Nursing 275 Exam 4

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A patient has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first?

Put on gloves.

Which instruction should the nurse provide to a patient for whom a topical anesthetic medication is prescribed to reduce eye inflammation?

"Do not rub the eye after administration of the medication."

A patient has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the patient indicates a need for further instruction by the nurse?

"I have two bottles of eyedrops because I will require a lot of medication."

A patient comes to the crisis clinic after an unexpected job termination. The patient paces around the room sobbing, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse's best initial comment to this patient. blems."

"I see you are feeling upset. I'm going to stay and talk with you to help you feel better." A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

The nurse reviews a patient's understanding of a keratoplasty procedure. What statement made by the patient indicates a need for further education?

"I will be discharged home the next day."

The nurse is caring for a patient who has undergone a keratoplasty. What postoperative instructions does the nurse provide? Select all that apply.

"Lie on the nonoperative side." "Avoid jogging and dancing for several weeks." "Report any bleeding or leakage from the eye."

A patient has undergone a keratoplasty. What postoperative care does the nurse teach the patient?

"Wear a shield at night for the first month after surgery."

A patient being seen in the clinic for superficial cuts on both wrists is pacing and sobbing. After a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking:

"What was happening just before you started to feel this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits assessment of the precipitating event. "Why" questions are non-therapeutic.

A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support.

"Who can be helpful to you during this time?" Only the answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

A patient who is visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is:

4 to 6(8) weeks. The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 8 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

Which patient is most in need of immediate examination by an ophthalmologist?

40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights

Above what age is the cost of cataract surgery of the patient covered by Medicare? Record your answer using a whole number. _____

65 years

A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity tolerance? a. Vital signs before, during, and after activity b. Body image and self-care abilities c. Ability to use assistive or adaptive devices d. Client's electrocardiography readings

A nurse assesses a client who is admitted with hip problems. The client asks, "Why are you asking about my bowels and bladder?" How should the nurse respond? a. "To plan your care based on your normal elimination routine." b. "So we can help prevent side effects of your medications." c. "We need to evaluate your ability to function independently." d. "To schedule your activities around your elimination pattern."

A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation? a. Nutritional intake and serum albumin levels b. Pressure ulcer diameter and depth c. Wound drainage, including color, odor, and consistency d. Dressing site and antibiotic ointment application

abce

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

A 35-year-old army combat veteran is being treated for migraines and hypertension. The nurse is particularly interested in the individual's response to which mental health-focused question? a. "Are you worried about anything in particular? b. "Is there any history of suicide in your family?" c. "Have you ever experienced a hallucination?" d. "How would you describe posttraumatic stress disorder?"

An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? (Select all that apply.) a. Speech-language pathologist - Evaluates and retrains clients with swallowing problems b. Physical therapist - Assists clients with ambulation and walker training c. Recreational therapist - Assists physical therapists to complete rehabilitation therapy d. Vocational counselor - Works with clients who have experienced head injuries e. Registered dietitian - Develops client-specific diets to ensure client needs are met

A B E

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents a. visit their child's grave daily. b. maintain their child's room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

A child reared in a minority culture is at greatest risk for: a. Bullying b. Homicidal thoughts c. Eating- and sleep-related disorders d. Traumatic experiences in early childhood

A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression.

bcd

A nurse caring for a patient who was sexually assaulted reports to the primary healthcare provider that the patient has effectively recovered. Which responses by the patient led the nurse to identify the patient's effective recovery? Select all that apply. a. The patient identifies emotions. b. The patient expresses the right to be protected. c. The patient starts interacting with family members. d. The patient expresses anger in a nondestructive way. e. The patient starts interacting verbally and nonverbally.

bce

A nurse has been caring for a patient with posttraumatic stress disorder. Which patient behaviors indicate an improved ability to cope? Select all that apply. a. The patient has improved eye contact. b. The patient asks for help when required. c. The patient has fewer physical complaints. d. The patient shows improved grooming skills. e. The patient tries to find information about treatment.

A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization

ace

A nurse is assessing a child who has witnessed violence at home. What should the nurse document when completing an admission genogram of the child? Select all that apply. a. Relationships b. Investigations c. Family history d. Laboratory testing e. Family composition

abdc

A nurse is caring for a child who needs treatment for mental trauma. Place the stages of the staged treatment protocol in the correct order. a. Provide safety. b. Reduce arousal. c. Nurture self-awareness. d. Teach coping skills.

A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.

A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a prn dose of antianxiety medication.

A patient who has been diagnosed with dissociative identity disorder asks, "What exactly are 'alters'? My health care provider told me I have several of them." Which statement by the patient illustrates that the education provided has been effective? a. "Alters are never aware of each other." b. "Alters are separate personalities that take over during stress." c. "Alters are based in mysticism and religiosity, such as demons." d. "Alters are just like me, but they have no memory of the trauma I went through."

A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

A client has an eye prosthesis and needs to have it inserted into the eye socket. Place the following steps of how to insert an eye prosthesis in the correct order. (Select in order of priority.) a. Wash your hands. b. Explain the procedure to the client. c. Remove the prosthesis from its container and rinse it with tepid water. d. Cover the work area with a cloth or towel. e. Don gloves. f. Place the prosthesis between the thumb and forefinger of your dominant hand with the notched end of the prosthesis closest to the client's nose. g. Insert the prosthesis with the top edge slipping under the upper lid. h. Lift the client's upper lid using your nondominant hand. i. Retract the lower lid slightly until the bottom edge of the prosthesis slips behind it. j. Release your hand slowly. k. Gently release the upper eyelid.

