for attention deficit-hyperactivity disorder. If a narcotic is used for a long time (oxycodone [Oxycontin]), it may become habit forming (causing mental or physical dependence). Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An antiemetic, such as ondansetron (Zofran), is used to control for nausea and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an antiemetic to control the side effect.

The nurse is developing a plan of care for a patient admitted following a motor vehicle accident (MVA) who reports regularly sleeping only 2 to 3 hours per night. The patient says this is the third MVA he's been involved in this year. The patient thinks he might have been asleep when he got into the accident. What is the most appropriate nursing diagnosis for this patient? a) Insomnia b) Sleep Deprivation c) Disturbed Sleep Pattern d) Risk for Injury

ANS: A The most appropriate nursing diagnosis for this patient is Insomnia. The duration of quality sleep is inadequate and it is impairing the patient's daily functioning (e.g., multiple MVAs caused by sleep while driving). Sleep Deprivation would not be appropriate because the patient is not describing symptoms associated with lack of sleep. Disturbed Sleep Patterns would not be indicated because this patient's lack of sleep is a regular occurrence and not time limited. Although this patient may be at risk for self-injury due to lack of sleep, this diagnosis does not address the cause of the problem; therefore, it would not be the best choice.

When should the nurse assess pain? a) Whenever a full set of vital signs is taken b) During the admission interview c) Every 4 hours for the first 2 days after surgery d) Only when the patient reports pain

ANS: A The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia.

A patient is prescribed morphine sulfate 4.0 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? a) Monitor the patient's respiratory status. b) Auscultate the patient's heart sounds. c) Check blood pressure in supine and sitting positions. d) Monitor the patient for psychological drug dependence.

ANS: A The nurse should assess the patient's respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to check blood pressure while the patient lies down (supine position) and sits up. Psychological dependence occurs rarely even after long-term prescribed use of morphine. Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drug dependence.

A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? a) "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." b) "You really need to continue breastfeeding your baby." c) "Give your baby formula until he is 6 months old; then you can introduce whole milk." d) "Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day."

ANS: A The nurse should not make the mother feel guilty about her decision to begin bottle feeding to supplement breastfeeding. Instead, she should educate the mother about best practices for bottle feeding. She can give it to supplement any stored breast milk she might have in supply. She should emphasize the importance of giving the baby iron-fortified formula because fetal iron stores become depleted by 4 to 6 months of age. Infants younger than 1 year of age should not receive regular cow's milk because it may place a strain on the immature kidneys. Because the baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 80 to 100 mL of formula or breast milk per kilogram of body weight per day.

The nurse is caring for a patient in the hospital. The patient states, "No matter what happens to me, I believe my path is already predetermined. Nothing is going to change my destiny." This patient is most likely exhibiting: a) Fatalism b) Hopelessness c) Lack of faith d) Self-pity

ANS: A The patient is exhibiting fatalism. Fatalism, which is rooted in Buddhism, views fatal diseases as destined by nature and acceptance as a sign of wisdom and maturity. In this view, diseases are predetermined with a predictable outcome. Faith is an evolving pattern of believing that grounds and guides us, helps us make sense of the world, and helps us confront the challenges we face. It allows us to trust and to maintain an optimistic perspective on life events and to find purpose in life. Hope is a dynamic process that reflects a positive orientation towards future outcomes. There is no evidence in this item that this patient is exhibiting self-pity or hopelessness.

What is typically the most reliable indicator of pain? a) Patient's self-report b) Past medical history c) Description by caregiver(s) d) Behavioral cues

ANS: A The patient's self-report is the most reliable indicator of pain. A patient's facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patient's experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. Sociocultural factors can influence a patient's nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression or anxiety, can influence the perception of pain.

Which portion of a nutritional assessment must the registered nurse complete? a) Analyzing the data b) Obtaining intake and output c) Weighing the patient d) Obtaining the history

ANS: A The registered nurse should review and interpret (analyze) the data collected as part of a nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to the licensed practical nurse.

A patient tells the nurse, "I feel that God has abandoned me. I am so angry that I can't even pray." The patient refuses to see his minister when he calls. Which is the most appropriate nursing diagnosis for this patient? a) Spiritual Distress b) Risk for Spiritual Distress c) Impaired Religiosity d) Moral Distress

ANS: A This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress exists, not the potential problem, Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the minister, but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action.

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? a) Blood pressure 160/82 mm Hg b) Temperature 100.6°F c) Heart rate 80 beats/min d) Oxygen saturation 95%

ANS: A This patient has an elevation in blood pressure, which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.

The nurse is caring for an immobile patient with chronic, unrelieved pain that is frequently severe. For what potential complication should the nurse monitor? a) Deep vein thrombosis b) Hypotension c) Dehydration d) Hypoglycemia

ANS: A This patient has an existing mobility problem. Unrelieved, chronic pain further contributes to reduced activity, which can lead to venous stasis and hypercoagulation. This combination of factors puts the client at risk for deep vein thrombosis. Hypertension is more likely to result than hypotension. Fluid overload, rather than dehydration, is more likely to occur secondary to excessive aldosterone, ADH, cortisol, angiotensin II, catecholamine, and prostaglandin secretion. Owing to decreased insulin production in immobility, hyperglycemia is more likely to result than is hypoglycemia.

A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient? a) Imbalanced Nutrition: More Than Body Requirements b) Risk for Imbalanced Nutrition: More Than Body Requirements c) Imbalanced Nutrition: Less Than Body Requirements d) Readiness for Enhanced Nutrition

ANS: A This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses.

The nurse is assigned a patient scheduled for a penectomy as treatment for penile cancer. The patient says, "I am going to be a freak. I won't be a man after surgery." The nurse recognizes that the patient connects having a penis with which aspect of sexuality? a) Role and identity b) Eroticism c) Intimacy d) Reproduction

ANS: A This patient is questioning his identity and role as a man after removal of his penis. The patient is not discussing concerns about eroticism or sexual function. The patient is not expressing concern about intimacy with a sexual partner. The patient is not talking about having children or the ability to reproduce at this time.

Which type of medicine do those of the Hindu faith typically practice? a) Ayurvedic medicine b) Western medicine c) Chiropractic medicine d) Tribal medicine

ANS: A Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of "hot" and "cold" foods, which have nothing to do with temperature or degree of spiciness. People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or tribal medicine. Native Americans practice tribal medicine or remedies that incorporates natural remedies.

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? a) Endogenous nosocomial b) Exogenous nosocomial c) Latent d) Primary

ANS: A Thrush in this patient is an example of an endogenous nosocomial infection. This type of infection arises from suppression of the patient's normal flora as a result of some form of treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is HIV infection. A primary infection is the first infection that occurs in a patient.

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? a) Closing the patient's door to limit room traffic while preparing the sterile field b) Using clean procedure gloves to handle sterile equipment c) Placing the nonsterile syringes containing flush solution on the sterile field d) Remaining 6 inches away from the sterile field during the procedure

ANS: A To maintain sterile technique, the nurse should close the patient's door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination.

During which of the following developmental stages does a person tend to need the most hours of sleep? a) Toddler b) Adolescence c) Middle adulthood d) Older adulthood

ANS: A Toddlers (ages 1 to 3 years) require 12 to 14 hours of sleep in a 24-hour period. Adolescents (ages 12 to 18 years) usually need 8 to 9 hours in a 24-hour period. Middle-aged adults (ages 40 to 65 years) typically require 7 hours in a 24-hour period. Older adults (age 65 years and older) often need 5 to 7 hours of sleep in a 24-hour period.

The nurse is caring for a patient with cancer who has been receiving chemotherapy. Based on Maslow's Hierarchy of Needs, which nursing intervention is your first priority? a) Assess for and treat pain. b) Determine whether the patient is hungry or thirsty. c) Explore feelings about dying. d) Observe client's self-care abilities.

ANS: A Untreated pain affects all biological/physiological needs. So, treating pain comes first. According to Abraham Maslow and his Hierarchy of Needs, lower-level needs (physiological) must be met before higher needs can be achieved. Maslow's hierarchy tells you that until the pain (physiological need) is controlled, the patient cannot consider exploring feelings or participating in self-care.

Which special consideration may the nurse need to make when caring for a female Rastafarian patient? a) Allow the patient to wear her own clothing. b) Provide a diet that is caffeine free. c) Allow the patient to wear jewelry with religious symbols. d) Provide free-flowing water for bathing.

ANS: A Wearing second-hand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea; however, some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible.

Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope: a) Could be used by the patient to hurt her b) Might cause the patient not to trust her c) Would distract her from focusing on the patient d) Will function as another stressor for the patient

ANS: A When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as a weapon to harm the nurse should be removed before entering the patient's room. It is unlikely a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely don't even notice their presence.

Why is it important for you as a nurse to understand stress and adaptation? Select all that apply. a) You need to identify your own stressors and develop healthy adaptation responses. b) Understanding stress will help you identify client stressors and adaptive responses. c) Understanding stress will help you balance stress for your patients. d) There are very specific adaptation strategies used for all patients and nurse must know them.

ANS: A, B As a nurse, you need to understand stress to help your clients cope effectively and adapt to the stressors of illness and caregiving. In addition, you will encounter many stressful situations in your own career, so you must develop healthful ways of responding. Nurses cannot alone balance the stress for a patient but rather assist the patient in identifying the stressors and adaptive responses that will "fit" for the patient. There are many adaptation strategies, but not all strategies will help all patients, as each patient is different.

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) is an incomplete protein that should be consumed with a complementary protein? Select all that apply. a) Whole grain rice b) Lentils c) Soybeans d) Egg whites e) Quinoa

ANS: A, B Incomplete protein foods do not provide all of the essential amino acids necessary for protein synthesis. By combining two or more incomplete proteins, a complete (whole) protein may be formed. The amino acids missing from one source can be made whole by adding another protein that contains that missing amino acid. For example, legumes (lentils) and grains (rice) with yellow peppers make a healthy meal using complementary proteins. Other examples are nuts (peanut) with legumes (black beans) in a salad. Dairy (yogurt) and seeds (sunflower and flax seeds) also work this way. Egg whites, soybeans, and quinoa are examples of complete proteins.

The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fats? Select all that apply. a) Palm oil b) Coconut oil c) Canola oil d) Peanut oil e) Safflower oil

ANS: A, B Palm and coconut oils are sources of saturated fat that are contained in many processed foods. The patient should be encouraged to read product labels to eliminate them from his diet. Olive, canola, and peanut oils are monounsaturated fats that tend to lower LDL cholesterol (the "bad" cholesterol). These should be substituted for saturated fats in the diet. Polyunsaturated fats that also tend to lower blood cholesterol are found in plant sources, such as sunflower, safflower, soybean, corn, and cottonseed.

The school nurse at the elementary school is preparing a presentation for parents on promoting self-esteem in children. What are some self-esteem promotion strategies she will teach at the presentation? Select all that apply. a) Treat children with respect. b) Be firm and consistent in applying rules. c) Do not allow children to make decisions independently. d) Provide frequent positive and negative criticism.

ANS: A, B Teaching parents to promote self-esteem in children is important. Some effective strategies include spending one-on-one time with the child as often as possible, refraining from frequent negative criticism, having clearly defined limits and consequences for breaking rules, being firm and consistent in applying rules, making sure rules are reasonable, treating the child with respect, and allowing some latitude for individual actions within defined limits.

The Centers for Disease Control and Prevention (CDC) is a federal agency devoted to infection control and prevention in healthcare settings. What are the goals of the CDC? Select all that apply. a) Reduce catheter-associated adverse events (infections) by 50% b) Reduce targeted antimicrobial-resistant bacterial infections by 50% c) Reduce all healthcare-associated infections by 75% d) Establish guidelines for safety, knowledge, and skills to reduce infections

ANS: A, B The Centers for Disease Control and Prevention (CDC) is a federal agency devoted to infection control and prevention in healthcare settings. Many healthcare facilities' policies and procedures are based on the CDC guidelines. Among its many goals for healthcare facilities, the CDC is advocating for a reduction in catheter-associated adverse events (infections) of 50% and a reduction of targeted antimicrobial-resistant bacterial infections of 50%. Guidelines specific to safety, knowledge, and skills to reduce infections are nursing competencies related to QSEN.

What are some strategies a new nurse can use to develop skills in achieving cultural competence? Select all that apply. a) Read the literature and study nursing theories and principles pertaining to culture b) Take advantage of as many opportunities as possible to interact with persons from diverse cultures c) Recognize that persons from different cultures have different healthcare practices but for safety purposes, need to follow the medical and nursing plan of care d) Understand basic practices of the most common cultures so he can choose the best interventions to care for patients from those cultures

ANS: A, B There are numerous strategies to assist in increasing one's skill level in cultural competency. These include the following: Keep learning; read as much as you can and study nursing theories and principles pertaining to culture. Take advantage of every opportunity to interact with persons from different cultural groups. Make an effort to incorporate beliefs and practices from various cultures into your nurse care and teaching materials. However, although it is important to understand basic practices of the most common culture, one cannot make generalizations about that culture. Each patient is unique and influenced by his culture but not defined by it. Recognizing that persons from different cultures have different healthcare practices is important; however, we cannot force or coerce patients into following our (medical or nursing) healthcare practices.

The nurse is obtaining her patient's health history related to infections. What are appropriate questions the nurse will ask the patient? Select all that apply. a) "Have you recently traveled out of the country?" b) "How would you describe your current stress level?" c) "Do you know your approximate weight?" d) "What is your normal blood pressure and heart rate?"

ANS: A, B To elicit information related to infection, ask the patient about any exposure to pathogens in the environment, recent travel outside the country, ingestion of any unusual foods, medications, current stress level, immunization history, and symptoms of any illness. Asking the patient about her weight and normal BP and heart rate are important information but these questions will not elicit the information needed related to infection.

The nurse assigned to an oncology unit reports that three of the patients with cancer do not have an appetite and have eaten little during the shift. What strategies can the nurse on the next shift use to increase her patients' appetites? Select all that apply. a) Offer frequent, smaller meals. b) Keep the patients' rooms neat and clean. c) Provide or assist with frequent oral hygiene. d) Increase liquid intake with meals. e) Serve foods with little aroma.

ANS: A, B, C Illness, with any accompanying pain, anxiety, and medications, often causes appetite loss. To improve appetite and intake and, subsequently, nutritional status, the nurse would offer frequent and smaller meals; keep the patient's environment neat and clean and free of unpleasant sights, odors, and medical equipment; order a late food tray or warm the food; provide or assist with frequent oral hygiene; provide a pleasant eating environment; serve foods attractively; control pain; encourage meals with family and friends; and position the person comfortably for mealtime. Fluids are usually not increased with meals to prevent gastric distention and feeling full before the patient consumes sufficient nutrients.

The nurse meets with a patient with chronic pain who has tried a new program to manage pain. On a scale of 1 to 10, she reports pain reduction from an 8 to a 5. What questions would the nurse ask to further evaluate the effectiveness of this program? Select all that apply. a) "Does this reduction in pain allow you to perform daily activities?" b) "Are you satisfied with the degree of pain relief you have achieved?" c) "May I review what you have recorded in your pain journal?" d) "Is the pain less than before you started the program?" e) "How has your family responded to the reduction in your pain?"

ANS: A, B, C The nurse needs to determine what this reduction in pain means to the lifestyle of the patient because a pain level even as low as 5 may still diminish the patient's ability to function. The goal of pain management is for the patient to achieve satisfaction with the amount of pain relief obtained. Each patient's pain experience is individual, and the amount of pain that a person can tolerate varies. A pain journal can help the nurse to evaluate the effectiveness of analgesic therapy as well as the patient's feelings about the chronic pain. The nurse already knows the pain has diminished from an 8 to a 5, so this question is not necessary. The family is most likely happy that she feels better, so this question is not worded in a way to obtain important data.

A nurse on a medical-surgical unit asks a licensed practical nurse (LPN) to help with nutritional assessments for newly admitted patients. What part of the nutritional assessment can be delegated to the LPN? Select all that apply. a) Height and weight b) Intake and output c) Nutritional history d) Interpreting laboratory findings e) Body fat measurement

ANS: A, B, C The registered nurse can safely delegate to the licensed practical nurse (LPN/LVN) the measurement of weight, height, body fat, hip-waist ratio, and other anthropometric measures. The LPN/LVN can document intake and output and obtain the patient's nutritional history. However, the registered nurse is responsible for reviewing and interpreting the findings of the nutritional assessment, including laboratory values.

A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scales would be appropriate to use with this patient? Select all that apply. a) Visual analogue b) Numerical rating c) Wong-Baker face rating d) Simple descriptor e) PAINAD scale

ANS: A, B, C The visual analogue requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty with the abstract nature of this scale. The Wong-Baker face rating scale uses simple illustrations of faces to depict various levels of pain. The scale was developed for children but has proved effective for adults with communication and cognitive impairments. When using the numerical rating scale, the patient must choose a number from 0 to 10 to denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia; however, it would be appropriate to try it if the face-rating scale is not available. Patients commonly find the simple descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity. The Pain Assessment in Advanced Dementia (PAINAD) scale is a five-item, observational tool, specifically geared to older adults with dementia.

The pediatric nurse is preparing a teaching plan about vitamins for parents of school-age children. What vital information will the nurse include in the plan? Select all that apply. a) Vitamins are needed for cellular metabolism. b) Vitamins are necessary for preventing particular deficiency diseases. c) Because the body does not make vitamins, they must be supplied by the foods we eat. d) The most important vitamin for children is vitamin C. e) Vitamin C toxicity occurs in people with liver dysfunction.

ANS: A, B, C Vitamins are organic substances that are necessary for metabolism or preventing a particular deficiency disease. Because the body cannot make vitamins, they must be supplied by the foods we eat. Vitamins are critical in building and maintaining body tissue, supporting our immune system so we can fight disease, and ensuring healthy vision. There is no reference that children need any other specific vitamin, such as vitamin C, more than others; all are important for healthy bodily functions. Because vitamin C is soluble in water, any excessive amount is regularly excreted by the kidneys into the urine. Thus, toxicity is rare except in people with renal disease—not liver disease.

The nurse admitting a new patient to the medical-surgical unit is conducting a dietary history. What information should the nurse include? Select all that apply. a) Basic eating habits b) Food preferences c) Attitude toward food d) A body mass index (BMI) e) Cultural dietary restrictions

ANS: A, B, C, D A nurse can obtain a dietary history during any routine assessment. The purpose is to collect baseline information about the patient's basic eating habits, food attitudes and preferences, cultural factors, and use of dietary supplements. A dietary history creates a picture of the patient's food habits and eating behaviors. A body mass index (BMI) is not part of the dietary history, although it is sometimes a part of a total nutritional assessment.