ANS: b, a, d, e, c, h, f, g, k, i, j The proper procedure for inserting an eye prosthesis is to explain the procedure, wash hands, prepare your work area with a cloth or towel, apply gloves, remove the prosthesis from its container and rinse it, use your nondominant hand to open the client's upper eyelid, hold the prosthesis properly, insert the prosthesis with the top edge slipping under the lid, release the lid, retract the lower lid until the prosthesis slides into place behind the lower lid, and take your hand away slowly.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home

ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph below: Which action should the nurse take next? a. Contact the provider with this abnormal finding. b. Assess bilateral legs for temperature and edema. c. Ask the client about pain in the lower leg and calf. d. Document the finding and continue the assessment.

ANS: A This finding indicates Babinski's sign. In clients older than 2 years of age, Babinski's sign is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted. This finding does not relate to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed immediately.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate, blood pressure, and level of consciousness.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.

ANS: D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

According to attachment theory, relationship disorders are related to trauma associated with: a. Culture or religion b. Siblings or strangers c. Caregivers or parents d. Insufficient food or shelter

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias

After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited.

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects

abc

An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.) a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer

Which of the following patient statements indicates that the levodopa/carbidopa (Sinemet) is effective? 1. "I'm sleeping a lot more, especially during the day." 2. "My appetite has improved." 3. "I'm able to shower by myself." 4. "My skin doesn't itch anymore."

Answer: 3 Rationale: Becoming more independent in ADLs shows an improvement in physical abilities. Options 1, 2, and 4 are incorrect. Drowsiness is a common adverse effect of medications for PD. Anorexia or loss of appetite is also a common adverse effect and skin itching is not related to medication use.

Levodopa is prescribed for a patient with Parkinson's disease. At discharge, which of the following teaching points should the nurse include? 1. Monitor blood pressure every 2 hours for the first 2 weeks. 2. Report the development of diarrhea. 3. Take the pill on an empty stomach or 2 hours after a meal containing protein. 4. If tremors seem to worsen, take a double dose for two doses and call the provider.

Answer: 3 Rationale: Taking dopamine replacement drugs such as levodopa with meals containing protein significantly impairs absorption. The drug should be taken on an empty stomach or 2 or more hours after a meal containing protein. Options 1, 2, and 4 are incorrect. Although the patient should be taught to rise gradually from lying or sitting to standing, the patient does not need to monitor blood pressure every 2 hours. Diarrhea should be reported but is unrelated to the effects of levodopa, and other causes should be explored. An increase in tremors should be evaluated, and the dose of the drug should not be independently increased.

abcde

Arrange the steps of the medical exam of a rape victim based on best practice guidelines. a. Head-to-toe physical assessment b. Genital examination c. Collection of evidence d. Documentation of biological and physical findings e. Treatment, discharge planning, and follow-up care

What refractive error occurs when the curve of the cornea is uneven?

Astigmatism

. A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach? a. Stroking the medial aspect of the thigh b. Valsalva maneuver c. Self-catheterization d. Frequent toileting

A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture? a. Apply shoes to improve foot support. b. Perform weight-bearing activities. c. Increase calcium-rich foods in the diet. d. Use pressure-relieving devices.

The patient is scheduled to receive rimabotulinumtoxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? A.Fever, aches, or chills B. Difficulty swallowing, ptosis, blurred vision C. Continuous spasms and pain on the affected side D. Moderate levels of muscle weakness on the affected side

B. Difficulty swallowing, ptosis, blurred vision Dysphagia, ptosis, and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction.

Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.

A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task? a. "The client has skid-proof socks, so there is no need to use your gait belt." b. "Teach the client how to use the walker while you are ambulating up the hall." c. "Sit the client on the edge of the bed with legs dangling before ambulating." d. "Ask the client if pain medication is needed before you walk the client in the hall."

A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? a. Insert an indwelling urinary catheter. b. Stroke the medial aspect of the thigh. c. Use the Credé maneuver every 3 hours. d. Apply a Texas catheter with a leg bag.

Which client is at greatest risk for developing an infection? A. A 54-year-old man with hypertension B. A 17-year-old girl with a fractured tibia in a cast C. A 65-year-old woman who had coronary bypass surgery 4 days ago D. A 71-year-old man in a nursing home

C. A 65-year-old woman who had coronary bypass surgery 4 days ago Older clients such as the 65-year-old people with decreased vascularity to the integumentary system (from the bypass surgery) and compromised skin (surgical incision) are at risk for infection. No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection.

A woman said, "I can't take anymore! Last year my husband had an affair, and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment?

Clarify what the patient means by "I can't take anymore." During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

Which clinical manifestation is an indication of graft rejection in a patient who has had a corneal transplant?

Cloudy cornea

A patient has been prescribed gentamicin eyedrops for a bacterial eye infection. What does the nurse teach the patient about the appropriate use of this medication? Select all that apply.

Complete the prescribed drug regimen. Apply exactly at the time interval prescribed. Clean exudate from the eyes before using the medication.

A woman says, "I can't take anymore. Last year my husband had an affair, and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention?

Coping with the reaction to the daughter's events The focus of crisis intervention is on the most recent problem: "the straw that broke the camel's back." The patient had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next? a. Splint the joint and continue passive range of motion to the shoulder only. b. Progressively increase joint motion 5 degrees beyond resistance each day. c. Apply weights to the right distal extremity before initiating any joint exercise. d. Continue to move the joint only to the point at which resistance is met.

Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Fever

D. Fever Fever (generally a temperature above 101°F [38.3°C]) is a common clinical manifestation of infection. Skin tends to be warm and moist, not dry and pink, when an infectious disease is present. Clients typically have hyperthermia (fever), not hypothermia, when an infectious disease is present, although some clients can have infection without fever. Respiratory rate typically increases, as does the heart rate, with infectious disease.

A priority problem of hyperthermia is identified by the long-term-care RN who is caring for a client with a urinary tract infection. Which intervention is most appropriate to delegate to a nursing assistant? A. Monitor for improvement after antibiotic therapy is initiated. B. Teach the client the reason for taking antibiotics as prescribed. C. Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D. Increase fluid intake by assisting the client to choose approved and preferred beverages.

D. Increase fluid intake by assisting the client to choose approved and preferred beverages. Nursing assistants can provide dietary choices to clients, and allowing clients to select the beverage of their choice will improve oral intake. In clients with hyperthermia (fever), fluid volume loss is increased from rapid evaporation of body fluids and increased perspiration. As body temperature increases, fluid volume loss increases, placing the client at risk of becoming dehydrated. Offering a choice of beverage may increase oral intake and help prevent/treat hyperthermia. Monitoring for improvement and teaching the client require advanced education and are within the scope of the RN. Administering acetaminophen (Tylenol) is within the scope of the licensed nurse, not a nursing assistant.

A troubled adolescent pulled out a gun in a school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next?

Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? Select all that apply.

Difficulty using a cell phone Rapid speech Trembling Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

Empathetic listening is therapeutic because it focuses on: a. Reducing anxiety b. Encouraging resilience c. Enhancing self-esteem d. Lessening feelings of isolation

Which statements about refractive errors are accurate? Select all that apply.

Eyeglasses can correct refractive errors Contact lenses can correct refractive errors Problems in eye length cause refractive errors

Which factors are possible causes of corneal abrasions? Select all that apply.

Foreign body Contact lenses

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school

Which communication technique will the nurse use more in crisis intervention than traditional counseling?

Giving direction The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

A patient has sustained damage to cranial nerve II after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury?

Identifying food on the patient's plate using the clock method

A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, "I cannot teach nor do any research. My mind is totally preoccupied with these false accusations." What is the priority nursing diagnosis?

Ineffective coping (role performance) related to distress from false accusations This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor's crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

Which statements about retinitis pigmentosa are correct? Select all that apply.

It causes degeneration of retinal nerve cells. It is inherited as an autosomal dominant (AD) trait. It is inherited as an autosomal recessive (AR) trait.

The health care provider prescribes ocular irrigation for a patient to remove cement dust from the eyes. How should the nurse perform the procedure?

Keep the patient in a supine position with the head turned toward the affected eye.

Which disorder of the eye is genetically inherited?

Keratoconus

Which term is used to describe an eye wound caused by sharp objects and projectiles?

Laceration

Which drug is appropriate for a patient with glaucoma?

Latanoprost

Which activity performed by the patient increases intraocular pressure?

Lifting heavy objects

What diagnostic procedure is contraindicated for a patient who has sustained a penetrating eye injury?

Magnetic resonance imaging

After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?

Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. There is no classification called reactive. Adventitious crises occur when disasters, such as natural disasters (e.g., floods, hurricanes), war, or violent crimes, disrupt coping.

A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? Select all that apply.

Mitigation Response This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

Which agency provides coordination in the event of a terrorist attack?

National Incident Management System (NIMS) The National Incident Management System (NIMS) provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

A patient is prescribed an ocular irrigation following an accidental splash of a chemical in the laboratory. What action should the nurse take?

Place a strip of pH paper in the cul-de-sac of the affected eye.

An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies?

Powerlessness The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not altered at this point.

Relaxation techniques help patients who have experienced major traumas because they a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

Which statements about retinal detachment are accurate? Select all that apply.

Retinal detachments are classified by the cause. Restricting head movement can prevent further detachment. Spontaneous reattachment of a totally detached retina is rare.

Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing?

Situational A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

Which situation demonstrates use of primary care related to crisis intervention?

Teaching stress reduction techniques to a first-year college student Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary care

The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis

What should the nurse teach a patient about using antibiotic eyedrops to prevent re-infection?

The importance of not wearing contact lenses during the period of drug usage

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

abcef

The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

bdef

The nurse is assessing a young child for posttraumatic stress disorder (PTSD). What does the nurse include in the assessment? Select all that apply. a. Bowel habits b. Motor function c. Blood pressure d. Speech patterns e. General appearance f. Characteristics of play

The nurse is caring for a patient with dissociative amnesia disorder. The patient gets extremely aggressive due to anxiety and causes physical harm to him or herself and to others. Which nursing intervention does the nurse follow to reduce anxiety and aggression in the patient? a. The nurse lets the patient make decisions on major issues. b. The nurse frequently observes the patient by visiting the patient's room. c. The nurse reminds the patient about the happy moments of the patient's life. d. The nurse prepares a schedule and instructs the patient to follow it regularly.

cde

The nurse meets with a patient who was a victim of sexual assault. Which statements made by the patient indicate recovery? Select all that apply. a. "I try not to think about the night that I was raped." b. "I realize that I am hopeless about trusting others." c. "I feel comfortable hanging out with my male friends." d. "I manage the really dark days by going to a gym class." e. "All of my bruises have healed, and I can wear tank tops again."

A patient is scheduled to undergo corneal implant surgery due to keratoconus. What does the nurse include in the preoperative instructions? Select all that apply.