Select the factors known to affect sleep. Select all that apply. a) Age b) Environment c) Lifestyle d) State of health e) Ethnicity

ANS: A, B, C, D Age, environment, lifestyle, and state of health are factors affecting sleep. Many older adults sleep less but require more rest. Alcohol, caffeine, and nicotine use and diet are examples of a lifestyle factor that affects sleep. When a person is ill, she may sleep more or find that she cannot sleep because of pain or other factors associated with illness. Changes in environment also affect sleep.

What are common reasons that a female victim of abuse might not report an incident of sexual assault? Select all that apply. a) Fear that her boyfriend would be angry if she reported it and would hurt her again b) Belief that she was to blame for starting a fight with her boyfriend c) Idea that the legal system couldn't prosecute him for the crime against her d) Desire to have the incident behind her, as if it never happened in the first place

ANS: A, B, C, D Reasons for not reporting sexual assault include fear of the assailant, fear of consequences to the assailant, knowledge of the low conviction rate for perpetrators of assault, the desire to avoid a trial, shame and embarrassment, past sexual history, self-blame, and wanting to "move on" and not face possible consequences involving pregnancy and sexually transmitted infection.

A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." Why do you recognize this reaction as Anxiety rather than Fear? Select all that apply. a) It concerns future or anticipated events. b) It concerns anticipation of danger rather than a present danger. c) There is no shakiness or tearfulness present. d) There is a psychological rather than a physical threat.

ANS: A, B, D Anxiety is an emotional response related to future or anticipated events. Fear is a cognitive response to a present, usually identifiable, source. Anxiety results from psychological conflict, whereas Fear can result from either a psychological or physical threat. Shakiness and tearfulness may occur in both Anxiety and Fear, which share several defining characteristics; therefore, those symptoms cannot be used to differentiate Anxiety from Fear.

Which statement(s) is/are most true about the concept of acculturation? Select all that apply. a) A person who accepts both his own culture and a new culture and adopts elements of each has been acculturated. b) It is theorized that it can take years and even generations for an immigrant group to acculturate. c) A person who gradually learns and takes on the essential values, beliefs, and behaviors of the dominant culture has been acculturated. d) Acculturation is the outgrowth of a minority group's need to survive and flourish in a new culture.

ANS: A, B, D Immigrants or new members of a group or country assume the characteristics of that culture through a learning process called acculturation. A person who is acculturated accepts both his own and the new culture, adopting elements of each. Acculturation is the outgrowth of the minority group's need to survive and flourish in the new culture. Many experts theorize that it takes years, perhaps three generations, for an immigrant group to become acculturated. Assimilation occurs when the new members gradually learn and take on the essential values, beliefs, and behavior of the dominant culture.

The nurse has finished teaching a class for adolescents and young adults on sexually transmitted infections (STIs) and safe sexual practices. The nurse determines further teaching is needed when which statements are made? Select all that apply. a) "It is important for me to avoid STIs, so I will get a prescription for birth control pills." b) "I cannot contract an STI if we only perform oral sex on one another." c) "I should see my provider to be tested if I experience burning on urination." d) "If I contract an STI, it isn't my fault because I had sex with only one person." e) "I need to have a discussion with my sexual partner about our past sexual histories."

ANS: A, B, D Oral birth control pills will not protect the individual from STIs; it is incorrect and indicates the need for further teaching. STIs can be transmitted through oral sex, which involves an exchange of body fluids; therefore, further teaching is needed. Blaming the partner suggests that the person is not taking personal responsibility; therefore, teaching is needed to encourage actions of self-protection from STIs. A person should see a provider with symptoms of burning on urination; the statement is correct and would not indicate the need for further teaching. Partners should discuss sexual histories with each other; that statement is correct and does not indicate need for further teaching.

The nurse is caring for a patient admitted to the hospital's hospice unit with terminal cancer and acute cancer pain. What factors does this patient have that will interrupt circadian rhythms? Select all that apply. a) Pain b) Fear c) Frequent vital signs d) Noise e) Lights

ANS: A, B, D Pain can disrupt circadian rhythms and make sleep difficult. Fear of the unknown, such as fear of death, can disrupt circadian rhythms and make sleep difficult. Noise in the facility can disrupt circadian rhythms and make sleep difficult. Vital signs would not be taken at night for a patient who is terminal, as changes in vital signs will not require interventions or alter outcome. Lights in the patient's room in a hospice unit should be turned out to avoid alterations in circadian rhythm and the door to the room can be closed to block out light from the hallway.

The nurse is caring for a patient in the late stage of Alzheimer's disease who is noncommunicative. The nurse suspects the patient is experiencing pain based on what assessment findings? Select all that apply. a) Rapid blinking b) Labored breathing c) Reduced respiratory rate d) Nighttime wakefulness e) Restlessness

ANS: A, B, E Rapid blinking can be seen as an indicator of pain in the noncommunicative older adult. Pain should be a consideration when any patient suddenly develops labored breathing. Restlessness is a common finding in patients with pain, often secondary to attempting to find a position of comfort. Respiratory rate is more likely to increase than decrease when the patient experiences pain, especially with acute pain. Nighttime wakefulness often occurs when pain is experienced.

Which assessment finding(s) might suggest that the patient has low self-esteem and requires more in-depth assessment? Select all that apply. a) Infrequent eye contact b) Straight posture c) Overly critical of others d) Careful grooming

ANS: A, C Assessment findings that suggest low self-esteem include avoiding eye contact and being overly critical of others. You would not need to follow up if the person displayed straight posture and careful grooming.

A client is admitted to the psychiatric unit of a local hospital. During the nursing assessment, the nurse finds the client is poorly groomed, wearing dirty clothes, tearful, and reports weight loss with poor appetite. The nurse formulates a nursing diagnosis of Depressed Mood. What are the most appropriate nursing outcomes for this client? Select all that apply. a) Eats a well-balanced diet b) Depressed mood resolves by discharge c) Bathes, washes, and maintains grooming and hygiene d) Develops a spiritual belief system or engages in a religious affiliation

ANS: A, C Based on the description of this client in this item, the nurse has developed the nursing diagnosis of Depressed Mood. Appropriate outcomes include eating a well-balanced meal and maintaining grooming and hygiene; both of these may be neglected when a client is depressed. The nurse can discuss and explore spirituality with this client; however, this outcome may or may not contribute to resolution of a problem of Depressed Mood. Additionally, an appropriate outcome may be that the client reports feeling less sad and depressed; however, it may not be realistic or attainable that this client's depressed mood will be resolved by discharge.

What are the best communication strategies that a nurse can use to encourage patients to share personal and sensitive information? Select all that apply. a) Be aware of your own biases and personal opinions with regard to the patient's information. b) Use very specific yes and no questions during the interview to keep the patient focused and attentive. c) Start an interview by asking very broad questions and then proceed to more specific questions. d) Avoid any questions related to cultural and gender-specific details about the person of family members.

ANS: A, C Psychosocial information is personal and sometimes sensitive. To encourage patients to share this information, the nurse will need to use good communication skills. For example, be aware of your own biases and discomforts that could influence your assessment, use active listening, proceed from general details and questions to specific details and questions, use an open and positive tone of voice, use open-ended questions (not yes and no questions), and be respectful and sensitive to cultural and gender-specific details. This does not mean you should avoid questions related to culture and gender.

What statements best describe the association between smoking and pulmonary infections? Select all that apply. a) Smoking interferes with respiratory functions, including the ability to move the chest, cough, and sneeze. b) Smoking increases alveolar elasticity, leading to overproduction of mucus that leads to pulmonary infections. c) Smoking decreases movement of the cilia in the lower airways, creating a favorable environment for bacterial growth. d) Nonsmokers chronically exposed to secondhand smoke have minimal risk for pulmonary infections.

ANS: A, C Smoking is a major risk factor for pulmonary infections. Smoking interferes with normal respiratory functioning, including the ability to move the chest, cough, sneeze, or have full air exchange. Smoking reduces alveolar elasticity; this interferes with oxygen exchange and reduces the lungs' effectiveness in clearing mucus, leading to pulmonary infections. Chemicals in tobacco paralyze cilia; thus, secretions pool in the lower airways, creating a hospitable environment for bacterial growth. Although tobacco users are most profoundly affected by these changes, people chronically exposed (bartenders, children of smokers) are also affected by these changes and are at increased risk for infection.

Which of the following protect(s) the body against infection? Select all that apply. a) Eating a healthy well-balanced diet b) Being an older adult or an infant c) Engaging in leisure activities three times a week d) Exercising for 30 minutes 5 days a week

ANS: A, C, D Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection.

The nurse is developing a plan of care for a client with anxiety. What are appropriate nursing interventions the nurse can use for assisting the client in reducing anxiety? Select all that apply. a) Assist the client to identify triggers and situations that create anxiety. b) Be vague in answering questions because you can't know how the client will react. c) Develop coping strategies and behavior modification techniques with the client. d) Remind the patient that he must not engage in any negative thinking.

ANS: A, C Specific nursing interventions for reducing anxiety include providing a calm and safe environment, establishing a trusting and caring relationship, helping the client identify triggers and situations that create anxiety, developing coping strategies and behavior modification techniques, and using clear and factual knowledge tailored to the client's circumstances. Although the nurse should discourage negative thinking, the nurse cannot tell the client that he cannot use it. The nurse should avoid using such terms as "shouldn't" or "you ought to," as these can be interpreted as being judgmental.

What are some activities nurses can do to gain a broader view of spirituality? Select all that apply. a) Develop critical and reflective thinking abilities b) Participate in religious and spiritual practices regularly c) Increase knowledge base of religion and spirituality d) Recognize that all spirituality is deeply ingrained in religion

ANS: A, C There are many activities nurses can engage in to gain a broader view and understanding of spirituality. You can increase your knowledge about spirituality, develop your critical and reflective thinking abilities, explore your own spirituality, reflect on thoughts and feelings about end-of-life issues, and reflect on your personal experiences with grief and loss. Spirituality is understood in different ways by patients, families, and nurses. Spirituality may be deeply ingrained in or totally separate from formal religion. There is nothing that supports that nurses need to participate in religious and spiritual practices on a regular basis.

Normal physiological changes in women's sexual responses that occur with aging include which of the following? Select all that apply. a) Delayed nipple erection b) Increased vaginal expansion c) Reduced vaginal lubrication d) Reduced labial separation and swelling

ANS: A, C, D As women age, normal physiological responses in sexual behavior include delayed nipple erection, reduced vaginal lubrication, and reduced labial separation and swelling. Vaginal expansion is reduced rather than increased because of decreased estrogen and progesterone levels.

What is meant by the nurse's being "present" with a patient? Select all that apply. a) Being open to patient's beliefs and concerns b) Setting the agenda and leading discussions c) Allowing the patient to tell stories about his illness d) Using active listening skills

ANS: A, C, D Being "present" means to be with the patient and family in meaningful ways. This requires not only a nurse's actual presence at the bedside, but also for him to be open to issues and concerns of the patient. Presence is allowing the patient to lead discussions, set the agenda, and control the conversation. It involves sincere communication and being fully available to the patient, and might include listening to the patient's "stories" about his illness. Active and focused listening is also a quality of being present with the patient.

Which statement(s) about culture is/are true? Select all that apply. a) Culture exists on both material and nonmaterial levels. b) Culture mainly influences food choices and special holidays. c) Cultural customs change over time at different rates. d) Culture is learned through life experiences shared by other members of the culture.

ANS: A, C, D Culture is learned through life experiences that are shared by other members of the culture, such as family members, those sharing similar religious beliefs, and people of similar cultural heritage in the same community. Culture exists at many levels, both material and nonmaterial. Cultural customs, beliefs, attitudes, and practices are not static but change over time at different rates, depending on current events, other significant people, and social influences. Culture is all encompassing and affects everything its members think and do. It is not limited to food and holidays, although those are visible manifestations of a culture, dietary practices and cultural calendars are not the essence of true and meaningful culture.

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper handwashing. The nurse will know that the teaching was effective if the NAP demonstrate which of the following? Select all that apply. a) Uses a paper towel to turn off the faucet b) Holds fingertips above the wrists while rinsing off the soap c) Removes all rings and watch before washing hands d) Cleans underneath each fingernail

ANS: A, C, D Handwashing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists.

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. a) Viruses b) Bacterial spores c) Yeasts d) Molds

ANS: A, C, D If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores.

What are common beliefs and practices associated with the North American (Western) professional healthcare system? Select all that apply. a) Values emphasize individualism and self-reliance. b) Health is defined as living in harmony with nature. c) Health is defined as absence or minimization of disease. d) Reliance is on the biomedical system.

ANS: A, C, D In North America, professional healthcare is dominated by a biomedical healthcare system that combines Western biomedical beliefs with traditional North American values of self-reliance, individualism, and aggressive action. This system is also known as Western medicine and allopathic medicine. It relies on the biomedical system. Additionally, this system defines health as absence of disease or minimization of disease. The definition of health as living in harmony with nature is most reflective of the Native American health and illness belief system.

Which of the following are considered sexual response cycle disorders? Select all that apply. a) Arousal disorder b) Date rape c) Orgasmic disorder d) Low libido

ANS: A, C, D Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle. These disorders affect desire, arousal, excitement, and orgasm. Rape occurs when there is nonconsensual vaginal, anal, or oral penetration. It occurs through force, by the threat of bodily harm, or when the victim is incapable of giving consent. Date rape is forced, unwanted sexual intercourse by an acquaintance when the assault occurs during an agreed-upon social encounter.

What should you include in a plan for teaching adults about dietary trans-fatty acids? Select all that apply. a) Trans fat increases the shelf-life of foods. b) Trans fat decreases blood cholesterol levels and LDL levels. c) The FDA mandates that trans fat content be listed on all food labels. d) Check for hydrogenated vegetable oils on food labels. e) Vegetable oil sprays used for cooking are high in trans fats.

ANS: A, C, D Trans-fatty acids are saturated fats created when food manufacturers add hydrogen to polyunsaturated plant oils, such as corn oil. This process solidifies the fat, improves texture and flavor, and extends the shelf-life of the food. Trans fats increase (not decrease) blood cholesterol levels. Additionally, they raise LDL levels. The FDA mandates that trans fat content be listed on all food labels. Intake of saturated and trans fat should be limited. Vegetable oil sprays are not high in trans fats. The CDC recommends cooking and baking with vegetable oils (liquid or spray) instead of solid fats (e.g., solid shortenings, butter, lard).

The nurse believes that a patient may be experiencing a lot of stress at home. The patient is angry and states, "It is too much for me to handle. You don't know what I am going through." What is the most appropriate response(s) by the nurse? Select all that apply. a) "I don't know what you are going through, can you tell me more?" b) "Please don't be angry with me. We all do the best we can here." c) "How long have you been dealing with this stress?" d) "How do you usually manage your stress?"

ANS: A, C, D When a patient is experiencing stress and verbalizing his complaints to the nurse, it would be usual for him to be anxious and angry. However, when expressed appropriately and clearly, some anger can be adaptive, because it temporarily releases the person's feelings of tension. The nurse, however, should not apologize to the patient nor minimize the anger by stating, "We are all doing the best we can." "What is causing stress?" "How long have you been dealing with stress?" "How have you managed stress in the past?" and "How long have you been dealing with this stress?" are all appropriate questions asked by the nurse.

Which instructions should the nurse give to the patient complaining of constipation? Select all that apply. a) Drink at least eight glasses of water or fluid per day. b) Include a minimum of four servings of meat per day. c) Gradually increase your fiber intake to 25 grams per day. d) Exercise at least 60 minutes per day as you feel necessary. e) Use the restroom when you feel the urge to defecate.

ANS: A, C, E To prevent constipation, the nurse should instruct the patient to consume a high-fiber diet, drink at least eight glasses of water or fluid per day, exercise regularly, and eat meals on a regular schedule. It is best to gradually increase fiber in the diet to approximately 20 to 35 grams a day. Eating a large amount of fiber when the body is not used to it can cause stomach cramping, bloating, and discomfort. Foods that worsen constipation include ice cream, cheese, and processed foods, particularly those high in refined sugars. Exercise improves digestive function and is best done in moderate amounts on most days of the week. When holding a bowel movement, the body can absorb the water in the stool, making it harder to pass.

The hospital nurse educator is preparing an orientation class for those newly hired on the surgical suite. Which of the following will the educator include in the orientation curriculum regarding hand and fingernail care? Select all that apply. a) Healthcare staff must routinely inspect their hands for breaks in skin. b) Artificial nails are permitted if properly secured to the nailbed. c) Wristwatches be may be worn as long as they are all metal. d) Healthcare staff are to avoid wearing nail polish at all times.

ANS: A, D Infection control and prevention measures regarding hands and nails in the surgical suite and in all areas of most healthcare facilities include keeping fingernails short and clean; avoiding nail polish and artificial nails; checking skin condition of the hands; and removing all wristwatches and rings, as they are sources for bacteria.

For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply. a) Check inside the mouth for pocketing of food after eating. b) Provide a full liquid diet that is easy to swallow. c) Remind the patient to raise the chin slightly to prepare for swallowing. d) Keep the head of the bed elevated for 30 to 45 minutes after feeding.

ANS: A, D The nurse should check for pocketing of food (storing food in cheeks) that the patient has not been able to swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding. Liquids should be avoided unless thickeners are added. The patient should flex the head forward (tuck the chin) in preparation for swallowing.

When caring for a woman who was sexually assaulted, what is your best approach for collecting information surrounding the event? Select all that apply. a) Use a calm, reassuring voice when asking questions of your patient. b) Ask only close family members to describe events related to the incident. c) Provide privacy by asking questions behind a closed curtain. d) Document the details using the patient's own words.

ANS: A, D Use a calm, professional approach as you collect sexual data from your patients. This will not only help them to feel more comfortable and confident, but will also yield more honest and complete information. Your patient might have difficulty discussing the events relating to the assault; however, this is a private matter and not a topic to discuss with family members, regardless of the apparent closeness of the relationship. When asking personal questions, provide privacy and be sensitive to your client's cues. A curtain is not secure enough because conversation easily could be overheard. Clear, unambiguous documentation is extremely important because of the criminal nature of sexual crime. Using the patient's own words is a way for the nurse to avoid misinterpreting the facts as well as to keep from introducing bias or drawing conclusions about the event.

Which statement(s) is/are most accurate regarding values and beliefs? Select all that apply. a) A value is a standard or principle that has meaning and worth to an individual. b) Values are a set of behaviors that one follows to guide health practices. c) All members of certain cultures will share the same values and beliefs. d) A belief is something one accepts as true.