The risk for corneal clouding or scarring is low Over correction or under correction of refraction is possible A flexible corneal ring will be placed in the outer edges of the cornea

The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

What information should the nurse give to the family of a patient who has had a dissociative episode? a. Brief periods of psychotic behavior may occur b. Dissociation is a method for coping with severe stress c. Dissociation suggests the possibility of early dementia d. Ways to intervene to prevent self-mutilation and suicide attempts

abce

What symptoms are included in adjustment disorder? Select all that apply. a. Guilt b. Anger c. Depression d. Overachieving e. Social withdrawal

acd

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

When caring for a child with posttraumatic stress disorder, which intervention should the nurse include in the patient plan of care? a. Provide changeable environment. b. Help patient learn positive avoidance. c. Reduce stimulation of traumatic memories. d. Promote arousal to build tolerance to stress.

When discussing the symptoms of posttraumatic stress disorder (PTSD), the nurse correctly states: a. "The symptoms can occur almost immediately or can take years to manifest." b. "PTSD causes agitation and hypervigilance, but rarely chronic depression." c. "PTSD is an emotional response that does not cause significant changes in brain chemistry." d. "When experiencing a flashback, the patient generally experiences a slowing of responses."

Which assessment finding best supports dissociative fugue? The patient states a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

ade

Which statement is true regarding the nursing care of a forensic patient? Select all that apply. a. A victim of a sexual assault meets the criteria of a forensic patient. b. Nurses should pose questions asking "why" certain events occurred. c. All sexual assault victims require a complete suicide assessment interview initially. d. Asking about possible suicidal ideations may be an appropriate interview question. e. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim.

The nurse is taking a history on an adult pt who reports acute back pain. Which question is the nurse most likely to ask to identify causative factors? a. "Have you had a recent fall or accident or lifted a heavy object?" b. "Do you have a family history for neurologic disorders?" c. "Are you having trouble walking or maintaining your balance?" d. "Are you having pain that radiates down the back of your leg?"

a. "Have you had a recent fall or accident or lifted a heavy object?"

A patient has just undergone spinal fusion surgery and returned from the OR 12 hrs ago. Which task is best to delegate to UAP? a. Assist the nurse to log-roll the patient every 2 hrs. b. Help the pt dangle the legs c. Assist the pt to put on a brace d. Help the pt ambulate to the bathroom

a. Assist the nurse to log-roll the patient every 2 hrs.

The nurse is caring for a pt who has been in a long-term care facility for several months following an SCI. the pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. What is an expected outcome of the training program? a. Does not experience a UTI b. Catheterizes himself independently c. Controls incontinence by decreasing fluid intake d. Takes initiative to call for help when needed

a. Does not experience a UTI

The home health nurse reads in the patient's chart that he has spinal cord injury and has developed heterotopic ossification of the right hip. What would the nurse expect to observe while assessing the hip? a. Redness, warmth, and decreased ROM b. Obvious deformity, with protrusion of the hip joint c. Pronounced muscle atrophy and wasting of the femur d. Poor skin turgor, with fragility and possible skin tears.

a. Redness, warmth, and decreased ROM

A pt has just undergone spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hrs? Select all that apply. a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention d. Assess for ability and independence in ambulating and moving in bed e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

Which neuro assessment technique does the nurse use to test a patient for sensory function? a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull. b. Ask the patient to elevate both arms off the bed and extend wrists and fingers. c. Have the patient close the eyes and move toes up or down, while identifying the positions. d. Have the patient sit with legs dangling; use a reflex hammer to test reflex responses

a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull.

The home health nurse sees in the patient's record that he takes riluzole. Which question is the nurse most likely to ask? a. When were you first diagnosed with amyotrophic lateral sclerosis? b. Has the medication relieved any of the symptoms caused by multiple sclerosis? c. Has your acute back pain returned to the more familiar chronic pain? d. Have you always had neurogenic bladder problems since your spinal cord injury?

a. When were you first diagnosed with amyotrophic lateral sclerosis?

A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is:

anxious and fearful. Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety.

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should:

ask what other relatives or friends are available for support. The assessment of situational supports should continue. Even though the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually non-therapeutic.

A patient who was involved in a high speed motor vehicle accident sustained multiple injuries. He is transported to the emergency department by EMS with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this patient? a. Check the mental status using the Glasgow Coma Scale b. Assess the respiratory pattern and ensure a patent airway c. Observe for intra-abdominal bleeding and hemorrhage. d. Assess for loss of motor function and sensation.

b. Assess the respiratory pattern and ensure a patent airway

The pt with MS has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication? a. Watch the patient walk and note smoothness of movement b. Check the pt's gag reflex and ability to swallow c. Ask the pt to use a pencil to write a sentence d. Have the pt stand and close eyes, and observe the pt for sway.

b. Check the pt's gag reflex and ability to swallow

The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? a. Going out in the cold b. Driving c. Sexual activity d. Bathing in the bathtub

b. Driving

Which symptoms indicate that a pt with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. a. Flaccid paralysis b. Hypertension c. Tachypnea d. Severe headache e. Blurred vision f. Loss of reflexes below the injury

b. Hypertension d. Severe headache e. Blurred vision

The nurse is caring for several patients who have spinal cord injuries. Which task is best to delegate to UAP? a. Encourage use of incentive spirometry; evaluate the pt's ability to use it correctly b. Log-roll the pt; maintain proper body alignment and place a bedpan for toileting c. Check for skin breakdown under the immobilization devices during bathing d. Insert an indwelling catheter and report the amt and color of the urine

b. Log-roll the pt; maintain proper body alignment and place a bedpan for toileting

The patient with chronic back pain is receiving ziconotide by intrathecal infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action? a. Request a psychiatric evaluation b. Notify the HCP c. Assess level of consciousness d. Decrease the dose of medication

b. Notify the HCP

Assessment of a patient with a lower spinal cord injury confirms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? a. Paraparesis b. Paraplegia c. Quadriparesis d. Quadriplegia

b. Paraplegia

The nurse is assessing a patient who presented to the emergency department reporting acute onset numbness and tingling in the right leg. How does the nurse document this subjective finding? a. Paraparesis b. Parasthesia c. Ataxia d. Quadriparesis

b. Parasthesia

The nurse is preparing a patient with quadriplegia for discharge and has taught the spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? a. Spouse assists the patient into a wheelchair or chair and coaches him to do deep coughing. b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales. c. Spouse places her hands on the pt's lateral chest and pushes inward as the patient exhales. d. Spouse assists the pt into high Fowler's position and encourages him to take deep breaths.

b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales.

The pt with a spinal cord injury has an HR of 42 bpm. Which drug does the nurse expect to administer? a. Methylprednisolone b. Dextran c. Atropine d. Dopamine

c. Atropine

A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hrs, the nurse is performing the change of shift assessment. Which post-op finding is immediately reported to the surgeon? a. Some serosanguinous drainage b. Pain along the incision site c. Swelling or bulging at the operative site d. Reluctance or refusal to cough and breath deeply

c. Swelling or bulging at the operative site

The nurse has provided teaching to the husband of a 33 year old woman who was recently diagnosed with MS. Which statement by the pt's husband indicates he needs additional teaching on the course of the illness? a. "She could fall bc she may lose her balance and have poor coordination." b. "Eventually she will not be able to drive because of vision problems." c. "She will probably have a decreased libido and diminished orgasm." d. "As the disease progresses, she could have intermittent short-term memory loss."

d. "As the disease progresses, she could have intermittent short-term memory loss."

A pt with a spinal cord injury has paraplegia and paraparesis. The nurse assesses the calf area of both legs for swelling, tenderness, redness, or pain. This assessment is specific to the patient's increased risk for which condition? a. Contractures of both joints b. Bone fractures c. Pressure ulcers d. Venous thromboembolism

d. Venous thromboembolism

The principle most useful to a nurse planning crisis intervention for any patient is that the patient:

is experiencing a state of disequilibrium. Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis.

An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response?

"Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

The nurse is teaching a patient about the administration of ophthalmic ointment. What does the nurse teach the patient? Select all that apply.

"Avoid driving after instillation of the ointment." "Avoid touching any part of the eye or lid with the tip of the tube." "Wipe away extra ointment with a tissue with the eyes gently closed."

A patient has a corneal abrasion in the right eye. What does the nurse instruct the patient about eye care?

"Avoid the use of contact lenses during the therapy."

A patient with conjunctivitis in both eyes has been prescribed an ophthalmic ointment. What does the nurse teach the patient about applying ophthalmic ointment? Select all that apply.

"Avoid touching any part of the eye or lid with the tip of the tube." "Avoid operating heavy machinery after instillation of the ointment." "Form a pocket with the lower eyelid, and instill the medication in the pocket."

A patient with "pink eye" has thick discharge with shreds of mucus and is prescribed a topical antibiotic. What does the nurse teach the patient?

"Avoid using any makeup near the eye."

A nurse is performing an assessment of a child diagnosed with disinhibited social engagement disorder. Which behavior should the nurse expect to find in the child? a. The child throws stones at strangers. b. The child willingly goes with a stranger. c. The child cries when touched by a stranger. d. The child hides when a stranger approaches

A nurse observes that a child is withdrawn from her parents and does not interact much with them. On inquiry, the nurse finds that the child has been a victim of domestic violence and does not interact with anybody. Which clinical condition is the child likely to have? a. Separation anxiety b. Developmental delays c. Reactive attachment disorder d. Disinhibited social engagement behavior

A nurse prepares the plan of care for a school-age child diagnosed with reactive attachment disorder. Which initial outcome should be the focus of the nurse's intervention? The child will: a. Decrease impulsive behavior b. Express feelings through journaling c. Verbally recount traumatic experiences d. Correctly identify the date, time, and place

A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

abc

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.) a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.

A patient with dissociative identity disorder reports an increased awareness of his or her surroundings and a reduction in dissociative episodes. Which instruction provided by the nurse while teaching the grounding techniques helped the patient to alleviate symptoms? a. "Have a positive insight." b. "Write your feelings in a diary." c. "Hold an ice cube in your hand." d. "Sit straight and upright in the chair."

The nurse is teaching the mother of a teenage patient with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction?

"I will place the ointment in the lower lid."

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills?

"In the past, how have you handled difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis.

A patient is prescribed erythromycin eyedrops for a bacterial eye infection. What does the nurse teach the patient to ensure appropriate use of the eyedrops? Select all that apply.

"Instill the drug exactly as prescribed." "Clean exudate from the eyes before using the eyedrops."

A patient is prescribed dorzolamide. What should the nurse teach the patient to ensure effective action of the drug?

"Shake the bottle vigorously before use."

A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.

A nurse conducts an initial interview with a veteran of two tours in the war with Iraq. The veteran says, "The war was years ago, but I still remember my friends who were killed. I don't know why I lived and they died." What is the nurse's priority response? a. "Are you having any thoughts of harming yourself?" b. "It's important to think about how good your life is now." c. "Are you saying you have some guilt about being a survivor?" d. "The outcomes of war are tragic and stay with us for many years."

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

A nurse is caring for an adult patient who has trauma-related disorder. The patient reports to the nurse that he has started using relaxation techniques and is sleeping better. How should the nurse interpret this behavior? a. The patient is feeling nervous. b. The patient is feeling less confident. c. The patient is able to manage anxiety. d. The patient has improved self-esteem.