ANS: A, D Values are important because they help shape health-related beliefs and practices. A value is a principle or standard that has meaning or worth to an individual. In contrast, a belief is something that one accepts as true. A practice is a set of behaviors that one follows.

A patient who had surgery 8 hours ago has not voided. The physician has prescribed that an indwelling urinary catheter be inserted. Which of the following statements should the nurse use to describe the procedure to the patient? "I need to: a) "Put a Foley in you because you haven't voided since your surgical procedure" b) "Insert a tube into your bladder to drain the urine because you haven't urinated since surgery" c) "Catheterize you because you haven't urinated since having your surgery" d) "Place a catheter in your bladder because you haven't voided since surgery"

ANS: B "I need to insert a tube into your bladder . . ." best describes the procedure for the patient because the explanation is in terms most patients will understand. The other options contain medical jargon that could confuse the patient.

A 19-year-old client asks if he is normal because he has always viewed himself as a female, although he has acted like a male to please his parents. The nurse should provide the client with education on which concept? a) Intersex b) Transsexual c) Transvestite d) Bisexual

ANS: B A bisexual person is attracted to both genders. A transvestite is also known as a cross-dresser. The client has been functioning as a male, so there is no indication that he has worn women's clothes. Transsexual is the concept that describes people who identify with the opposite gender. Intersex is a concept that describes a person born with ambiguous sex organs.

Which patient is most likely experiencing positive nitrogen balance? A patient admitted: a) With third-degree burns of his legs b) In the sixth month of a healthy pregnancy c) From a nursing home who has been refusing to eat d) With acute pancreatitis

ANS: B A positive nitrogen balance typically exists during pregnancy when new tissues are being formed. Patients with burns, malnutrition, and serious illness commonly experience negative nitrogen balance because tissues are lost.

A group of pediatric nurses accepts an international assignment in an underdeveloped country. The nurses are informed that they will be caring for many children with kwashiorkor. The nurses will create a care plan focusing on which primary nutrient for these children? a) Calories b) Protein c) Lipids d) Glucose

ANS: B Malnutrition is most common in underdeveloped nations and among children, older adults, and people with chronic illness such as cancer, HIV, and COPD. Malnutrition caused by deficiency of protein in a diet that is primarily starches is called kwashiorkor. When protein sources in food are scarce and overall caloric intake is low, marasmus occurs, particularly in young children. Kwashiorkor is not a disease of low calorie, lipid, or glucose intake.

What is the purpose of using a sleep diary? a) Identify sleep-rest patterns over a 1-year period. b) Note the trend in sleep-wakefulness patterns over a 2-week period. c) Note typical sleep habits and most common daily routines. d) Examine the patterns of sleep during the night and naps during the day.

ANS: B A sleep diary provides specific information about the patient's sleep-wakefulness patterns over a certain period of time. It allows identification of trends in sleep-wakefulness patterns and associates specific behaviors interfering with sleep. The diary is typically kept for 14 days.

The emergency room nurse receives a male patient experiencing an acute myocardial infarction (heart attack) who is dressed in his wife's bra, panties, and nightgown. What is the most accurate inference the nurse can make about the patient with this data? The patient: a) is transsexual b) is a transvestite c) is homosexual d) has gender confusion

ANS: B A transsexual perceives himself or herself to be of the opposite sex, which is not clearly identified in this item and would require further information to determine. A transvestite is a man who dresses as a woman or a woman who dresses as a man. Cross-dressing may be an occasional or frequent occurrence. This term best describes this patient. A homosexual is a person attracted to those of the same sex, which is not indicated in this item. There is no indication that this patient is confused about the fact that he is a man (gender confusion).

As a general rule, how much liquid soap should the nurse use for effective handwashing? At least: a) 2 mL b) 3 mL c) 6 mL d) 7 mL

ANS: B APIC guidelines dictate that 3 to 5 mL of liquid soap are necessary for effective handwashing.

The nurse teaches a class for new parents promoting safe sleep for infants. The nurse determines a participant understood the important safety points when a parent makes which statement? "I will a) "Gently lay my son down on his back with a soft pillow to support his head" b) "Put my son on a firm crib mattress on his back and remove all padding" c) "Position my son to sleep on his back and place soft pads around the crib to prevent injury" d) "Have my son sleep in my bed so I can be sure he is safe at night."

ANS: B According to the American Academy of Pediatrics, it is safest for infants to sleep positioned on their back on a firm surface with no soft padding (e.g., stuffed animals, blankets, or pillows). Supine position is especially discouraged before 3 months or at the point that the infant develops strength of his head, neck, and upper body. Pillows should never be used for infants because they can lead to poor airway alignment, which increases the risk for apnea and even sudden infant death syndrome. The safest place for an infant to sleep is in the same room as the caregiver, but not in the same bed. Sleeping with the newborn is associated with smothering or rolling on top of the baby and should be discouraged.

A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: a) Increased exercise b) Nicotine withdrawal c) Caffeine intake d) Environmental changes

ANS: B Based on the information given, the patient is not experiencing significant stress, or change in sleep routine or environment, which commonly leads to insomnia. People who use nicotine tend to have more difficulty falling asleep and are more easily aroused than those who are nicotine free. People who stop smoking often experience temporary sleep disturbances during the withdrawal period.

A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? a) Dehydration b) Constipation c) Hyperglycemia d) Diarrhea

ANS: B Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. It does not place the patient at risk for dehydration, hyperglycemia, or diarrhea.

When evaluating the treatment plan for a patient with erectile dysfunction (ED), you would deem the treatment successful if the patient made the following statement: a) "I feel very good about the treatment; I am now comfortable with my sexual orientation." b) "I am happy with the treatment as I can now maintain an erection through orgasm." c) "Now I can communicate my sexual needs to my partner without embarrassment." d) "I now know how to prevent further sexually transmitted infections."

ANS: B Men with erectile dysfunction have persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual performance. When the patient is maintaining penile erection through orgasm, this is an indication the interventions were successful. ED is not related to sexual orientation or exposure to STIs. Comfort with communicating about sexual needs is helpful for sexual satisfaction but is not the cause of ED.

The nurse is caring for a male patient who states, "I have been smoking two packs of cigarettes a day for 20 years and now my nurse practitioner wants me to take vitamins. Do you think I need to take vitamins?" What is the most appropriate response by the nurse? a) "Smoking is bad for your health. I believe if you stop smoking you would certainly be better off and not have to take vitamins." b) "Smokers use vitamin C faster than do nonsmokers, and is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements." c) "It is probably a good idea. With your history of tobacco use, I'm sure you are lacking in vitamins and nutrients." d) "I really cannot answer this question. You will need to speak with your nurse practitioner to find out more about this."

ANS: B Because vitamin C is an antioxidant, smokers metabolize vitamin C faster than do nonsmokers. The more a person uses tobacco, the more vitamin C is lost, yet, the body needs more vitamin C to counteract the damage smoking causes to cells. Additionally, because vitamin C aids in absorption of iron, a low level of vitamin C is also linked to iron deficiency. If a person cannot quit smoking, vitamin C and iron supplementation may help compensate. This is the best explanation to give to the patient. It is informative and nonjudgmental. Nurses can answer these questions without having to refer the patient to the nurse practitioner. Telling a patient he would be better off not smoking may be true, but it reflects a judgmental attitude on the part of the nurse. Telling the patient that he is lacking in many vitamins is too broad and not helpful.

A student nurse is preparing a Mormon female for surgery. Which statement made or question asked by the nurse indicates an understanding of the patient's religious practices or beliefs? a) "This is a new gown. No one else has worn it." b) "How would you like me to handle your undergarments?" c) "I will let your surgical team know that only females can touch you." d) "Would you like me to pray with you?"

ANS: B Both male and female Mormons wear special sacred undergarments that are removed only for hygiene, intimacy, and bathroom use. Nurses may also remove it before surgery, but it must be considered intensely private and be treated with respect. Rastafarian females will not wear second-hand clothes and require a gown that has not been worn by others. Muslim women prefer to be treated by female staff. Inquiring about prayer is inappropriate because the patient should initiate the request; further, prayer is not specific to this religion.

Which class of nutrients is the body's primary source of energy? a) Proteins b) Carbohydrates c) Lipids d) Vitamins

ANS: B Carbohydrates are the primary energy source for the body. Carbohydrates perform several functions. They supply energy for muscle and organ function, spare protein, and enhance insulin secretion. Carbohydrates are more easily and quickly digested than are proteins and lipids, fuel strenuous short-term skeletal muscle activity, and provide nearly all the energy for the brain. If carbohydrates are not available, proteins and lipids (fats) can also be used for energy. Proteins primarily perform the following functions: build tissue and maintain metabolism, immune systems functions, fluid balance, and acid-base balance. They are a secondary energy source. The primary functions of lipids include supplying the body with essential nutrients, acting as an energy source, providing flavor and satiety, and providing insulation. Although vitamins provide no energy, they are critical in regulating a variety of body functions.

An 18-year-old female has just been accepted to nursing school in another state. She says to her parents, "I know I am going away to college, but I am nervous about going." What type of stressor is this student most likely experiencing? a) External b) Developmental c) Situational d) Biophysical

ANS: B Developmental stressors are those that can be predicted to occur at various stages of a person's life. For example, most young adults face the stress of leaving home for college or beginning a new career. In this item, the young adult is expressing concern over a normal developmental stressor. Situational stressors are unpredictable. Biophysical stressors affect body function or structures, and external stressors are usually something external to a person, for example, death of a family member.

A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse? a) "It depends on what you mean by high blood sugar. You will need to obtain more information from your provider as diabetes is a very complicated disease process." b) "I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells will allow only a limited amount to enter. The cells can't use the excess glucose." c) "I will be able to explain this to you a little better later when we talk about diabetes. For now, I have to finish my assessment and then we can get back to your question." d) "I will teach you how to perform glucose testing when I finish your assessment. As long as your blood sugar remains somewhere in the 120 to 140 range, you will be doing well."

ANS: B Diabetes, an endocrine problem, may develop as a result of either insufficient insulin production or resistance to the existing supply of insulin. A high blood glucose level does not mean that there is more fuel available for cellular energy. A characteristic of diabetes is that although there is more than enough glucose in the blood, it cannot enter and be used by the cells. Putting the patient off by telling her to ask the provider indicates either her own poor understanding of the disease, or an unwillingness to provide patient teaching. The nurse should clarify, explain, and teach this information to her patient in a timely way. Glucose testing is important; however, a random blood sugar range of 120 to 140 mg/dL is too high for diabetic patients.

Which side effects associated with opioid use may improve after taking a few doses of the drug? a) Constipation b) Drowsiness c) Dry mouth d) Difficulty with urination

ANS: B Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use.

A 60-year-old male attends a smoking cessation class. He tells the nurse, "Even though I smoke, I don't smoke around children, in my car, or in my house" Which defense mechanism is this male exhibiting? a) Displacement b) Rationalization c) Denial d) Repression

ANS: B Ego defense mechanisms are unconscious mental mechanisms that make a stressful situation more tolerable by decreasing the inner tension associated with the stressors. They protect the person from anxiety and assist with adaptation. When used sparingly, and for mild to moderate anxiety, they can be helpful. When overused, they become habits that give us a false illusion that we are coping. In this item, the male is using rationalization: the use of a logical-sounding excuse to cover up or justify true actions or feelings. The male is attending a cessation class, recognizing the desire to quit smoking, but he is rationalizing his smoking habit by citing all he does well in providing some socially acceptable rationales. Displacement is a transferring of emotions, ideas, or wishes from one object or situation to a substitute, inappropriate object. Denial is transforming reality by refusing to acknowledge thoughts, feelings, or desires. Repression is an unconscious burying or forgetting of painful thoughts, feelings, memories, ideas: pushing them from a conscious to an unconscious level. This is a step deeper than denial.

A patient who has a temperature of 101°F (38.3°C) most likely requires: a) Acetaminophen (Tylenol) b) Increased fluids c) Bedrest d) A tepid bath

ANS: B Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever.

The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patient's indigenous healthcare system and should be included in the plan of care? a) Asking the family to bring in medals and amulets b) Scheduling a visit from the local shaman c) Providing the patient with her favorite herbal tea d) Requesting that the physician consult the patient's acupuncturist

ANS: B For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea, medals, and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. Asians and Pacific Islanders might benefit from a visit by the acupuncturist.

The nurse is performing a sleep assessment for a newly admitted patient. He says his sleep habits are satisfactory and that he normally feels well rested. What would the nurse ask next? a) "Would you be willing to complete a sleep diary for the next 2 weeks?" b) "What time do you usually go to bed and awaken?" c) "How many times do you usually awaken?" d) "Do you have trouble falling asleep at night?"

ANS: B If the patient is happy with his sleep habits and feels rested, the nurse need only support normal sleep habits and bedtime rituals; therefore, learning when the patient goes to bed would be important to ask in order to meet his needs. If the patient is satisfied with his sleep habits and feels rested, then there is no need for a sleep diary. If the patient is satisfied with his sleep habits, then there is no need to inquire about sleep problems such as awakening at night. If the patient is satisfied with his sleep habits, then there is no need to inquire about sleep problems such as having trouble falling asleep.

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? a) Cell mediated b) Passive c) Humoral d) Active

ANS: B Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Cellular (cell-mediated) immune response acts directly to destroy pathogens without using antibodies. The humoral immune response (or antibody-mediated response) protects the body by circulating antibodies to fight against pathogens (e.g., bacteria). Passive immunity occurs when antibodies are transferred by antibodies from an immune host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host itself. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but instead fights infection from macrophages that kills pathogens.

A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients? a) Iron b) B vitamins c) Calcium d) Phosphorus

ANS: B Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. Vitamin A deficiency can be associated with night blindness in heavy drinkers; vitamin D deficiency leads to softening of the bones. Because some alcoholics are deficient in vitamins A, C, D, E, and K and the B vitamins, they experience delayed wound healing. In particular, because vitamin K, the vitamin needed for blood clotting, is commonly deficient in those who regularly abuse alcohol, those patients can have delayed clotting, resulting in excess bleeding. Deficiencies of other vitamins involved in brain function can cause severe neurological damage.

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? a) Place the tray in a specially marked trashcan inside the patient's room. b) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. c) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. d) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.

ANS: B Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patient's door. The items must be placed on the inside of the bag without touching the outside of the bag.

The mother of a 6-year-old child says to the pediatric nurse, "My son had such a bad case of the measles. I hope he doesn't get them again." What is the most appropriate response by the nurse? a) "It sounds like he was very sick. Let's hope he doesn't get them again." b) "Measles is a disease that once you've had it, you won't get it again. The body has learned to make cells that will fight off any future exposures." c) "Would you like me to prepare a plan for you with ways you can prevent future episodes of measles?" d) "It will be important for you to keep your son away from other children with measles, as he is now more susceptible."

ANS: B People who recover from some infectious diseases such as measles and chickenpox never get the disease again, even if they are repeatedly exposed to the virus. The reason is "specific immunity": the process by which the body's immune cells learn to recognize and destroy pathogens they have encountered before. Keeping a child who has had measles away from a child who currently has measles will have no effect on the child acquiring measles.

In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? a) Transduction b) Transmission c) Perception d) Modulation

ANS: B Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed.

Which laboratory test result most accurately reflects a patient's nutritional status? a) Albumin b) Prealbumin c) Transferrin d) Hemoglobin

ANS: B Prealbumin levels fluctuate daily and give the best indication of the patient's immediate nutritional status. Albumin level is not as accurate because the half-life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that binds to iron, has a half-life of 8 to 9 days; therefore, it allows for faster detection of protein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects iron intake or blood loss.

Which nutrient deficiency increases the risk for pressure ulcers? a) Carbohydrate b) Protein c) Fat d) Vitamin K

ANS: B Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown and pressure ulcer formation. Carbohydrates are the primary fuel of the body. Fat is a source of energy and contains essential nutrients. Vitamin K aids blood clotting.

The nursing student asks his instructor, "Why do some of my patients get a headache when they have stress and others cry?" The most appropriate response by the instructor is which of the following? a) "All patients react to stress differently." b) "Stress responses can be physical, mental, behavioral, and spiritual." c) "Some patients are more emotional than others." d) "Some patients overreact to the stress they are experiencing."

ANS: B Responses to stress are holistic. This means they can be physical, psychological, mental, behavioral, spiritual, and social. It is important for a nurse to understand these responses to assist patients to develop healthy and adaptive coping skills. The most appropriate response is to cite the holistic responses to stress and not merely respond that "all patients react to stress differently." All patients do react to stress differently; however, this is not the most comprehensive and explanatory response the instructor could make.

For an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements? a) Serum glucose of 78 mg/dL b) Serum albumin of 3.2 g/dL c) Creatinine of 1.0 mg/dL d) Potassium of 4.1 g/dL

ANS: B Serum albumin is a blood protein and marker for nutritional status. The value should be between 3.5 and 5.0 g/dL. This situation is consistent with undernutrition due to low nutritional intake. As there is no indication that the woman has been vomiting, the potassium level should be within normal limits (3.4 to 4.8 mEq/L). However, if she had been vomiting over a period of days or longer, you would anticipate her to have low potassium, sodium, and other electrolyte levels. Serum glucose is normal (70 to 100 mg/dL) in this scenario. The serum creatinine is within normal limits for women (0.5 to 1.0 mg/dL).

A patient undergoing fertility treatments for the past 9 months learns that despite in vitro fertilization she still is not pregnant. This patient is at risk for experiencing a crisis in which component of self-concept? a) Body image b) Self-esteem c) Personal identity d) Role performance

ANS: B Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem. The patient is not at risk for experiencing a crisis in body image, personal identity, or role performance.

A patient who lost his job last month has now been told that his wife wants a divorce. He says, "I know I don't have much to offer a woman. She wants more than what I am, and now I'm not even bringing home any money." Which nursing diagnosis is most appropriate? a) Chronic Low Self-Esteem b) Situational Low Self-Esteem c) Disturbed Personal Identity d) Disturbed Body Image

ANS: B Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of a job and a marriage). There are no data to indicate long-standing (chronic) Low Self-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself.

Which characteristic about pain would the nurse most consider when developing a pain management plan for a patient with chronic lower back pain? a) An objective experience that disrupts daily living that can be measured with altered vital signs b) An unpleasant sensory and emotional experience association with actual or potential tissue damage, or described in terms of such damage c) A generalized response of the body as a result of trauma or damage to the tissues resulting in discomfort d) An emotional response to tissue damage that differs significantly from one individual to another

ANS: B The International Association for the Study of Pain (IASP) defined pain as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.'' This definition emphasizes that pain is a complex experience. Pain is a subjective experience; unlike a pulse or blood pressure, you cannot measure pain objectively. Pain is not a generalized response but rather a neurological response. Although a patient with chronic back pain would experience an emotional response, the sensation of pain is primarily physiological, involving transmission of an impulse along a pain pathway.