A nurse is developing a plan of care for a patient with dissociative amnesia. Which strategies should the nurse include in the plan? a. Allow the patient to rest. b. Ask the patient to recollect past events. c. Instruct the patient on grounding techniques. d. Ask the family member to make routine decisions.

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."

Which scenario is an example of an adventitious crisis?

A riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate? a. "I have seen rape victims from 6 months to 90 years old." b. "I noticed that most rapes are impulsive acts of the rapists." c. "I feel that patients get severe injuries when they try to escape." d. "I overlook my feelings toward sexual assault before caring for the patient."

A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

abd

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. PTSD e. Reactive attachment disorder f. Disinhibited social engagement disorder

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Most antibiotics are effective for infection.

A. Antibiotics have been given to clients for conditions that do not require antibiotics. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics. Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection.

A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? A. Apply with a gloved hand only to the site of pain. B. Apply the medication liberally above and below the site of pain. C. Apply to areas of redness and irritation only. D. Apply liberally with a bare hand to the affected limb.

A. Apply with a gloved hand only to the site of pain. Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 2, 3, and 4 are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs.

Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply.) A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns C.Encouraging frequent ambulation D. Providing oral suction for excessive oral secretions E. Providing assistance with activities of daily living such as reading

A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns E. Providing assistance with activities of daily living such as reading Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options 3 and 4 are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided.

Which information does the nurse include when teaching a client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection.

A. Take all antibiotics as prescribed, unless side effects develop. Antibiotics should be taken as prescribed until they are gone. Teach the client about possible side effects and allergic manifestations. The provider must be contacted immediately if any side effects develop. Antibiotics must be taken until they are gone, even if the client feels better or when symptoms of infection appear. They should be taken only by the person for whom they are prescribed and not shared with anyone else.

While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical debridement for gangrene. Which precaution is best for this client? A. Wear a gown and gloves to prevent contact with the client or client-contaminated items. B. Assign the client to a private room with a negative airflow. C. Wear a mask when working within 3 feet (91 cm) of the client. D. Have the client wear a surgical mask when being transported out of the room.

A. Wear a gown and gloves to prevent contact with the client or client-contaminated items. Caregivers should wear a gown and gloves to prevent contact with the client or contaminated items when caring for a client with this infection. This is the best way to prevent the spread of infection. Gloves should also be worn when entering the room. A private room is preferred for this client. If a private room is not available, the client may be cohorted with another client with the same active infection and with the same microorganisms if no other infection is present. The client does not require respiratory isolation and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection.

A patient who has been prescribed baclofen (Lioresal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather? A. Whether the patient has been taking the medication consistently or only when the pain is severe B. Whether the patient has been consuming alcohol during this time C. Whether the patient has increased the dosage without consulting the health care provider D. Whether the patient's log of symptoms indicates that the patient is telling the truth

A. Whether the patient has been taking the medication consistently or only when the pain is severe Muscle relaxers such as baclofen (Lioresal) work best when taken consistently and not prn. Noting consistency of dosing helps to determine the appropriateness of dose, frequency, and drug effects. Options 2, 3, and 4 are incorrect. Consumption of alcohol or increasing the dose of muscle relaxers will increase the risk of sedation and drowsiness. The patient's log of symptoms and drug dose and frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of pain or continued spasms should be considered an accurate account.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

In the emergency department, the nurse is caring for a client diagnosed with a hyphema. Which statement by the client indicates a need for further teaching? a. "When I get home, I can lie flat in bed and turn from side to side." b. "For a few days, I cannot even read a book or watch television." c. "I will need to protect the eye with a patch and shield." d. "I need to stay on bedrest and will try not to make any sudden movement."

ANS: A A hyphema is a hemorrhage in the anterior chamber of the eye due to blunt force such as a motor vehicle accident. For management of this condition, the client must be on bedrest but must remain in a semi-Fowler's position to prevent accumulation of blood around the optical center of the cornea. The client cannot lie flat in bed and rotate from side to side. The client cannot read a book or watch television and must protect the eye if paralytic eyedrops were used. The client needs to be as still as possible to prevent further bleeding.

A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the client's back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

ANS: A An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk of infection. A nurse would want to notify the health care provider if shingles were identified on the client's back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the client's needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching? a. "Avoid caffeine-containing substances for 12 hours before the test." b. "Drink at least 3 liters of fluid during the first 24 hours after the test." c. "Do not take your cardiac medication the morning of the test." d. "Remove your dentures and any metal before the test begins."

ANS: A Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging.

A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

ANS: A Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore, the client's gag reflex would not be compromised.

The nurse is assessing a client who wishes to be considered as a potential donor for corneal transplantation. Which medical diagnosis at the time of death excludes the client from consideration? a. Small cell lung cancer b. Chronic heart failure c. Profound nearsightedness d. History of detached retina

ANS: A Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death. The other problems would not keep a client from donating corneas.

A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler's position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the UAP should tell the client where different food items are on the meal tray. The other options are not appropriate for a client with cranial nerve II impairment.

Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy? a. "Do not drive or operate machinery until the drug wears off." b. "Use at least a 30 SPF sunscreen agent when going outdoors." c. "Remain on bedrest for 24 hours in a prone position." d. "Turn up the lights because acuity will be decreased in low-light environments."

ANS: A Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated pupil. The pupil cannot accommodate to bright light, causing eye discomfort and pain. Turning up the lights will not assist the client to see more clearly. Bedrest and sunscreen are not measures needed for this drug.

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

ANS: A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse's priority action? a. Apply an ice pack to the affected eye. b. Patch the eye to prevent eye movement. c. Assess the client's vision in both eyes. d. Irrigate the affected eye with normal saline.

ANS: A Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary oozing. Treatment with ice begins at the time of injury. Whenever the eye or surrounding tissue is injured, visual acuity is assessed next.

A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the client's feet.

ANS: A If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings.

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.

A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

ANS: A The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client? a. "You may return to your previous activity level immediately." b. "You are radioactive and must use a private bathroom." c. "Frequent assessments of the injection site will be completed." d. "We will be monitoring your renal functions closely."

ANS: A The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the urine after SPECT, but no monitoring or special precautions are required. The injection site will not need to be assessed after the procedure is complete.

A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift

ANS: A The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Romberg's sign.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the client's phlebostatic axis

ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.

The nurse is providing discharge teaching for a client with posterior uveitis. Which is the most important precaution for the nurse to teach the client? a. Correct technique for eyedrop instillation b. Clinical manifestations of retinal hemorrhage c. Correct technique for insertion of contact lenses d. Proper timing of opioid analgesics

ANS: A Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and decrease the inflammatory response. The client may have to instill eyedrops as frequently as every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the client's renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels.

ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The client's kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the client's breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the client's safety during the procedure.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever

ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care? (Select all that apply.) a. "Plan to bathe the client in the evening when the client is most alert." b. "Encourage the client to use a cane when ambulating." c. "Assess the client for symptoms related to pain and discomfort." d. "Remind the client to look at foot placement when walking." e. "Schedule additional time for teaching about prescribed therapies."

ANS: A, B, D The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information, including new teaching. These are not items the nurse can delegate.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

ANS: A, B, E The nurse should urgently communicate changes in a client's neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste

ANS: A, C, D Wernicke's area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

The nurse is teaching a postoperative client who had a keratoplasty. Which responses by the client require further teaching about safety in the home? (Select all that apply.) a. "We use throw rugs in the bathroom." b. "Our neighbors will be bringing food for a week." c. "We may have two extension cords in the living room." d. "Most of the furniture is placed against the wall, except for one rocking chair." e. "Every room has at least one window." f. "The hallway has low lighting."

ANS: A, C, D, F Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is flat or elevated. Extension cords should be placed under or behind the furniture to decrease the possibility of tripping. Furniture should be out of the normal walking pathway. Low lighting in the hallway may pose a problem when the client has a patch and shield over the operated eye. Lighting from a window should not be a problem. When neighbors bring food, the chance of burns occurring while cooking with limited vision is reduced.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test? a. "Have you had a recent blood transfusion?" b. "Do you have allergies to iodine or shellfish?" c. "Are you taking any cardiac medications?" d. "Do you currently use oral contraceptives?"

ANS: B Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography.

A client is recovering from cataract surgery and needs medication to prevent a potential eye infection. Which drug does the nurse question administering to the client? a. Tobramycin (Tobrex) b. Apraclonidine (Iopidine) c. Gentamicin (Genoptic) d. Ciprofloxacin (Ciloxan)

ANS: B Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This medication usually is administered to clients with glaucoma. Tobramycin, gentamicin, and ciprofloxacin are anti-infectives.

Which statement indicates that the client understands teaching about the use of aspirin post-cataract surgery? a. "It may increase intraocular pressure after cataract surgery." b. "It changes the ability of the blood to clot and increases the risk of bleeding." c. "It reduces inflammation and might mask any symptoms of infection." d. "It can cause nausea and vomiting and may increase intraocular pressure."

ANS: B Aspirin disrupts platelet aggregation and increases the risk for bleeding after surgery. Aspirin may decrease inflammation but would not mask symptoms of infection. Aspirin does not cause increased intraocular pressure, nor does it typically cause nausea and vomiting. Aspirin should not mask signs of infection.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift.

ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.

The nurse is teaching a client how to apply eye medication. Which is the correct technique for applying ointment into the eye? a. From the middle out b. From the inner canthus to the outer canthus c. From the outer canthus to the inner canthus d. Against the inner aspect of the eyelid

ANS: B Ointment should be applied by pulling down the lower lid and forming a pocket. Application should proceed from the inner canthus toward the outer canthus, with the client tilting the head backward and looking up at the ceiling.

The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera

ANS: B Secondary open-angle glaucoma results from another condition that interferes with drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary open-angle glaucoma is seeing halos around lights; this is not considered secondary open-angle glaucoma. The client with reactive pupils and clear sclera has normal assessment findings, not related to secondary open-angle glaucoma.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

ANS: B The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today.

ANS: B White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery. Because the drainage is white and no other symptoms of infection are noted, a culture does not need to be done and an antibiotic will not be needed. Urgency is not an issue because this is an expected effect from the trauma of surgery. The physician does not need to be called.

A blind client is admitted to the hospital unit. Orientation to the unit includes which information? (Select all that apply.) a. Introduce the staff to the client. b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. d. Tell the client to use the call light if he or she wants to go to the bathroom. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

ANS: B, C, E, F The client needs to know where everything is located to be independent and safe from falls. Clients need to be shown where things are and how to do things such as turn on the call light and raise the head of the bed. The client should be introduced to the staff, not the reverse, and should first be shown how to use the call light.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A client just underwent a keratoplasty. Which activity does the nurse suggest that the client begin possibly 1 week after surgery? a. Continue with salsa dance lessons. b. Jog only one-half mile versus the usual 2 miles. c. Return to employment as a receptionist. d. Help the family move furniture from room to room.

ANS: C Activities that raise the intraocular pressure (e.g., jogging, dancing, any movement that can cause jerky head motion) should be discouraged for at least 3 weeks after surgery. No heavy lifting should be done for 6 to 8 weeks. A sedentary job such as a receptionist can be tolerated a week after surgery.