Which nursing intervention specifically helps reduce a patient's anxiety? a) Teaching the importance of adequate nutrition and hydration b) Giving clear facts pertaining to the patient's circumstances c) Promoting small-group activities to improve self-esteem d) Monitoring the patient for the risk of suicide

ANS: B Using clear and factual knowledge that is tailored to the patient's circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promoting small-group activities to improve self-esteem, and monitoring the patient for suicide risk are interventions designed to help the patient with depression.

The nurse is removing personal protective equipment (PPE). Which item should be removed first? a) Gown b) Gloves c) Face shield d) Hair covering

ANS: B The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering.

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is more than 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? a) Continue using the gloves inside the package because the package is intact. b) Remove gloves from the sterile field and use a new pair of sterile gloves. c) Throw all supplies away that were to be used and begin again. d) Use the gloves and make sure the yellow edges of the package do not touch the client.

ANS: B The gloves should be thrown away because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated.

When in the reproductive cycle is there marked growth of ovarian material and regrowth of the endometrium, ending with the release of the ovum? a) Menstrual phase b) Follicular phase c) Luteal phase d) Fertilization

ANS: B The luteal phase occurs after the menstrual phase. At this time, the endometrial lining builds back up after being shed with menstruation. Ovarian follicles mature until the ovum is released. The luteal phase occurs after ovulation. In this phase, if fertilization does not occur, progesterone drops and menses begins again. Fertilization occurs at the time of ovulation at which a sperm joins with the mature egg and the endometrium is ripe to support the embryo.

The nurse working on the postpartum unit is preparing a first-time mother for discharge to home. What information should be included in the teaching plan? a) Try to reduce work-related stress to promote sleep. b) Nap frequently during the day when you can. c) Avoid fluids in the evening to reduce nocturia. d) Avoid vigorous-intensity exercise to reduce fatigue.

ANS: B The mother should be taught to nap when the baby naps as frequently as possible to meet her sleep needs. The postpartum patient who is employed would be most likely on leave from work for the first weeks after discharge, so this would not be a component of patient teaching. The older adult is more likely to experience frequent nocturia, and reducing hydration status is not an effective or safe sleeping strategy. It is unlikely the new mother will lose sleep because of late night television watching, but her sleep deprivation is more likely due to the interruptions related to the infant feedings and other nighttime awakenings. Physical activity improves strength, circulation, and feelings of well-being.

The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the: a) Practices of the patient's ethnic group b) Patient's individual cultural beliefs c) Values of her own culture d) Spanish-speaking community

ANS: B The nurse cares for this patient by becoming familiar with the patient's individual cultural and ethnic beliefs and values. It is helpful to become familiar with the patient's ethnic group and the Spanish-speaking community; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as his ethnic group or community. The nurse should explore her own culture but not assume that the patient holds those same beliefs and practices.

A patient who underwent a left above-the-knee amputation reports pain in his left foot. The nurse should document this finding as what type of pain? a) Psychogenic b) Phantom c) Referred d) Radiating

ANS: B The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person that does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations.

The nurse is updating a care plan for a patient who has a nursing diagnosis of Anxiety. Which patient behavior might suggest that the problem is resolving? a) Pacing in the hallway at intervals b) Using relaxation techniques c) Speaking rapidly when spoken to d) Avoiding eye contact

ANS: B Using relaxation techniques might suggest that the patient's anxiety is resolving. Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the patient. The patient's use of relaxation techniques indicates problem-solving by the patient.

A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? a) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. b) Explore with the patient her beliefs and determine which might have caused her to make this statement. c) Assure the patient that each nurse is capable of providing professional nursing care, regardless of gender. d) Comply with the patient's request and assign a female nurse to care for the patient.

ANS: B The nurse should explore reason behind the patient's request, which may have implications for additional nursing needs. If the reason is religious or spiritual, this provides an optimal time to engage in spiritual care. Explaining hospital policy or reassuring the patient of the nurse's competence does not help the nurse understand the primary reason for the request, nor promote patient trust. The same is true of simply complying with the patient's request.

Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? a) Acute Pain secondary to surgery b) Acute Pain (abdominal) secondary to surgery for colon cancer c) Chronic Pain secondary to cancer diagnosis d) Chronic Pain (abdominal) secondary to abdominal surgery

ANS: B The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

A patient prescribed an NSAID, naproxen (Aleve, Naprosyn), for treatment of arthritis reports stomach upset. What should the nurse instruct the patient to do? a) Notify the prescriber immediately. b) Take the medication with food. c) Take the medication with 8 ounces of water. d) Take the medication before bedtime.

ANS: B The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen.

The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient reporting a severe headache. When should the nurse reassess the patient's pain? a) 15 minutes after administration b) 60 minutes after administration c) 90 minutes after administration d) Immediately before the next dose is due

ANS: B The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due.

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? a) Droplet transmission b) Airborne transmission c) Direct contact d) Indirect contact

ANS: B The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission.

The nurse is admitting a young adult male and asks him where he works. The patient appears embarrassed and says, "You're going to think I'm lazy, but I stay home with our young children while my wife works." The nurse recognizes this patient is experiencing what type of conflict? a) Gender b) Gender role c) Gender identity d) Sexual orientation

ANS: B The patient is not indicating confusion over whether he is male or female. Gender roles are those behaviors society identifies as being male or female. This patient indicates conflict over being male while being the nurturer in the family instead of the breadwinner. Gender identity is an internal experience indicating whether the individual feels like a man or a woman, which is not what this patient is conflicted about according to the statement made. Sexual orientation involves to whom the person is sexually attracted, which is not an issue according to the statement made by this patient.

A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse? a) Oral pain medication once every 6 to 8 hours b) Patient-controlled analgesic c) Oral pain medication instead of the IV form d) Only nonpharmacological pain measures

ANS: B The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic, as is possible with PCA. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse.

There are many theories and treatments for depression. Based on current research, which of the following is considered to be the most effective treatment for serious depression? a) Psychotherapy b) Antidepressant medications c) Education d) Social support networks

ANS: B The physiological theory of depression predominates in the medical community, and current evidence shows that biochemical processes determine moods, thought, cognition, and perception. Therefore, treatment of serious depression relies more heavily on antidepressant medications than on psychotherapy. Psychotherapists acknowledge that individual tolerance of symptoms, coping resources, education, and social support networks all have an important effect on outcomes and treatment. These therapies are used as adjuncts to medications.

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: a) Experiences less pain than in earlier stages of cancer b) Cannot communicate the character of his pain effectively c) Knowledges pain at a later time than when it occurs d) Relies on caregiver to provide pain relief without asking

ANS: B There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to habitually ask for it or reliance on others; rather, it is likely owing to inability to effectively express to the caregiver that analgesia is needed.

Your 35-year-old client tells you that his boss requires him to massage her shoulders and she rubs his legs, thighs, and genitals. He further states that he does not want to upset her because he needs the job. Which statement best applies to this situation? a) The male is receiving sexual satisfaction from having his legs, thighs, and genitals massaged. b) This is an example of quid pro quo sexual harassment and should be reported to her supervisor. c) This is an example of hostile work environment sexual harassment and should be immediately reported to her supervisor. d) This is not a situation of harassment because no sexual intercourse occurred.

ANS: B This is an example of quid pro quo sexual harassment—the employer is massaging the legs, thighs and genital areas of the employee, while making him massage her shoulders. Touching is a sexual advance. Sexual intercourse is not required in sexual harassment cases. The sexual advances in this situation are overt and there is no discussion of the client's feelings or the work environment. Sexual harassment is about the power difference, which can negate the element of consent; thus, it is irrelevant whether the client receives sexual satisfaction. Sexual harassment should be immediately reported because it is illegal.

After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting? a) Reaction formation b) Displacement c) Denial d) Conversion

ANS: B This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feelings, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis.

After undergoing dural puncture while receiving epidural pain medication, a patient reports a headache. Which action can help alleviate the patient's pain? a) Encourage the client to ambulate to promote flow of spinal fluid. b) Offer caffeinated beverages to constrict blood vessels in his head. c) Encourage coughing and deep breathing to increase CSF pressure. d) Restrict oral fluid intake to prevent excess spinal pressure.

ANS: B Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a "spinal headache" after epidural anesthesia.

The nurse is teaching the patient about foods that promote sleep versus those that may disrupt sleep. What diet chosen by the patient demonstrates understanding of foods that promote sleep? a) A hamburger, potato fries, and a milkshake b) Turkey fettuccini, whole wheat bread, and a glass of milk c) Chicken salad sandwich, pineapple salad, and a diet cola d) Fish, broccoli, applesauce, and a cup of tea

ANS: B Turkey, pasta, whole wheat bread, and milk (presuming the patient is not lactose intolerant or gluten sensitive) contain L-tryptophan and carbohydrates that may help to promote sleep. Carbohydrates found in fruit also promote relaxation. This meal is high in saturated fat, which is slow to digest, and can interfere with sleep. Diet cola contains caffeine than can interfere with sleep patterns. While some tea is caffeine free, many teas are high in caffeine that interferes with sleep. However, keep in mind, this meal is not as effective at promoting sleep as other options.

Which of the following actions would the nurse prioritize for the patient who is experiencing chronic back pain that interferes with activities of daily living (ADLs)? a) Maintain a pain journal to document quality of his pain experience. b) Meet with the healthcare team to discuss a pain management plan. c) Attempt to take only analgesic medication when absolutely needed. d) Suggest use of a deep-pressure back massage with effleurage technique.

ANS: B With complex pain management that has been unsuccessful in the past, it is important to collaborate with other members of the team to consider alternative approaches. A pain journal is a useful assessment tool for collection of patient subjective and objective pain experiences, which would aid the healthcare team in developing a collaborative pain management plan with the patient. Taking a prescribed analgesic is important for keeping the pain threshold at a tolerable level. Once the patient "gets behind" on managing pain, it is more difficult to achieve control. The goal of pain management is that chronic pain does not prevent the patient from performing activities of daily living. Although massage has been shown to be effective in reducing pain by providing cutaneous stimulation and relaxing the muscles, the priority is to develop an effective, comprehensive pain management plan that might also include nonpharmacological interventions, such as massage. However, in the case of chronic back pain, the patient should consult the provider before seeking deep massage therapy. Effleurage, or the use of slow, long guiding strokes, is used for obstetrical patients during labor.

You are caring for a 32-year-old woman who has been sexually assaulted. What nursing interventions are initially most important for this client? Select all that apply. a) Help her to communicate effectively with police about the attack. b) Obtain permission from your client to test for pregnancy and STIs. c) Refer your client to a sexual assault support group. d) Promote and model empathy and support for her family members.

ANS: B, C A victim of rape has experienced psychological and physiological trauma. Sexual assault is a risk factor for sexually transmitted infection (STI). Testing for STIs and pregnancy is a necessary component of the physical care of a victim of sexual violence. Referral to a local sexual assault support group is critical when planning care. A sexual assault nurse examiner (SANE), who is a registered nurse, can assist the client through the physical examination, police interview, and disclosure to family members, all of which are important activities.

A patient has a nursing diagnosis of Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications. The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following statements made by the patient would indicate that progress is being made toward achieving compliance with healthcare therapy? Select all that apply. a) "I will try to pray more often for stronger faith that God will heal me." b) "Let me think about it until tomorrow; I may see my way to taking those pills then." c) "You know, I've known some very holy people who were not cured by God." d) "There is no confusion in my mind as to the right thing for me to do."

ANS: B, C Agreeing to consider treatment ("think about it") and recognizing that sometimes faithful people are not cured both suggest that the patient is at least considering that it is all right for her to question her beliefs. Praying for stronger faith in God's healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith. Having "no confusion" about the right thing to do would be evidence of problem resolution, provided the "right thing" to do is to take the medication. However, you need more information to know whether that is what the patient means. It could just as easily mean that she is more sure than ever that she should not take the medication.

Where in the body is glucose stored? Select all that apply. a) Brain b) Liver c) Skeletal muscles d) Smooth muscles e) Bone marrow

ANS: B, C Human beings store glucose in liver and skeletal muscle tissue as glycogen. Glycogen is converted back into glucose to meet energy needs. Blood is produced in the bone marrow (not glucose). The brain requires glucose to function but does not store glucose.

A nurse in the intensive care unit has been experiencing an excessive amount of stress in her workplace. She sees the employee health nurse and states, "I feel nervous and stressed all the time. Even when I go home, I don't feel better. What am I going to do?" What is the most appropriate response(s) from the employee health nurse? Select all that apply. a) "If you are doing the best you can and it is not working, maybe you need to find another job." b) "I'm happy to see you are here and asking for help dealing with your anxiety." c) "Have you talked to some of your colleagues about the way you feel?" d) "I will make a list for you of some coping strategies that may be helpful."

ANS: B, C In the workplace, nurses must pay attention to their own feelings, body, and personal responses to stress. There are many concerns and questions to be asked. Is the nurse eating more, experiencing a loss of appetite, or losing weight? Are there concerns with sleep patterns, feeling nervous, taking work home, or feeling unable to stop thinking about work? These are all feelings associated with workplace stress. Solutions, healthy responses, and strategies to manage stress include setting realistic expectations of yourself and others, asking for help, being supportive of colleagues and sharing your feelings with colleagues, joining professional organizations, and striving for balance. When all options have been explored or exhausted and a high level of stress remains or continues, then the person may not have any option other than leaving employment. In this item, the nurse is seeing the employee and is beginning an assessment of her concerns. She has not yet explored the stressors, length of time of the stress, nor what strategies have been used. The most appropriate response is to acknowledge that the employee is seeking help and ask about colleague sharing. The employee health nurse would not make a list for the employee, as this would be developed collaboratively. Leaving employment is the final option and not necessarily appropriate at this time.

The nurse is caring for a patient of Japanese heritage who refuses opioid pain medication despite the nurse's explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. a) Assess the patient's pain levels at less frequent intervals. b) Document in the record that the patient does not want to take opioids. c) Use nonpharmacological measures to help control the patient's pain. d) Notify the primary care provider of the patient's noncompliance.

ANS: B, C Patients of Japanese heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that they improve the healing process. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patient's wishes and employ nonpharmacological measures to control pain. The nurse should document that the patient wishes to avoid opioid use in the nurses' notes. The nurse should continue to assess pain levels in this patient at the same frequency as before. She should recognize and respect his cultural beliefs and not label him as noncompliant. Note that the same intervention would be appropriate for any patient in this situation, not just a Japanese patient. It would be necessary to contact the primary provider only if these measure are ineffective and the patient experiences severe pain.

The nurse is caring for a Native American in a rural rehabilitation facility. The nurse notices that the patient has eaten very little since his admission 10 days ago. When she asks the patient about his eating, he states, "I can't eat any of this food. It just isn't what I eat at home and we don't prepare our foods this way." The nurse explains that the patient is on a very specific cardiac diet as a result of his heart attack and that he has lost 7 pounds since admission. Based on this scenario, what is/are the most appropriate nursing diagnosis(es) for this patient? Select all that apply. a) Noncompliance related to difficulty adhering to the medical regimen b) Possible Knowledge deficit related to disease process c) Imbalanced nutrition: less than body requirement related to cultural dietary practices d) Decreased appetite related to anxiety secondary having a heart attack

ANS: B, C The most appropriate nursing diagnoses for this patient are Possible Knowledge deficit related to disease process and Imbalanced nutrition related to dietary preferences. Both these diagnoses relate to the patent's verbalization of different food choices and preparations. Given the scenario, it seems likely the patient does not understand the relationship of diet and cardiac health, but there are no specific data to support lack of knowledge. Therefore, the knowledge is (at this stage) possible rather than actual. At this time, the nurse can assess how much the patient knows, and as necessary teach the patient about the disease process and how the cardiac diet relates to his diagnosis. The patient can then participate in planning food choices and food preparations congruent with his diagnosis and culture. One must be careful with using "noncompliance" as a nursing diagnosis as (1) it has a negative connotation, and (2) it is used when the plan of care is mutually agreed upon and then the patient does not follow the plan. In this item, there is no indication that the plan (diet) was mutually agreed upon. Additionally, there is no information in this item indicating the patient is anxious.

Which intervention(s) by the nurse might help the patient maintain a sense of personhood during hospitalization? Assume that all are culturally appropriate. Select all that apply. a) Addressing the patient by his first name b) Making eye contact if it is comfortable for the patient c) Always offering an explanation before beginning a procedure d) Speaking to others about the patient so that the patient can hear you

ANS: B, C The nurse can help the patient maintain a sense of personhood by addressing the patient by his preferred name, which might be his first name or might be his surname with title. Making eye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the room are additional ways for the nurse to offer care that respects patient rights.

What are some possible barrier(s) for nurses in providing spiritual care? Select all that apply. a) Spiritual care is related to end-of-life care and many nurses do not work in this area. b) Greater emphasis in nursing is placed on meeting patients' physical needs. c) Many nurses experience time constraints and inadequate staffing. d) Many nurses lack an understanding of their own spiritual belief systems.

ANS: B, C, D Although most nurses would acknowledge that patients have a spiritual dimension, few actually identify spiritual problems or provide spiritual interventions. This may be a result of economic constraints, poor staffing, and high-tech care, which force nurses to focus only on physical needs. Other barriers include a general lack of awareness of spirituality and a lack of awareness of one's own spirituality. Spiritual interventions and care, although prevalent in critical care areas and at end-of-life events, can take place in any area and at any time in the patient's life journey.

The patient tells the nurse, "I've always been able to maintain a steady weight by exercising and watching what I eat, but lately I seem to be steadily gaining weight." The nurse then collects a thorough sleep history. Why will the nurse ask the patient about her sleep habits? Select all that apply. Lack of sleep: a) Causes increased insulin production b) Reduces activity levels c) Increases appetite d) Leads to poor glucose tolerance e) Reduces total energy output

ANS: B, C, D Lack of sleep may increase the body's energy output to maintain the body's function, but exhaustion leads to less activity. Leptin and ghrelin hormone levels (hormones that regulate appetite) are altered with lack of sleep; this leads to an increase in appetite. Lack of sleep increases insulin resistance, not insulin production. Lack of sleep makes the body less able to tolerate glucose and causes greater insulin resistance, leading to weight gain. Sleep deprivation leads to fatigue with reduced opportunity for restoration, repair, healing, and growth.

A 64-year-old patient just returned from surgery. She is breathing rapidly and moving constantly in bed. She states, "I am scared and I hurt so much." What would be an appropriate intervention? Select all that apply. a) Immediately notify the surgeon of these data (physical symptoms and patient's statement). b) State calmly, "I am going to do everything I can to make you more comfortable." c) Tell the patient you would like to help her calm down and take some deep breaths. d) Ask the nursing assistive personnel to stay with the patient while you get an analgesic for her. e) Turn on the television to distract her from the pain and anxiety.

ANS: B, C, D Relaxation exercises, deep breathing, and other nonpharmacological measures can also help to take the edge off the patient's pain experience and help the patient to feel more in control; therefore, you should provide comfort measures to the patient. The goal would be to calm her so you can perform a thorough assessment. Calming anxiety also helps to relieve pain. Analgesics help reduce pain, which will also lessen the anxiety that can aggravate a pain experience. You would not call the surgeon before the assessment, but rather after you have determined that her condition requires medical evaluation. Although turning on the television might be helpful by providing distraction, for others the noise might overstimulate and further increase the pain. It would be better to manage the pain with therapeutic measures, instead of turning on the television while the patient is still in pain.

The community health nurse is preparing a teaching plan for emergency preparedness in the instance of a major disease outbreak. Which of the following will the nurse include in the plan for the home setting? Select all that apply. a) Keep a supply of broad-spectrum antibiotics. b) Have nonprescription drugs available. c) Store a 2-week supply of bottled water. d) Obtain an annual influenza vaccination.

ANS: B, C, D Teaching patients emergency preparedness in case of disease outbreaks is an important nursing role. This role has become increasingly important with the recent outbreaks of anthrax, pertussis, and H1N1. In preparing for a major disease outbreak, the nurse should teach patients and families to establish an exit and preparedness plan; keep a 2-week supply of bottled water and nonperishable foods on hand; check regular prescriptions and be sure to have enough on hand; keep some over-the-counter medications available, such as vitamins, antidiarrheal medications, and ibuprofen; and obtain an annual influenza vaccine. There is no recommendation to have a supply of a broad-spectrum antibiotics on hand. In fact, there is growing concern regarding the overuse and overprescribing of antibiotics because this has now been shown to contribute to the rise of microbial-resistant diseases.

A 2-year-old boy has come to the well-child clinic with his mother for a checkup. When the nurse asks his mother whether she has any concerns, she says, "I don't know why he won't quit touching his 'privates' all the time. I have tried sitting him in a chair, smacking his hand, and telling him no, but he continues to do this. I just don't know how to make him stop." How would you best respond to her concerns? Select all that apply. a) "Give him a little time, and he'll grow out of it. He's just too young to understand right now." b) "How often do you punish him by giving him a time-out or by using physical discipline?" c) "Physical punishment, such as smacking his hand, is not the best way to modify a child's behavior." d) "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body."

ANS: B, C, D The first 2 years of life are highly sensual as infants are nursed, stroked, bathed, and massaged, and they develop their first attachment experience through bonding with the mother. It is not unusual for infants and preschoolers to fondle their genitals and enjoy being nude. This is part of their exploration of their bodies, and parents should not overreact. Although health teaching about normal sexual development of toddlers is important, this mother's comments are a red flag to appropriate discipline. Her exaggerated response using physical reprimands to a 2-year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternate methods of dealing with the behavior.

Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Select all that apply. a) The wound is most likely infected. b) This is a vascular response to inflammation. c) Damaged cells are being regenerated. d) Exudate formation is occurring.

ANS: B, D During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonly appears at surgical incisions. When a wound becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here.

A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately 3 to 4 times per week. The nurse's best response would be which of the following? Select all that apply. a) "Your daughter's bladder is still developing at this point in her life." b) "Be patient; most children outgrow enuresis." c) "Wake your daughter every 4 hours to use the bathroom." d) "You might consider purchasing protective pads for the bed." e) "Try a bed alarm to wake her when she starts wetting the bed at night."

ANS: B, D Enuresis is nighttime incontinence past the stage at which toilet training has been well established. Most incidents occur during NREM sleep when the child is difficult to arouse. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. A bed alarm can be used for older children (typically older than age 10 or 12) who are resistant to other behavioral strategies.

During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Select all that apply. a) Rate of metabolism decreases. b) Liver converts more glycogen to glucose. c) Use of amino acids decreases. d) Amino acids and fats are more available for energy.

ANS: B, D The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: the rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of amino acids and mobilization of fats for energy

A nurse identifies a patient's nursing diagnosis as "Diarrhea related to stress." Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea? a) Monitor and record the frequency of stools on the graphic record b) Administer prescribed antidiarrheal medications as needed c) Encourage the patient to verbalize about stressors and anxiety d) Provide oral fluids on a regular schedule

ANS: C (Answer to specific patient scenario is not directly stated in text.) The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patient's diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea.

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? a) Tea with milk b) Orange juice c) Gelatin d) Skim milk

ANS: C A clear liquid diet consists of water; tea (without dairy); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. Skim milk, tea with milk, and orange juice are included in a full liquid diet.

Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? a) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. b) The patient will rest quietly when undisturbed. c) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. d) The patient will receive pain medication every 2 hours as prescribed.

ANS: C A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numericalscore gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patient's pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome.

A person who is deprived of REM sleep for several nights in succession will usually experience: a) Extended NREM sleep b) Paradoxical sleep c) REM rebound d) Insomnia

ANS: C A person who is deprived of REM sleep for several nights will usually experience REM rebound. The person will spend a greater amount of time in REM sleep on successive nights, generally keeping the total amount of REM sleep constant over time.

The nurse is talking to a patient with chronic pain secondary to psoriatic arthritis in multiple joints about developing a pain management program. Which goal identified by the patient would be realistic for the program? a) "I would like for all my pain to be gone and not recur in the future." b) "I want to be able to do all the things I used to do before this pain started." c) "I want to control the pain enough to allow me to sleep through the night." d) "My goal is to lead a normal life without experiencing so much pain every day."

ANS: C A reasonable goal is to obtain adequate pain control to allow for the patient to sleep during the night. It is not realistic to think that the pain can be completely eliminated. The patient will not be able to do everything she did before the pain started because strenuous activity will likely exacerbate the pain in the damaged joints. The patient's life will not be the same as it was before the pain, because the damaged joints will not return to normal; however, pain reduction enough to function and engage in ADLs is a reasonable expectation.

Which of the following is considered a strength of the nursing profession? a) Biomedical focus b) Psychosocial focus c) Biopsychosocial focus d) Physical focus

ANS: C A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient.

You are assessing a 16-year-old female's knowledge of sexuality. Which of her statements indicates that she requires further teaching? a) "I don't practice oral sex, because it could lead to sexually transmitted infections." b) "I don't have sexual intercourse because I want to remain a virgin until marriage." c) "My boyfriend and I are practicing abstinence by engaging in shared touching." d) "My parents are lesbians, but it has not affected my sexual orientation."

ANS: C Abstinence occurs when persons refrain from any sexual activity. Shared touching or masturbation is an alternative to sexual intercourse, but is a type of sexual activity. The nurse should clarify the two concepts. STIs can be transmitted by oral sex; the orientation of a person's parent may not impact sexual orientation, and she will lose her virginity status if she engages in sexual intercourse (penetration of the vagina). These are true statements and do not need further clarification.

The nurse is beginning her assessment on a 35-year-old woman. The patient appears to be of Asian descent. As part of the nurse's cultural assessment, what question is most appropriate for the nurse to ask pertaining to race prior to documenting the patient's race? a) "You appear to be Asian. Am I correct?" b) "Can you tell me a little about your oriental background?" c) "What race do you identify with and what name do you call it?" d) "Which Asian country are you from?

ANS: C Although we commonly think of race as being based on biological characteristics, many, including the U.S. Census Bureau, believe that race is socially rather than biologically determined. For a culturally sensitive nurse, it is therefore most appropriate to ask the patient what race she identifies with and what name she prefers to use for it. We must avoid using our own assumptions and categories as the basis for determining race as this can lead to bias and even worse, a lack of providing proper patient centered focused care.

During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate? a) Increases the rate by 7% b) Decreases the rate by 14% c) Increases the rate by 35% d) Decreases the rate by 28%

ANS: C Basal metabolic rate increases 7% for each degree Fahrenheit (0.56°C); therefore, this patient's temperature rise is an increase of 35%.

A patient admitted to the cardiac unit is going to the cardiac catheterization lab for a procedure. The patient tells the nurse, "I am so anxious about this. I am afraid the procedure might trigger a heart attack." What is the first action by the nurse? a) Contact the physician for an anti-anxiety medication prior to the procedure. b) Assure the patient that this is a very common procedure for all cardiac patients. c) Instruct the patient prior to the procedure about what he can expect of the procedure. d) Offer the patient some stress-reducing techniques to use before the procedure.

ANS: C Because anxiety is a common response to illness, medical tests, and treatments, the nurse will use anxiety-relief interventions. In this patient scenario, instructing the patient about what to expect of the procedure will lessen anxiety and is the first and best action. Contacting the physician for an anti-anxiety medication is appropriate and many patients will receive a mild anti-anxiety medication prior to the procedure. Additionally, offering the patient some stress-reducing techniques and strategies can also be appropriate, for example, instructing him to take some deep breaths. However the first action by the nurse is to instruct the patient about the procedure.

A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? a) Sepsis b) Pneumothorax c) Hypoglycemia d) Thrombophlebitis

ANS: C Because of the high glucose content of 2:1 parenteral nutrition, any interruption in therapy places the patient at risk for hypoglycemia. A PN of this type should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the final concentration of glucose is less than 10%. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy. Pneumothorax can occur as a result of central venous catheter insertion. Central venous catheters are typically employed for parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use.

Over the past few centuries, nurses have placed less attention on spiritual care primarily because: a) Nurses providing care are less religious and spiritual now b) Spirituality and religion are unproven with regard to influencing health c) Greater emphasis has been placed on science and scientific evidence d) Nurses are uncomfortable when discussing spiritual aspects of care

ANS: C By the mid-20th century, nursing in the United States began to see spiritual care as less important. As science has continued to develop and expand, and as more nurses studied in university settings, nursing joined ranks with scientific disciplines: Its spiritual underpinnings were replaced by what could be "seen and tested" by the scientific method. Only recently has nursing reclaimed the spiritual dimension as a vital part of its identity and recognized its power to influence health.

Which is the third stage of sexual arousal? a) Desire b) Excitement c) Plateau d) Orgasm

ANS: C The sexual response cycle is the sequence of physiological events that occurs when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. The third stage is plateau.

Which of the following is the main difference between sleep and rest? a) In sleep, the body may respond to external stimuli. b) Short periods of sleep do not restore the body as much as do short periods of rest. c) Sleep is characterized by an altered level of consciousness. d) The metabolism slows less during sleep than during rest.

ANS: C During rest, the mind remains active and conscious; sleep is characterized by altered consciousness. Sleep is a cyclical state of decreased motor activity and perception. A sleeping person is unaware of the environment and does respond selectively to certain external stimuli. However, at rest, the body is disturbed by all external stimuli; sleep restores the body more than does rest. The metabolism decreases more during sleep than during rest.

When released in response to alarm, which of the following substances promotes a sense of well-being? a) Aldosterone b) Thyroid-stimulating hormone c) Endorphins d) Adrenocorticotropic hormone

ANS: C Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralcorticoids.

At a clinical post conference, a nursing student states, "I had a Chinese patient today and while I understand some of her cultural practices, she needs to understand that she is in the United States now and should follow our practices because we use scientific evidence." Which cultural barrier is the student demonstrating? a) Racism b) Archetyping c) Ethnocentrism d) Stereotyping

ANS: C Ethnocentrism is the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened. The tendency to ethnocentrism exists in all groups, not just in the dominant culture. Stereotyping is a widely held belief that all people from a certain racial or ethnic group are alike in certain respects. Racism is a form of prejudice and discrimination based on the belief that a race is the principal determining factor of human traits and capabilities and that racial difference produce an inherent superiority or inferiority.

The nurse is developing a plan of care for a mother of three small children who has been admitted with a serious acute illness, which is likely to continue long term. The nurse writes the following intervention: "Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness." The purpose of this intervention is to help: a) Promote self-esteem b) Promote positive body image c) Facilitate role enhancement d) Prevent depersonalization

ANS: C Facilitating communication between the patient and significant other regarding sharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. The intervention is not designed to promote self-esteem or positive body image or to prevent depersonalization.

The nurse working in a gynecology office recognizes what sexual practice by a patient as a form of sexual expression that is illegal in the United States? a) Public displays of affection b) Private sexual behavior c) Female circumcision d) Transgender surgery

ANS: C Female circumcision, or genital mutilation, is considered atypical behavior and is illegal in the United States. It is normal for some individuals to feel comfortable displaying affection in public in a variety of different ways. Some individuals, depending on their cultural and religious beliefs, prefer to maintain complete privacy related to sexuality. Transgender surgery is a natural procedure to assist a patient to transform his or her body into the sexual gender he or she most identifies with, if the patient requests the procedure.

A 70-year-old male with diabetic peripheral neuropathy reports a burning sensation in his feet. He also states, "Those pain pills make me feel funny and they don't help my pain, so I don't take them." Which of the following is likely to be most beneficial for treating this patient's neuropathic pain? a) Opioid analgesic (morphine) b) NSAID (ibuprofen) c) Antiepileptic drug (gabapentin) d) Narcotic analgesic with acetaminophen (hydrocodone)

ANS: C Gabapentin is an antiepileptic (also known as an anticonvulsant) that is also used in adults to treat neuropathic pain. Opioids (e.g., morphine, hydrocodone) are most effective for certain types of pain. For instance, visceral pain, which is more generalized, is most responsive to opioid treatment, whereas neuropathic pain is resistant to opioids. Acetaminophen alone is likely not strong enough to relieve neuropathic pain.

Which polysaccharide is stored in the liver? a) Insulin b) Ketones c) Glycogen d) Glucose

ANS: C Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. If fats must be used for energy, they are converted directly into ketones. Insulin is a pancreatic hormone that promotes the movement of glucose into cells.

The patient reports pain after surgery, ranking it 6 on a scale of 1 to 10. She tells the nurse, "I don't want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them." Which of the following medications would likely be most effective for postoperative pain relief without excessive sedation? a) Fentanyl IV b) Morphine IV c) Ibuprofen PO d) Hydrocodone PO

ANS: C Ibuprofen is a nonsedating analgesic. This would be the best choice but the nurse should instruct the patient to call if the pain is not tolerable because a stronger analgesic may be needed. If the patient desires to be alert, an opioid analgesic would not be the best choice because it produces drowsiness. Hydrocodone and fentanyl are opioid agonists and, based on the patient's request to be alert, would not be the best choice.

As a nursing student and nurse, you will encounter many patients from diverse cultures. When caring for a culturally diverse patient, what initial question can you ask your patient that will best assist you to improve your cultural competency? a) "Can you tell me about your culture and cultural practices?" b) "Do you understand how we do things here in the United States?" c) "What matters most to you about your illness and treatment?" d) "Can you please make me a list of your cultural preferences?"

ANS: C If there were only one intervention or question the nurse could use to improve cultural competence, it should be to routinely ask patients what matters most to them in their illness and treatment. No matter how busy the nurse is, she can find time to do this. From that point, she can use this information to incorporate cultural needs and preferences into the patient's plan of care. Each of the other questions can be asked of the patient; however, the first question that will elicit the most information is to ask the patient what matters most to him. The other three questions can follow in assisting to formulate the plan of care.

A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? He may: a) Believe in taboos against narcotic use to relieve pain b) Expect immediate and effective treatment to relieve pain c) Endure pain longer and report it less frequently than some patients do d) Use herbal teas, heat application, and prayers to manage his pain

ANS: C In general, patients of Mexican heritage may endure pain longer and report it less frequently than will some other patients. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes, and are not necessarily true for all members of a cultural group.

The nurse is seeing a home-care client with a history of mental illness. The client has just been discharged from the hospital after undergoing a mastectomy for breast cancer. As the nurse begins to perform a dressing change over the left breast area, the client states, "Every time I have a nurse come here, they do this dressing differently. I can't seem to have a nurse that does it right." What is the best response by the nurse? a) "I don't know how other nurses do your dressing change, but I will do it correctly." b) "I have done this type of dressing many times, so you don't need to worry." c) "How would you like this dressing change done? Tell me how you do it." d) "It seems you have some concerns with our agency. You may need to talk to the supervisor."

ANS: C In this item, the client has a history of mental illness and a medical condition. There are specific interventions and actions a nurse can use in caring for such clients. One of the best strategies is to have the client participate in care and allow the client some control over the dressing change. Asking the client, "How do you usually do the dressing?" or "How would you like the dressing done?" is completely appropriate as long as the client preference is consistent with safe and effective nursing practice. Each of the other responses by the nurse may be common; however, they will not foster participation or control for this client.

A 45-year-old man with a history of anxiety comes into the emergency department and is diagnosed with a myocardial infarction (MI). He says to the nurse, "This is the most ridiculous thing I've ever heard of. I eat well, exercise, and am too young to have a heart attack." The nurse recognizes that this man is most likely experiencing: a) Fear related to the diagnosis b) Anxiety related to the diagnosis c) Ineffective denial d) Overreaction

ANS: C Ineffective denial occurs when a person consciously or unconsciously rejects the knowledge or meaning of an event such as having a heart attack. The patient may frequently respond with statements such as "This can't be me," "They've made a mistake." In this item, the man is denying he has had a heart attack because he believes he is too healthy and too young to be having a heart attack. Fear is a response associated with anxiety; however, it is usually a response to a perceived threat that is recognized as a danger. Decisional conflict arises when a person is uncertain about what action to take when making choices among alternatives. There is no evidence in this item that the man is making any decisions. Overreaction can occur with some psychosocial disorders; however, the patient statements are not reflective of overreacting, as he has been diagnosed as having a heart attack.

A client presents in the clinic and tells the nurse, "I was taking my blood pressure medications and watching my diet, but that didn't help my blood pressure. So now I have stopped the medication and will just eat whatever I want." What is the most appropriate nursing diagnosis for this client? a) Anxiety b) Risk for Hopelessness c) Ineffective health maintenance d) Depression

ANS: C Ineffective health maintenance may occur as a result of low self-esteem: not perceiving one's self as capable, or feeling there is no point in making the effort. In this item, there is no evidence of low self-esteem or depression; however, the patient is verbalizing an action and direction that will negatively impact his health. This patient should not arbitrarily and abruptly stop his medications and instead be instructed to see his PCP for follow-up regarding medications. There are no defining characteristics for Anxiety or Risk for Hopelessness.

Which statement made by the student nurse to a Jehovah's Witness patient indicates a need for further learning? a) "I documented in your medical records that you do not want blood transfusions or blood products." b) "I will decorate your room with holiday ornaments." c) "Happy Birthday. I will have the dietary department send up a cake for you." d) "The organ procurement (donation) center was notified that you did not want to donate an organ."

ANS: C Jehovah's Witnesses do not celebrate birthdays or holidays, with the exception of the anniversary of Christ's death. Thus, asking the dietary department to send up a birthday cake for celebration indicates that the nurse does not understand the Jehovah's Witnesses beliefs and practices. The nurse is correct in noting that Jehovah's Witnesses do not accept blood transfusions or products or donate their organs. Decorating the patient's room for Christmas shows the nurse does not understand the patient's religion.

Which of these statements made by a client whose BMI is 34 and is attempting to lose weight would indicate the need for further teaching? a) "I should limit the number of fruit juices that I drink every day." b) "I need to tell my family and friends about my commitment to lose weight." c) "An online food diary is unlikely to help me to improve my food intake." d) "I should limit the amount of time that I spend in front of my computer and TV."

ANS: C Keeping a food diary (either traditional or online), reviewing nutritional intake (both food selections and serving size), and patterns of consumption have all been shown to assist clients in decreasing dietary intake. Sugar-sweetened beverages (e.g., soda, fruit juices, fruit drinks, and energy drinks) have a high concentration of empty calories and minimal micronutrients. Setting realistic, measurable goals that are shared with family members (accountability) increases the likelihood of success. Increased exercise and reduced sedentary activities (e.g., screen time), coupled with reduced dietary intake with improved food quality, tend to result in weight loss.

The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present-oriented? a) "I know I need to lose weight; I'll have to begin an exercise program right away." b) "If I change my diet and begin exercising, maybe I can control my blood pressure without medications." c) "I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult." d) "I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke."

ANS: C Knowing an action is needed, but giving reasons for not beginning it "just now" shows a focus on the present. The patient knows that he should reduce his sodium intake, but his present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future-oriented because they indicate that the patient is planning lifestyle changes that will affect his future.

What intervention might the nurse suggest to the patient to promote rest? a) Take benzodiazepine as prescribed. b) Avoid caffeine for several hours pc (after meals). c) Meditate for 30 to 60 minutes in the evening. d) Avoid watching television in the bedroom.

ANS: C Meditation helps to calm and relax the patient, reducing anxiety and stress, promoting rest. Medications are used to promote sleep, not rest. Caffeine before bedtime can disturb sleep, so this would not be the best advice to promote rest. Although watching television in the bedroom can interfere with falling asleep (generally it is best that the bedroom be an area used only for sleeping), television viewing is a passive activity and can be restful for some (depending on the program).

A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient? a) Anger b) Fear c) Anxiety d) Hopelessness

ANS: C NANDA International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely experiencing anxiety. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.

The nurse is caring for a patient with chronic low back pain. The patient reports taking 800 mg of ibuprofen tid for the past 12 years. For this patient, which lab result is most important for the nurse to review? a) WBC with differential b) Serum sodium, potassium, chloride, and CO2 c) Hemoglobin and hematocrit d) Platelet count

ANS: C NSAIDS can irritate the gastric mucosa, causing bleeding, which will be reflected in the hemoglobin and hematocrit levels. White blood cell count is an indicator of infection and is not likely to be impacted by long-term NSAID use. Serum electrolytes are not likely to be impacted by long-term NSAID use unless the patient experiences kidney damage. Platelet count is usually not impacted by NSAIDs, although platelet aggregation may be increased; however, this does not affect the number of platelets.

What physiological process causes the severe pain of menstrual cramps? a) Mechanical stimuli b) Thermal stimuli c) Prostaglandin activity d) Histamine activity

ANS: C NSAIDs inhibit prostaglandin activity that is largely the cause of menstrual cramping. Mechanical stimuli include external forces that result in pressure or friction. This pain is not caused by external sources. Thermal stimuli are those caused by heat or cold, which does not apply to menstrual cramps. Histamine activity is part of the process of inflammation, but is not involved in menstrual cramps, nor are histamines impacted by NSAIDs.

Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? It: a) Prevents microorganisms from adhering to the skin b) Facilitates the absorption of latex proteins through the skin c) Decreases the risk of latex allergies d) Prevents the skin from drying and chaffing.

ANS: C Non-petroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin.

A patient states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (such as Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this? a) Benzodiazepines are eliminated from the body faster than are nonbenzodiazepines, so they do not provide a full night of sleep. b) Nonbenzodiazepines cause daytime sleepiness, allowing people to rest throughout the day. c) Benzodiazepines produce daytime sleepiness and alter the sleep cycle. d) Nonbenzodiazepines remain in the body longer than do benzodiazepines.

ANS: C Nonbenzodiazepines (such as Ambien) have a short half-life, which means that they are eliminated from the body quickly and do not cause daytime sleepiness. Ativan is a long-acting benzodiazepine and remains in the body longer than Ambien, often causing daytime sleepiness.

The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and unimportant in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement? a) Spiritual support b) Self-Esteem Enhancement c) Values Clarification d) Hope Inspiration

ANS: C One of the steps of most valued clarification processes is to list values (what is important and not important in life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although the process can indirectly contribute to development of spiritual identity.

A patient who sustained rib fractures in a motor vehicle accident is stating that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? a) Metabolic alkalosis b) Pneumothorax c) Pneumonia d) Hemothorax

ANS: C Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting.

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: a) Disinfects dirty hands with antibacterial soap b) Allows alcohol-based rub to dry for 10 seconds c) Washes hands primarily after leaving each room d) Uses cold water for medical asepsis

ANS: C Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Handwashing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds.

What is the most frequent cause of the spread of infection among institutionalized patients? a) Airborne microbes from other patients b) Contact with contaminated equipment c) Hands of healthcare workers d) Exposure from family members

ANS: C Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers.

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: a) Limit his intake of protein b) Avoid foods containing gluten c) Restrict his use of sodium d) Limit his intake of potassium-rich foods

ANS: C Patients with hypertension should limit their intake of sodium. Those with liver disease should control their protein intake. Patients with renal disease must limit their intake of potassium-rich foods. Patients with celiac disease should avoid foods containing gluten.

After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing? a) Alarm b) Resistance c) Exhaustion d) Recovery

ANS: C Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place.

The nurse is performing a sleep assessment and suspects a patient is experiencing sleep apnea. What will be implemented next to confirm the diagnosis? a) Sleep diary b) Sleep history c) Polysomnography d) CPAP

ANS: C Polysomnography is the sleep study often implemented to confirm sleep apnea and determine the significance and cause of the problem. A sleep history is more comprehensive than is a sleep diary, although both would contribute to assessing the nature and extent of the patient's sleep issue. If the nurse performed a sleep assessment, then a sleep history would have been part of the process. CPAP (continuous positive airway pressure) is an intervention (not an assessment tool). This is a device that delivers oxygen using forced air pressure to keep the airways open when apnea occurs.

After inserting a nasogastric tube, what would be the nurse's priority action prior to starting the first tube feeding? a) Auscultate bowel sounds over the abdomen. b) Aspirate gastric contents and obtain a pH reading. c) Obtain radiographic verification (x-ray). d) Mix the feeding with water for the first feeding only.

ANS: C Radiographic (x-ray) verification is the only reliable method for confirming tube placement; it must be performed before the first feeding is administered. All feeding tubes contain markings that can be detected by radiographic films. Reliable bedside assessment is necessary following the initial x-ray verification and is used prior to feedings because even when the tube is initially placed correctly in the stomach/intestines and verified by x-ray, it may move upward. However, no bedside method alone is reliable. Feeding tube placement can be checked by testing the pH of the aspirate in combination with other methods; however, this is not the most reliable indication of proper placement prior to a first feeding. Auscultating bowel sounds does not provide any reliable information related to tube placement, although it is an indicator of intestinal motility. For an initial feeding, the prescriber may order the feeding to be mixed with water to assess the patient's tolerance of the feeding. Nevertheless, tube placement must be verified prior to feeding.

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication? a) Kidney failure b) Liver failure c) Stroke d) Lung cancer

ANS: C Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk of heart disease, atherosclerosis, and stroke, not kidney failure, liver failure, or lung cancer.

The 65-year-old patient tells the nursing student that his sex life was ruined after having rostate surgery. What statement by the student would be most appropriate? a) "I am so sorry to hear that. A close sexual relationship is so important." b) "It is possible to have a close, intimate relationship without intercourse." c) "Let's talk a little more about the ways in which your sex life has been ruined." d) "You might want to try one of the medications available to treat erectile dysfunction."

ANS: C Seeking more specific information about the patient's sex life and what he means by "ruined" will help the nurse understand the problem that the patient is experiencing. "I'm sorry to hear that . . ." reflects kind intentions, but it does not help the patient or address his problem. It is true that one can have a close, intimate relationship without having intercourse; however, that statement does not help the patient or explore the meaning of "ruined," nor obtain useful information. It is outside the nurse's scope of practice to discuss medications without an order from the physician.

From what stage of sleep are people typically most difficult to arouse? a) NREM, alpha waves b) NREM, sleep spindles c) NREM, delta waves d) REM

ANS: C Stage III NREM (delta wave) is the deepest stage of sleep—not REM. It is difficult to awaken someone in stage III slow wave NREM sleep, and if she is awakened, the person may appear confused and react slowly. Stage I NREM is a light sleep from which the sleeper can easily be awakened. Stage II (sleep spindles) is also light sleep; the sleeper in this stage is easily roused. REM sleep is the stage at which most dream activity occurs, as well as more spontaneous awakenings.

When making rounds on the night shift, the nurse observes her patient to be in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient most likely experiencing? a) NREM I b) NREM II c) NREM III d) REM

ANS: C Stage III NREM is the deepest sleep. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage III sleep; if awakened, the person may appear confused and react slowly. During this stage, the body releases human growth hormone, which is essential for repair and renewal of brain and other cells.

The nurse is presenting a workshop on stress and adaptation to a group of teenagers at the local high school. A teenager approaches the nurse and says, "Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think?" What is the most appropriate response by the nurse? a) "No amount of stress is healthy, especially if your heart is going faster." b) "As long as you are getting through the test, I think you will be just fine." c) "A little stress is not necessarily a bad thing. It can help you to focus." d) "You may need to develop some additional stress-reducing activities."

ANS: C Stress is not necessarily bad. It can keep one alert and motivate one to function at a higher performance level. For example, when preparing for an examination the desire to succeed can create just enough anxiety to motivate the student to study. Conversely, if a person becomes too anxious he may be unable to focus on the task or think clearly. In this item, the student identifies that he feels some anxiety but is able to focus. The nurse's response, "as long as you are focusing and getting through the test" is an acceptable one; however, this is not the best response as it will not assist the student in learning about and understanding mild stress and the motivating aspect of mild stress.

When providing care for a client with concerns about his sexual orientation, you use the PLISSIT model. You recognize that the first step you must take is to: a) Provide information about sexual orientation and common alterations b) Plan time to discuss concerns with the client in a private, comfortable setting c) Permit the client to speak openly by communicating an open, accepting attitude d) Provide referrals to the client so he can identify resources to assist him in the future

ANS: C The PLISSIT model was developed as a guideline for sex therapy. Although basic nursing education does not prepare you to provide sex therapy, the first three PLISSIT steps have been adapted to address sexual knowledge deficits that you are qualified to treat. The first step, P, is to provide permission. Permission means that you communicate an open, accepting attitude so the client feels free to ask questions and express concerns and feelings.

A parent of a 10-year-old calls the clinic and tells you that she recently found out that a convicted sex offender is living in their neighborhood. She asks your advice on how to protect her child. What is your best response? a) "Keep the child indoors to prevent any contact with the sex offender." b) "Discuss your concerns with the sex offender." c) "Teach your child to stay away from strangers and never let another person touch her private parts." d) "Teach your child to walk on the opposite side of the street and away from the house of the known sex offender."

ANS: C The best way to protect children is to teach them how to protect themselves from strangers and sexual predators. The child should be taught not to let anyone touch her private parts or show her their private parts. She should know never to get in the car with strangers and to tell an adult or parent if another person makes her feel uncomfortable. Talking with the sex offender does not protect the child. It is impractical to keep the child indoors at all times. Walking on the opposite side of the street is not the best answer, because the child can encounter the offender in numerous settings.

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? a) Phagocytosis b) Complement cascade c) Inflammation d) Immunity

ANS: C The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses of phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection.

The nurse is working in a pediatric intensive care unit. A young couple has just been informed that their 6-year-old son has died after being in the unit for 1 month. The couple is grief stricken and says to the nurse, "We can't believe this has happened. He was too young. God is watching over him. Do you believe in God?" What is the most appropriate response by the nurse? a) "It was his time. He is in a better place." b) "He suffered enough. He is in peace now." c) "I believe he is with angels, but what you think is most important." d) "It doesn't matter what I think. It is only important what you think."

ANS: C The death of a child is one of the most difficult life events for a family as well as for the nurse who may witness it. In this item, a seemingly harmless statement such as "He is in a better place" or "He has suffered enough" may be hurtful and even offensive for the family. It is better not to offer opinions or judgments. If a family asks what you, the nurse, think, you can briefly share your beliefs and answer their question, but reflect their questions back to them. The most appropriate response by the nurse is to briefly answer the question and refer back to the family. The answer, "It doesn't matter what I think . . ." sounds abrupt and opinionated.

While the nurse is performing a nutritional assessment her patient states, "I am on a vegan diet. I have been a vegan for 10 years. What do think?" What is the best response by the nurse? a) "Is this a religious or cultural requirement for you?" b) "It is fine; however, you may not be getting all the nutrients you need." c) "Can you tell me about the foods you eat along with any other supplements you take?" d) "I think it is your right to be on whatever diet you would like to be on."

ANS: C The most appropriate response by the nurse is to first assess what the patient is eating and what supplements the patient uses. This will assist the nurse in identifying the patient's knowledge level of the diet and in identifying proper supplements. The nurse cannot assume that although the patient is following a specific diet, she is obtaining the proper nutrition. Asking the patient whether this is a religious or cultural requirement may be judgmental, is a closed question, and will not elicit information regarding specific dietary intake. All vegetarian diets exclude red meat and poultry, but beyond this distinction is a wide spectrum of vegetarian diets. Vegans eat only foods of plant origin. When choosing a vegetarian diet, one cannot use animal products, such as eggs and milk, to supply necessary nutrients. For example, vegans must eat foods fortified with B12 or take B12 supplements because a deficiency can result in severe and irreversible neurological impairment. Other nutrients that may be inadequately supplied in vegan diets include vitamin D, calcium, iron, and zinc. It is certainly an individual's right to make his or her own choices regarding diet; however, this response again will not assist the nurse in conducting a thorough nutritional assessment.

The patient tells the nurse, "My partner and I never have intercourse when I have my period because I read that it is dangerous." What statement by the nurse is most appropriate? a) "You can protect the bed linens by placing protective padding under the buttocks." b) "Reaching orgasm during your period can help to relieve menstrual cramps." c) "The blood is from the uterus, not the vagina, so intercourse will not harm the vagina." d) "The increased blood flow to the pelvis will make sex more pleasurable for you."

ANS: C The most important point for the nurse to make is that it is safe to have intercourse during menstruation so that the patient can make an informed choice about whether to do so; therefore, explaining that intercourse will not harm the vagina is the best response. Although the statements about protecting bed linens and about orgasm reducing cramping are true, they do not address the patient's concern that intercourse is dangerous during menstruation. Increased blood flow to the pelvis may or may not increase the patient's pleasure; and it does not address the patient's concerns about safety.

22. Which pain management task can be safely delegated to nursing assistive personnel? a) Assessing the quality and intensity of the patient's pain b) Evaluating the effectiveness of pain medication c) Providing a therapeutic back massage d) Administering oral dose of acetaminophen

ANS: C The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patient's pain, monitoring the patient's response to pain management strategies, administering medications (including over-the-counter preparations), or evaluating the pain management plan.

When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan? a) "The patient will limit his intake of fat to 15% of the daily calories consumed." b) "The patient will eat three meals per day at approximately the same time each day." c) "The patient will limit his intake sweet and salty foods." d) "The patient will consume no more than three alcoholic beverages a day."

ANS: C The nurse should advise the client to limit the intake of sugar (to avoid sugar highs and crashes) and salt (to avoid increasing blood pressure); limit the intake of fat to no more than 30% (not 15%) of daily calories (to prevent cardiovascular disease); eat smaller, more frequent meals (rather than three meals a day) to aid in digestion; and consume no more than two alcoholic beverages per day but not necessarily every day.

A patient develops a respiratory rate 6 breaths/min after receiving IV hydromorphone (Dilaudid) 2.0 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? a) Physostigmine (Antilirium) b) Flumazenil (Romazicon) c) Naloxone (Narcan) d) Protamine sulfate

ANS: C The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous system depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin.

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? a) Place the cold pack directly on the skin over the ankle. b) Apply the cold pack to the ankle for 30 minutes at a time. c) Check the skin frequently for extreme redness. d) Keep the cold pack in place for at least 24 hours.

ANS: C The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time. The patient should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur.

The nurse conducting a pain assessment for a patient would recognize deep somatic pain as which of the following? a) Achy b) Superficial c) Radiating d) Crampy

ANS: C The pain occurs because of potentially damaging stimuli, so it is nociceptive; it originates in the bone so it is somatic; and arthritis is chronic because it is usually lifelong resulting from joints that do not correct once they have been damaged.

A patient comes to the emergency department complaining of headache, palpitations, nausea, and dizziness. After determining that the patient is anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting? a) Mild b) Moderate c) Severe d) Panic

ANS: C The patient experiencing severe anxiety may experience physical symptoms including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. The patient experiencing moderate anxiety might experience a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. The patient suffering from panic anxiety might believe he has a life-threatening illness. Physical symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements.

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? a) Incubation b) Prodromal c) Decline d) Convalescence

ANS: C The stage of decline occurs when the patient's immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to heal as the organisms disappear.

The nurse is working on an orthopedic unit in the local hospital. While assessing her patient the patient states, "Ever since we had the earthquake in California I can't sleep for fear of another one happening during the night, and I just keep having flashbacks of the earthquake." The nurse knows that these patient statements are most consistent with: a) Anxiety b) Lack of coping skills c) Post-traumatic stress disorder d) Crisis

ANS: C The statements by this patient are most consistent with post-traumatic stress disorder (PTSD): a specific response to a violent, traumatizing event such as a natural disaster (flood, earthquake) or physical or emotional abuse (war, rape). The victim experiences anxiety and flashbacks that may last for months or years. A crisis exists when an event in a person's life drastically changes the person's routine and he perceive it as a threat to self. Such events are usually sudden and unexpected such as a serious illness, death of a loved one, serious financial loss, and natural disaster. It is not common, however, for people in crisis to experience flashbacks. Flashbacks are most consistent with PTSD.

The nurse uses his hands to direct energy fields surrounding the patient's body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention? a) Tactile distraction was performed and appeared effective in reducing pain. b) Guided imagery was effective to relax the patient and reduce the pain. c) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. d) Sequential muscle relaxation was performed; patient states pain is less.

ANS: C Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain.

A Spanish-speaking patient in the hospital is getting ready surgery and needs to sign the surgical consent form. Existing regulations determine the healthcare organization's responsibility for obtaining informed consent from this patient. The healthcare organization is required to do which of the following? a) Provide a licensed interpreter b) Provide a translator approved by the organization c) Ensure adequate resources to comply with informed consent requirements d) Choose an interpreter, a translator, or a family member to interpret

ANS: C There are times when a nurse may use gestures, pictures, and family members in communicating with a patient. This is usually the case for some assessment issues such as assessing and locating pain. However, if and when there is a consent issue, the hospital or healthcare organization must ensure adequate resources to comply with informed consent requirements. At times, a translator is used, but this person usually only translates or restates information and does not necessarily explain the meaning of information. An interpreter is usually used for explaining the meaning of information, but there are requirements for licensing and approval. Each answer is too specific. The best answer is to ensure adequate resources that will comply with informed consent requirements.

An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states, "I don't want a man taking care of me." Which cultural barrier is this patient exhibiting? a) Ethnocentrism b) Racism c) Sexism d) Chauvinism

ANS: C This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased toward her own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior.

A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response? a) Histamine b) Prostaglandin c) Bradykinin d) Serotonin

ANS: C Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and not involved in the inflammatory response.

Which statement by the nurse is best when communicating with a patient with clinical depression? a) "It's a beautiful day today; you'll feel better if you look out the window." b) "You're having a bad day; I'm sure you'll feel better soon." c) "Life seems overwhelming at times; would you like to discuss how you're feeling?" d) "You are very lucky to have such a supportive family."

ANS: C When caring for a patient with depression, the nurse should encourage the patient to discuss his feelings. "It's a beautiful day . . ." and "You're having a bad day . . ." offer false reassurance. It would not be therapeutic to say, "You are very lucky . . ."; that is offering a judgment.

A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis? a) Glycogen b) Insulin c) Ketones d) Proteins

ANS: C When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis. Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be used for fuel as long as fats were available.

A client approaches the nurse in the health clinic and states, "I have been dealing with my husband's illnesses for years. Now my children want me to start babysitting for my grandchildren. I don't know whether I can handle all this." What is the nurse's interpretation of this woman's statements? a) Some events are producing more stress for her than other events. b) Her coping abilities are extended to her limit and she is unable to cope. c) When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. d) Coping strategies that she has used in the past are no longer successful for her now.

ANS: C When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. In this item, the client is verbalizing both a concern in caring for a family member over a long period of time and the possibility of dealing with a new stressor: babysitting grandchildren. Some events produce more stress than others. However, a person with good coping skills can usually adapt to a single stressful event, even a demanding one. This client has been managing one stressful event. It is the addition of another that is concerning her. In this item, we are unable to determine that coping strategies are no longer successful because we do not have any information on past coping strategies. Additionally, we cannot determine that she is unable to cope because she states, "I don't know whether I can handle all this."

The nurse teaches a class on reproduction for adolescents and explains that which female reproductive organs engorge and become sensitive during stimulation? Select all that apply. a) Vagina b) Labia majora c) Labia minora d) Clitoris e) Bartholin's glands

ANS: C, D Both the labia minora and the clitoris become engorged and increase in sensitivity during sexual stimulation. The vagina and labia majora do not increase in sensitivity or engorge with stimulation. Although Bartholin's glands secrete mucus during sexual arousal, they do not become engorged or sensitive.

The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Select all that apply. a) Bruxism b) Enuresis c) Daytime fatigue d) Snoring e) Drooling

ANS: C, D Obstructive sleep apnea is caused by partial airway occlusion (usually by the tongue or palate) during sleep. The patient experiences interrupted sleep as he arouses frequently to clear the airway. As a result, the patient has episodes of snoring and daytime fatigue.

Which of the following statements about race and ethnicity is/are true? Select all that apply. a) Ethnicity refers to a person's cultural use of the indigenous healthcare system. b) A person can have several aspects of a racial culture or be multicultural. c) Ethnicity refers to groups whose members share a common and social heritage that is transmitted to the next generation. d) Race primarily reflects biology and refers to grouping of people based on biological similarities.

ANS: C, D Race refers to the grouping of individuals who share similar biological characteristics, such as blood type, skin color, and so forth. A person can be biracial; however, multicultural describes groups rather than individuals. Ethnicity refers to groups whose members share a common and social heritage that is transmitted to the next generation.

In which situation would using standard precautions be adequate? Select all that apply. a) While interviewing a client with a productive cough b) While helping a client to perform his own hygiene care c) While aiding a client to ambulate after surgery d) While inserting a peripheral intravenous catheter

ANS: C, D Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). If the disease is not spread by air or droplets, then there is no likelihood of the nurse's encountering body fluids when interviewing a client. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery.

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. a) Question the order because the patient must remain in isolation. b) Place an N-95 respirator mask on the patient and transport him to the test. c) Place a surgical mask on the patient and transport him to CT lab. d) Notify the computed tomography department about precautions prior to transport.

ANS: C, D Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport.

The nurse is performing a sexual assessment on a newly admitted married 60-year-old female patient. Which question should the nurse omit from the nursing assessment? a) "Are you sexually active?" b) "How often do you have sexual intercourse?" c) "Do you experience any discomfort during sex?" d) "What method of birth control are you currently using?"

ANS: D A woman aged 60 is not capable of becoming pregnant, so questions about birth control are not needed, but use of barrier methods to prevent STIs may be asked when appropriate. People aged 60 and older may or may not be sexually active. Marriage is not an indicator of sexual activity because some married people are not sexually active. Asking about frequency of sexual activity can be an indicator of health, exercise tolerance, and other important factors, so should be asked of this patient. Questions about discomfort during sex are important because patients may not bring up the subject if not asked directly.

A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? a) Use of herbs and roots b) Application of oils and poultices c) Burning of dried plants d) Acupuncture

ANS: D Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects.

An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and become frail. Her appetite and activity level are reduced and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be? a) Need for teaching about nutrition b) Anxiety c) Distaste for the food served d) Adult failure to thrive

ANS: D Adult failure to thrive is a complex disorder seen in many institutionalized older adults. It is characterized by weight loss, decreased activity and interactions, and increasing frailty. The overall description presented by the nurse is consistent with adult failure to thrive. The resident's poor appetite is not a result of not understanding nutrition or the need to eat. Teaching would not be helpful in this instance. In this situation, the resident's poor appetite is more likely related to depression and social withdrawal or even dementia than to anxiety. Most skilled nursing facilities could individualize the dietary selection to some degree to provide residents with adequate nutrition.

The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the following actions by the nurse is appropriate? a) Offer a prayer for healing using the nurse's usual words and format. b) Begin the prayer with "Jehovah God," as she always does, while avoiding the name of Jesus. c) Avoid saying any name for the Supreme Being while praying, and quote an Old Testament Bible scripture as the prayer. d) Say, "What name would you like for me to use to address the Supreme Being when I am praying for you?"

ANS: D Ask how the patient prefers to address the divine. Some people prefer the use of parental language in their prayers, for example, Father God or Divine Mother. Some use Jehovah, Yahweh, or Allah. Hindus may address one or more multiple gods, each of whom has several names. Seek direction from the patient in these matters: most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. The nurse should not assume that using the names "Jesus" and "Jehovah God" would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing god by a name, but the most supportive way to do so is to find out the name the patient wishes to use. Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually.

Which statement below is a myth regarding sexuality and bodily functions? a) Douching after intercourse does not prevent pregnancy. b) Wearing a condom during intercourse does not prevent pregnancy. c) Celibacy is 100% effective in the prevention of pregnancy. d) Antibiotics can cure all types of sexually transmitted infections.

ANS: D Because this item asks which statement is a myth, a test-taking strategy is to ask which statement is false. The only false statement is that all STIs can be cured with antibiotics. HIV is an example of an STI that cannot be cured with antibiotics. Some STIs, like gonorrhea, are becoming resistant to antibiotics. The other options are all true.

The nurse is caring for several patients on a medical-surgical unit. To which patient statement is the nurse most alerted for making a mental health referral? a) "Since finding out I have cancer, I feel nervous and uneasy all the time." b) "Sometimes I feel very down about my job, but if I get to the gym and do some exercising, I feel better." c) "When things really bother me, I just put them right out of my head and go on." d) "Things at home are just piling up. I just feel so alone and empty inside of me."

ANS: D Chapter 13: Psychosocial Health & Illness Unlike the feeling of true sadness, such as feelings that may accompany a divorce, death, or other loss, the depressed mood is typically marked by a sense of emptiness. The patient in most need of a mental health referral is the patient who verbalizes the feeling of loneliness and emptiness. Feelings of nervousness and uneasiness may be symptoms of anxiety. This patient should first talk to his primary care provider regarding his diagnosis of Cancer and Feelings. The other patient statements reflect effective coping methods at this time and do not warrant a mental health referral.

The patient tells the nurse, "After a couple of glasses of wine I sleep very soundly." After assessing further about the patient's alcohol history, what response by the nurse is most accurate? a) "Although alcohol helps you fall asleep, you will be more likely to awaken during the night and have trouble falling back to sleep." b) "If you quit drinking, you will find falling asleep more difficult, but you'll feel more rested when you awaken." c) "I know alcohol helps you to sleep but you could take a sleeping pill instead to help you fall asleep." d) "What else do you do on a regular basis that helps you to fall asleep and stay asleep?"

ANS: D Collecting a complete sleep history is the first step in caring for a patient with sleep difficulty. Alcohol (even wine), especially consumed in excess, hastens the onset of sleep but also disrupts REM and slow-wave sleep; it may cause spontaneous awakenings with difficulty returning to sleep. There is no evidence to support the benefit of alcohol in helping people to feel more rested upon awakening after heavy consumption, so this would be an inaccurate statement. Taking a sleeping pill instead of drinking alcohol is not an ideal trade-off because the goal is to promote natural sleep.

Which of the following interventions would help to prevent or relieve persistent nausea? a) Assess for signs of dehydration. b) Provide dietary supplements. c) Have the patient sit in an upright position for 30 minutes after eating. d) Immediately remove any food that the patient cannot eat.

ANS: D Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for it. However, this intervention does not prevent nausea. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. Having the patient sit upright helps to prevent respiratory aspiration should the patient vomit; it does not prevent or relieve nausea. Odors (even pleasant ones) and even the sight of food can cause nausea, so any uneaten food should be removed immediately from the room.

A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis? a) Decision Making b) Distorted Thought Content c) Role Performance d) Depression Level

ANS: D Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis Chronic Low Self-Esteem. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem; Role performance with Ineffective role performance; and Distorted Thought Content with Disturbed Personal Identity. Although the other options might contribute to the patient's low self-esteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate resolution of the nursing diagnosis. Decision Making is the only outcome that does that.

A frail, elderly patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. What is most important for the nurse to do? a) Recognize these symptoms as signs of normal, physiologic aging. b) Obtain a urine specimen before notifying the primary care provider. c) Be sure she is placed in a room occupied with another patient. d) Interview the patient to screen for clinical depression.

ANS: D Depression is often masked in older adults and expressed as physical and personality changes. Memory loss and confusion are also common symptoms of depression in older adults. Any one of the symptoms might occur as a result of physical illness, but the combination should prompt the nurse to suspect depression and interview and screen for it before exploring physiological causes for the symptom (as with a urine specimen). Placing the patient with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes.

The nurse sees a patient in the clinic who is diagnosed with pelvic inflammatory disease. What assessment finding does the nurse suspect as the possible cause of this infection? a) Soaking in a hot bath every evening. b) Skipping showers over the weekend c) Wearing cotton underwear d) Douching two times per week

ANS: D Douching washes away protective bacteria that protect the vagina from infection, so this behavior will increase the patient's risk of pelvic inflammatory disease. Soaking in a hot bathtub is not likely to result in pelvic inflammatory disease. Daily showers and skipping showers on the weekend will not necessarily cause pelvic inflammatory disease. Wearing cotton underwear helps to wick moisture away from the perineal skin and reduces risk of pelvic inflammatory disease.

The nurse is updating the care plan of a patient who must undergo a right mastectomy for breast cancer. Which nursing diagnosis should the nurse anticipate in expectation of the body changes associated with the upcoming surgery? a) Deficient Knowledge b) Impaired Adjustment c) Hopelessness d) Grieving

ANS: D Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associated with the expected body changes associated with the upcoming surgery, although they could certainly occur.

Which question is most important to ask of a newly admitted patient to effectively incorporate spiritual care in the nursing care plan? a) "What is your family's religious background?" b) "With what organized religion are you affiliated?" c) "Do you go to church, and if so, how often?" d) "What are your personal spiritual beliefs?"

ANS: D Identifying the patient's personal spiritual belief will provide you with more information to incorporate into the plan of care. These beliefs may be associated with or independent of religious affiliations. Not all people of a religious group adhere to its norms, rituals, and/or practices; therefore, questions should extend beyond focusing only on the patient's or his family's religion.

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would be most likely to be found in a test of immunoglobulin levels? a) IgA b) IgE c) IgG d) IgM

ANS: D IgM antibodies are the first to be made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear later— perhaps up to 10 days later.

A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first? a) Cellular inflammation b) Exudate formation c) Tissue regeneration d) Vascular response

ANS: D Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase.

Which patient teaching would be most therapeutic for someone with sleep disturbance? a) Give yourself at least 60 minutes to fall asleep. b) Avoid eating carbohydrates before going to sleep. c) Catch up on sleep by napping or sleeping in when possible. d) Do not go to bed feeling upset about a conflict.

ANS: D Intense emotion before bedtime can interfere with rest and sleep. Lying awake longer than 30 minutes is counterproductive. Eating a small amount of a complex carbohydrate can aid in falling asleep. Avoid simple sugars because sucrose can lead to a short-term energy boost instead of relaxation. Taking naps during the day and sleeping late on some mornings can actually exacerbate a sleep disturbance. It's better to establish a consistent routine for wake and sleep. The extra sleep during the day can interfere with the body's readiness for sleep at night.

The pediatric nurse is caring for a 4-year-old child who is experiencing chronic pain secondary to tissue injury from past sickle cell anemia crises. Which of the following nonpharmacological pain reduction interventions might the nurse implement? Have the child: a) Perform vigorous activity b) Practice visualization c) Listen to rap music d) Watch a funny movie

ANS: D Laughter from watching a funny movie is likely to result in pain reduction without causing stress on the joints. Strenuous exercise would likely aggravate the pain experience and potentially cause injury. Visualization is associated with the endogenous analgesia system but might not be effective in a young child. Rap music is a form of distraction that would cause excitation rather than relaxation, so this would not be effective.

After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic? a) "I usually use dessert only as a reward for eating other foods." b) "I will hide vegetables in casseroles and stews to get my child to eat them." c) "I do not give my child snacks; they simply spoil his appetite for meals." d) "I know that lifelong food habits are developed during this stage of life."

ANS: D Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child. Desserts should not be used as rewards for eating other foods. This practice can shape an attitude about food that can lead to eating disorders later in life. Preschool-age children often refuse combined foods such as casseroles and stews. Because they are active, preschoolers require nutritious between-meal snacks.

You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing? a) Hypochondriasis b) Somatization c) Somatoform pain disorder d) Malingering

ANS: D Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically.

Which of the following statements by a teenage client would indicate that your teaching about detection of STIs has been effective? a) "A healthcare provider can tell whether you have an STI just by looking at your genitals." b) "The doctor has to do surgery to biopsy the tissue to find out if a person has an STI." c) "A healthcare provider can tell whether you have an STI by getting a detailed sexual history." d) "A genital swab culture can be done at the office or clinic to determine whether a person has an STI."

ANS: D Many STIs have few or no symptoms. To find out whether a patient has an STI, you must obtain a swab culture of secretions. For a man, a culture is obtained from the urethra. For a woman, secretions are swabbed near the cervix.

A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? a) Perception b) Transduction c) Transmission d) Modulation

ANS: D Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation).

The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which of the following is an example of an individualized goal for that patient? a) Distorted Thought Control b) Anxiety Level c) Self-Mutilation Restraint d) No Self-Injury, Consistently Demonstrated

ANS: D No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. The other options are examples of NOC outcomes; they are not written as goals.

The nursing student is completing her clinical rotation in the intensive care unit. While caring for a patient, she says to the primary nurse, "This family is bringing in all kinds of beads and medals and putting them on the patient and bed. This is intensive care! What should I do?" What is the most appropriate response by the nurse? a) "Remove the medals from the patient so they don't get in the way of your work." b) "Remove the beads from the bed so they don't get in the way of your work." c) "Explain to the family that these objects cannot be brought into intensive care as our work is too intricate and these things can get in the way." d) "This is not uncommon in intensive care. Try to work around this as best you can, as these objects are important to the family and patient."

ANS: D Nurses must respect a patient's dress and other requirements or symbols as determined by his religion. It is not uncommon for religious groups such as Hindus and Roman Catholics to wear medals or beads as symbolic icons of their religion. The most appropriate response by the nurse is to inform the student that this practice is common in all units of care and must be respected. If the nurse needs to remove any items, she should first obtain permission from the patient or significant other.

A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as: a) A punishment for immoral behavior b) An expected, normal part of life c) Best treated with herbal teas and prayer d) A virtue and a matter of family honor

ANS: D Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarily apply to all members of a cultural group.

The mental health unit separates from others a male patient who repeatedly talks rapidly, makes sexual comments to female patients, and touches them inappropriately. While reviewing his medical records, which diagnosis can the nurse best anticipate for this patient? a) Depression b) Schizophrenia c) Alzheimer's disease d) Bipolar disorder

ANS: D Patients with bipolar disorder, particularly during manic phases, are likely to be preoccupied with pleasurable activities and commonly display increased sexual activity in the form of verbalizing and acting out. Depressed patients often experience loss of interest in all activities, including pleasant ones, and are not likely to exhibit this type of behavior. Patients with schizophrenia experience delusions that interfere with sexuality, so would not likely display this behavior. Patients who have Alzheimer's disease are often confused in earlier stages and nonresponsive in later stages. This patient would not be the most likely to exhibit this behavior.

A 35-year-old female comes to the clinic for her annual physical. Upon examination, the nurse palpates a lump in the left breast. She informs the client of the finding and the client responds, "Yes, I found it a few months ago too but just didn't want to think about it." The nurse recognizes that this client has been using which approach to coping with the lump? a) Altering b) Adapting c) Changing d) Avoiding

ANS: D People use three approaches in coping with a stress. Altering the stressor is removing or changing the stressor. Adapting to the stressor involves changing one's thoughts or behaviors related to the stressor. Avoiding the stressor at times may be effective, but in this item it is maladaptive, as the client has coped by putting it out of her mind, thus avoiding earlier medical care.

Which response by the patient demonstrates an internal locus of control? a) "My blood sugar wouldn't be out of control if my wife prepared better foods." b) "I knew I shouldn't have come to this hospital; I'd be better if I hadn't." c) "God must be getting even with me for my past behavior." d) "I'm just glad to be alive; the accident could've been a lot worse."

ANS: D People who demonstrate an internal locus of control take responsibility for their life experiences and their responses to them. This allows them to interpret unexpected events in a positive light, as the response ". . . the accident could've been a lot worse" illustrates. The other options demonstrate an external locus of control; control of the situation is attributed to external factors.

Which statement best describes self-esteem? a) View of oneself as a unique human being b) One's mental image of one's physical self c) One's overall view of oneself d) How well one likes oneself

ANS: D Personal identity is one's view of oneself as a unique human being. Body image is described as one's mental image of one's physical self. Self-concept is defined as one's overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect—that is, how well one likes oneself.

The nurse on a psychiatric unit is caring for a client with severe depression. The client states, "I just cannot go on. It is hopeless for me and there is no end in sight. My family would be better off without me burdening them." The nurse recognizes that this client is most at risk for: a) Ineffective coping b) Denial c) Impaired recovery d) Suicide

ANS: D Risk for suicide must always be considered when a client is depressed, especially when the client has a history of prior attempts or is verbalizing the desire to die or the intent to kill himself. In this item, the client is most at risk for suicide based on the statements verbalized. Ineffective coping is present and therefore an actual rather than a risk problem. There is no evidence of denial or impaired recovery.

A female client tells the nurse, "I see how people look at me with my crooked back and short leg. No one has to tell me that I'm not pretty." The nurse realizes this client is exhibiting: a) An overinflated sense of self-esteem b) A well-developed self-concept c) An overactive imagination d) A low self-concept

ANS: D Self-concept forms out of a person's evaluation of his physical appearance, intellectual ability, success in the workplace, friendship, and approval from others. A person with a low self-concept has a mostly negative perception of these evaluations of self. A low self-concept may cause withdrawal from social interactions and make it difficult to form relationships.

Which is a major factor regulating sleep? a) Electrical impulses transmitted to the cerebellum b) Level of sympathetic nervous system stimulation c) Amount of sleep to which a person has become accustomed d) Amount of light received through the eyes

ANS: D The circadian rhythm is a biorhythm based on the day-night pattern in a 24-hour cycle. A person's circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brainstem that respond to changing levels of light. A major factor in regulating sleep is the amount of light received through the eyes—not the typical amount of sleep the person has within a 24-hour period. The autonomic nervous system (rather than central nervous system) controls the involuntary processes of the body, such as sleep, digestion, immune function, and so on.

A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boy's sleep patterns, she says, "Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed." The nurse explains that he is sleepwalking. The best nursing diagnosis for the boy would be: a) Risk for Insomnia related to sleepwalking b) Risk for Fatigue related to sleepwalking c) Disturbed Sleep Pattern related to dyssomnia d) Risk for Injury related to sleepwalking

ANS: D Sleepwalking occurs during stage III NREM sleep. The sleeper leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings. Insomnia is a medical diagnosis rather than a nursing diagnosis. Certainly his sleep pattern is disturbed; however, there is little in the way of independent actions that the nurse could take for either the problem or etiology of this diagnosis, so it would not be useful. The boy does not awaken while sleepwalking and is not likely to experience fatigue from the event.

A patient infected with a virus but who does not have any outward sign of the disease is considered a: a) Pathogen b) Fomite c) Vector d) Carrier

ANS: D Some people might harbor a pathogenic organism, such as HIV, within their body and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings.

A patient with Raynaud's disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief? a) Cordotomy b) Rhizotomy c) Neurectomy d) Sympathectomy

ANS: D Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynaud's disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission.

The nurse is assessing a patient for depression. Which of the following sets of behavioral symptoms may indicate depression? a) Preoccupation with loss, self-blame, and ambivalence b) Anger, helplessness, guilt, and sadness c) Anorexia, insomnia, headache, and constipation d) Tearfulness, withdrawal, and present substance abuse

ANS: D Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are affective findings associated with depression. Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain, and constipation.

The patient tells the nurse, "I have terrible insomnia. It seems as though I am exhausted all the time." What question is most appropriate for the nurse to ask this patient? a) "What time do you go to bed at night?" b) "Are you experiencing much stress right now?" c) "Have you tried meditation to help you relax?" d) "Do you have trouble falling asleep or staying asleep?"

ANS: D The first question the nurse should ask the patient with an alteration in sleep is whether she has trouble falling asleep, staying asleep, or returning to sleep after she has awakened. Before recommending interventions to promote sleep, it is important for the nurse to gather data related to what the patient means by insomnia. The time the patient goes to sleep is not as important as how long she sleeps or whether there has been a significant change in sleep patterns. While assessing stress is an important factor in various alterations in sleep, the nurse would first gather information about the sleep quantity and quality before assessing specific factors contributing to insomnia.

A physician frequently approaches a nurse and complements her on her appearance, including making comments about private areas of the nurse's body. What is the nurse's initial best action? a) Inform the nursing supervisor of the physician's behavior. b) Call the medical board to report the physician's behavior. c) Document the physician's behavior and report concerns to the chief of staff. d) Inform the physician the behavior is inappropriate and unwelcome.

ANS: D The first step the nurse should take is to inform the physician that the behavior is both unwelcome and inappropriate, and the physician should be told to stop immediately. It may become necessary to inform the nursing supervisor of the physician's behavior but it is not the best first step for the nurse to take. Calling the medical board would be inappropriate and should not be the first step. Reporting the behavior to the chief of staff would ignore the chain of command and would be unprofessional.

The nurse is speaking with a 40-year-old woman at a fund-raiser. The woman states, "I have never had a mammogram. I am a Buddhist and I believe if I get cancer, then that is what my fate will be." What is the most appropriate response by the nurse? a) "You are 40 years old and really should start thinking about having a mammogram." b) "Breast cancer can be cured if caught and treated early enough. You are not giving yourself an opportunity think about your own health." c) "I don't know of any religion that just allows people to die. You may need to rethink this." d) "This is certainly your choice; however, there is research that shows screening is helpful and effective."

ANS: D The focus of this item is to demonstrate that certain religions, spirituality, and ways of thinking can and do have an effect on patients' willingness to seek out healthcare, most specifically, preventive screening. Researchers have investigated the effect of religious beliefs on health disparities. Fatalism, which is rooted in Buddhism, views fatal diseases as destined by nature and acceptance as a sign of wisdom and maturity. This group is known to have a highly pessimistic perception that preventive screening would lower their risk of getting cancer. The patient in this item is less likely to obtain a mammogram as a screening tool. The most appropriate response by the nurse is to first acknowledge and accept the patient's belief in her religion or way of life; however, the nurse should also provide a nonthreatening and educated response by giving the facts in support of what research has demonstrated and what prevention can do. Nurses cannot tell patients what they should and should not do, nor should they be critical of a person's religion.

A patient is in crisis. After assessing the situation, what should the nurse do first? a) Determine the imminent cause of the crisis b) Intervene to relieve the patient's anxiety c) Decide on the type of help the patient needs d) Ensure the safety of both the nurse and patient

ANS: D The goals of crisis intervention are to assess the situation first. Then ensure safety of self and patient, defuse the situation, decrease the person's anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost.

The nurse teaching 8th grade girls addresses common myths about sexuality and body functions. Which statement by a student is an indication that teaching was effective? a) "After the first time I have sex, I need to begin some form of birth control to avoid pregnancy." b) "Condoms are the most effective birth control and it is the only way I can be sure I won't get pregnant." c) "I only have to worry about being infected with a sexually transmitted infection if I see a sore or have pain." d) "Enjoyable sexual relationships or reaching orgasm simultaneously does not indicate the quality of the relationship."

ANS: D The goals of this teaching would be to dispel myths about sex and sexuality. The statement is accurate that simultaneous orgasm and good sexual relations do not predict the quality of a relationship. This dispels a myth to the contrary and reflects learning. The statement that a person cannot get pregnant the first time she has sex is a myth and would indicate the need for further teaching. Although condoms may be most effective when used correctly, they do not always prevent pregnancy; therefore, that statement indicates the need for further teaching. Sexually transmitted infections may not produce noticeable symptoms, especially in women, so this statement indicates the need for further teaching.

Which of the following patients with inadequate or poor quality of sleep would be the best choice for a nursing diagnosis of Disturbed Sleep Patterns? a) Adolescent diagnosed with somnambulism b) Patient with obstructive sleep apnea c) Attorney who says she has no time for sleep d) New mother of twins

ANS: D The new mother of twins would experience disturbed sleep until the babies are mature enough to sleep through the night; therefore, this is a time-limited sleep problem and fits the diagnosis of Disturbed Sleep Patterns. The patient who is reported to walk in her sleep (somnambulism) would not fit the diagnosis of Disturbed Sleep Patterns because sleepwalking would not be time limited. In this case, the patient may not know she sleepwalks and may report no sleep problems. The patient diagnosed with obstructive sleep apnea would not fit the diagnosis because the irregular breathing pattern during sleep is not time limited. This patient does not have a time-limited change in sleep patterns and would not fit the diagnosis.

What is the most effective action for the nurse to take when delivering spiritual care to a patient of the same religion as the nurse? a) Understanding that the patient shares the same beliefs b) Striving to meet the patient's spiritual needs independently c) Explaining her own religious beliefs to the patient d) Developing a greater awareness of her own spirituality

ANS: D The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patient's spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient.

The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells the nurse that he is often "short of breath" and says, "I lie awake nights worrying about everything." He has been unable to work or care for his family for the past 6 months. What is the nurse's priority after documenting this information in the nurses' notes? a) Provide emotional support for the patient using reflective listening technique. b) Do nothing; people with duodenal ulcers typically cannot work. c) Question the patient's family about the information received from the patient. d) Notify the primary care provider and ask for a referral to a mental health professional.

ANS: D The nurse should involve a mental health professional immediately, because the patient is exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. Doing nothing is neglectful. Questioning the patient's family about the information violates the patient's right to privacy, unless the nurse obtains the patient's permission to do so.

After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? a) Use nonpharmacological therapy while waiting 3 more hours before next dose. b) Administer an additional 800 mg oral dose of ibuprofen right away. c) Do nothing because the patient's facial expression indicates he is comfortable. d) Notify the prescriber that the current pain management plan is ineffective.

ANS: D The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescriber's order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is.

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? a) When fingers feel sticky b) After 5 to 10 seconds c) When leaving the client's room d) Once fingers and hands feel dry

ANS: D The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness.

A patient receiving an epidural analgesic complains of a headache. Which of the following should the nurse suspect? a) Catheter migration b) Local anesthesia toxicity c) Common side effect of the analgesic d) Dural puncture

ANS: D The patient with a dural puncture while receiving epidural analgesic would likely report a headache. Catheter migration often produces nausea, a decrease in blood pressure, and a loss of motor function without a recognizable cause. Signs of local anesthesia toxicity occur when anesthesia is injected directly into the bloodstream instead of the epidural space. The patient might report numbness or tingling around the mouth (circum-oral paresthesia) or ringing in the ears (tinnitus), or the nurse may assess irritability, tremors, seizures, or cardiac arrhythmias

The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will: a) Limit exercise to 1 hour per day early in the day b) Consume only one caffeinated beverage per day c) Demonstrate effective guided imagery to aid relaxation d) Verbalize that she is sleeping better and feels less fatigued

ANS: D The patient would verbalize that she is sleeping better and feels less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem. The other options are outcomes that demonstrate only that the patient took certain actions. They would not, if achieved, demonstrate that the problem of Disturbed Sleep Pattern had been resolved.

The nurse is developing a plan of care for a female patient who expresses loss of interest in sexual intimacy with her husband following a mastectomy several months ago. What nursing diagnosis would be most appropriate for this patient? a) Ineffective sexuality patterns b) Sexual Dysfunction c) Activity Intolerance and Fatigue d) Disturbed Body Image

ANS: D The patient's lack of sexual intimacy resulted following the mastectomy, so the most likely cause is the change in body image. Disturbed Body Image would be the most appropriate nursing diagnosis for this patient. If interventions help improve her body image, the sexual issues may resolve themselves. Although this patient is displaying an ineffective sexuality pattern, this is not the most appropriate diagnosis for this patient because it does not address the root cause of the problem the patient is experiencing; it is an etiology of the main problem. The choice of Sexual Dysfunction would not be wrong; however, it is not the best choice for this patient because it does not address the primary cause (or etiology) of the patient's change in sexual intimacy. There are no data cues in the item to indicate that this patient is experiencing activity intolerance or fatigue.

A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following? a) Role strain b) Interpersonal role conflict c) Role performance d) Interrole conflict

ANS: D The patient's wife is most likely experiencing interrole conflict, in which her role as a mother and worker are making competing demands on her. Role strain is a mismatch between role expectations and role performance. Interpersonal role conflict results when another person's idea about how a role should be performed differs from that of the person who is performing the role. Role performance is defined as the actions a person takes and the behaviors he demonstrates in performing a role.

The spouse of a patient recently diagnosed with cancer reports feeling anxious and is having trouble sleeping at night despite feeling tired. The spouse says sleep was never previously a problem. What type of interventions would be first priority for the spouse? a) Promote physical comfort. b) Support bedtime routines. c) Create a restful environment. d) Promote relaxation.

ANS: D The stress of having a loved one diagnosed with cancer appears to be causing anxiety; therefore, interventions aimed at helping the spouse to relax would be most helpful in resolving the problem. The spouse is not experiencing pain, so interventions aimed at promoting comfort would not help this person to sleep. The spouse is physically tired; therefore, supporting bedtime rituals and routines would not resolve the underlying issue that is keeping the spouse from achieving restful sleep. The spouse reports feeling tired, so restful environment interventions would not resolve the anxiety causing the spouse to experience insomnia.

The nurse is caring for a patient recently diagnosed with cancer. The patient states, "I really never believed in a god or followed any religion. Should I do something now?" What is the most appropriate response by the nurse? a) "Religion and spirituality are not for everyone. If you've not had it in your life to this point, you may not need it." b) "I am a Catholic and it works for me. Would you like me to tell you about my religion?" c) "It is important to have some religion or spirituality in your life as it can help you get through difficult times." d) "It is up to you. If you would like, I can arrange for one of our nondenominational chaplains to come and speak with you."

ANS: D There are times when a nurse may not know the answer to a patient question regarding spirituality or religion. Clearly, there are times when the nurse should then refer to others with more knowledge and experience and with the patient's permission. Referring the patient to a facility chaplain is the best response by the nurse. A person may not have any religion or spirituality in his life; however, this does not mean that with changes in health status, aging, and developmental levels, a person should not reach out to ask for help or seek guidance. It is also important to understand the point at which a patient is in his thinking and not impose or convert others to ones own beliefs.

The nurse is assessing the patient's sexual functioning. With cultural patterns in mind, which patient will the nurse expect most likely to be uncomfortable discussing this topic? a) 34-year-old African American male patient b) 54-year-old Hispanic male patient c) 71-year-old African American female patient d) 48-year-old Asian American female patient

ANS: D There would be no reason to anticipate that an African American male, an African American female, or a Hispanic male would be especially uncomfortable with discussing sexual functioning because of cultural norms. The Asian American and Muslim American cultures tend to be the most sexually conservative and their members may be embarrassed to discuss a subject they consider private. Of course, there are always individuals who differ from the overall norms for their culture.

The pediatric nurse caring for a 3-year-old recognizes the most likely cause of sleep disturbances would be what? a) Concerns about friends b) Staying up to watch television c) Side effect of medication d) Fear of monsters

ANS: D Toddlers and preschoolers are likely to fear monsters or imaginary figures. Social concerns (worries about friends) are more likely to be seen in an older child. Staying up to watch television is more of a concern for older children. Use of medication that interferes with sleep is more common in adolescents and young adults.

A client confides to you that he feels guilty because when he has intercourse with his girlfriend, he pretends that she is a certain female actress. What is your best response? a) "This behavior is known as a voyeuristic disorder and is perfectly normal." b) "Are there problems in your relationship with your girlfriend?" c) "I can provide you with a referral to a sexual counselor who can help you work through these guilt feelings." d) "Fantasy before or during sexual intercourse can add excitement to a relationship."

ANS: D Voyeurism disorder occurs when a person likes to observe an unsuspecting person who is disrobing, naked, or engaged in sexual activity. The client needs to understand that engaging in fantasy can be stimulating for the relationship—it increases self-esteem and arousal. At this point, you do not have enough information to determine whether this is a situation that would require a referral.

Vulnerable populations are those most likely to develop health problems and experience poorer outcomes because of limited access to care and a wide variety of other stressors. Therefore, when caring for a patient from a vulnerable group, it is most important for the nurse to focus on: a) Methods to connect the patient with a social worker b) Family members and their interactions in planning care c) Identifying the patient's difficulties and risks d) Identifying the patient's strengths and resources

ANS: D Vulnerable populations are groups who are more likely to develop health problems and experience poorer outcomes because of limited access to care. Examples of vulnerable populations include the homeless, the poor, children, the elderly, and some ethnic and minority groups. When caring for patients from vulnerable groups, it is most important that the focus be on the patient's strengths and resources and not exclusively on the difficulties and risks. Working with family members is important in developing a plan of care, as is contacting a social worker if the situation warrants; however, the focus is first on the patient.

A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? a) Precrisis b) Impact c) Crisis d) Adaptive

ANS: D When a patient begins to think rationally and attempt to solve problems, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase.

A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patient's religious affiliation, which of the following actions should the nurse take? a) Administer the medication as prescribed. b) Hold the medication until after Yom Kippur. c) Explain the importance of taking the medication despite the holiday. d) Ask the physician to change the route of administration.

ANS: D Yom Kippur is one of the holiest of the Jewish holidays. Self-denial includes abstaining from eating, drinking, bathing, and other rituals. Digoxin is not a non-kosher medication, so the most spiritually appropriate nursing intervention is to ask the provider to change the route of administration. The patient is in heart failure and needs the medication; thus, withholding the medication is not an option. Although the patient may understand the importance of the medication, it is not appropriate to create internal conflict between adhering to religious practices and complying with the medical regimen, when changing the route would address both concerns.