Which statement made by a client after corneal transplantation indicates a need for further teaching? a. "I will wear an eye shield at night for at least 1 month." b. "I will avoid bending at the waist and straining when moving my bowels." c. "I won't worry if I have increased tearing, because it is normal." d. "I'll notify the ophthalmologist if any signs of rejection occur."

ANS: C Aqueous humor can leak from the incision site if wound closure is incomplete. Any fluid coming from the eye in the early postoperative period needs to be checked by the provider.

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this client's assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14

ANS: C The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the client's Glasgow Coma Scale score is: 3 + 3 + 6 = 12.

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's discharge teaching? a. "Connect a light to flash when your door bell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm."

ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client's white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the client's impaired sensory perception.

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How should the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."

ANS: C Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not accurate.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure.

ANS: C If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A client is having intraocular pressure measured for both eyes. Which response by the client best indicates that the client understands why this is necessary every year? a. "Elevated eye pressure can cause high blood pressure." b. "If eye pressure is too high, your eyes will dry out." c. "Elevated eye pressure can press on blood vessels in the eye." d. "Increased eye pressure causes the tear ducts to become blocked."

ANS: C Intraocular pressure is the pressure generated by the fluids inside the globe of the eye. As intraocular pressure increases to above normal, it compresses the blood vessels and the optic nerves. As the blood vessels are compressed, oxygenation to the internal eye structures, including the nerves and photoreceptors, is diminished. The nerves and photoreceptors require a constant supply of oxygen and will die if blood flow is inadequate, leading to blindness. The other statements are inaccurate.

Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage? a. Presence of a red reflex b. Reddened whites of the eye c. Red haze or floaters in the line of vision d. Swelling of the upper and lower eyelids

ANS: C Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is reduced. Reddened whites of the eye and swelling of the eyelids would indicate irritation and infection of the eye.

After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching? a. "I must increase my fluids because of the dye used for the MRI." b. "My urine will be radioactive so I should not share a bathroom." c. "I can return to my usual activities immediately after the MRI." d. "My gag reflex will be tested before I can eat or drink anything."

ANS: C No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the client's urine would not be radioactive. The procedure does not impact the client's gag reflex.

A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet." b. "Bathe in warm water to increase your circulation." c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure ulcers from your shoes."

ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions.

ANS: C The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear. The other interventions do not address the client's left temporal lobe damage.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.

A client with acute-angle glaucoma has several medications ordered. Which medications does the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

ANS: C, F Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker that decreases the formation of aqueous humor. All these help decrease IOP.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

An older adult client who has a mature cataract in the right eye states, "Now I have lost the sight in my right eye because I waited too long for treatment." How does the nurse best respond to the client? a. "Yes, this type of blindness could have been prevented by earlier treatment." b. "It is fortunate you came for treatment in time to save the sight of your other eye." c. "Nothing you could have done would have made any difference." d. "Surgery can still save the sight in your eye with removal of the cataract."

ANS: D Although sight is increasingly impaired as a cataract matures, no other damage is done to the eye by waiting. Removal of the cataract will result in improved vision, regardless of how long the cataract has been present. No indication suggests that the client will develop a cataract in the other eye. The other statements are inaccurate.

A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head."

ANS: D Arm position does not influence intraocular pressure. All other activities listed decrease the incidence of increased intraocular pressure.

Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

ANS: D As the lens becomes opaque and less able to refract light appropriately, the client experiences blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision, nor does it result in aching in the brow area.

A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "I ate oatmeal with wheat toast and orange juice for breakfast."

ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.

A client has conjunctivitis in both eyes and is being treated with topical antibiotics. Which statement by the client indicates a need for further teaching? a. "I'll avoid sharing washcloths or towels with other family members." b. "I will wash my hands after applying the eye ointment to each eye." c. "I will call the ophthalmologist if the drainage continues after the antibiotics are started." d. "I'll use the same tube of topical ointment for each infected eye."

ANS: D Bacterial conjunctivitis is highly contagious; therefore the client must avoid sharing anything with others that has the potential to come in contact with the infected eye, such as washcloths or towels. The client needs to protect from reinfection by washing hands frequently during application of the antibiotic ointment and must let the eye doctor know if drainage continues after treatment is begun. Separate tubes of eye ointment should be used, with one specifically labeled for each eye.

The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."

ANS: D Eye pain accompanied by nausea and vomiting is an indication of increased intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon must be contacted by the client. The other responses are correct. The client will not need an eye patch, cool compresses will decrease the slight swelling, and dark glasses are necessary outdoors until the pupil responds to sunlight.

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How should the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Give me more information about what worries you, so we can see if we can do something to make adjustments."

ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. On either side of the client

ANS: D Macular degeneration decreases central vision but usually does not affect peripheral vision. Clients looking straight ahead can see people and objects off to the side. Therefore the television should be placed on either side of the client. The other options would not help the client with macular degeneration to see the screen.

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure? a. Creatine phosphokinase (CPK) of 100 IU/L b. Atrioventricular graft c. Blood urea nitrogen (BUN) of 50 mg/dL d. Internal insulin pump

ANS: D Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure.

A client has just returned from having surgery, and sulfahexafluoride gas was used intraocularly. How does the nurse position the client? a. Completely supine, with sandbags beside the head b. On the nonoperative side in the Trendelenburg position c. On the operative side in the Trendelenburg position d. On the abdomen, with the affected eye up

ANS: D Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will float to the highest position. The client should be positioned so that the gas will float up and against the newly reattached retina. The other positions are incorrect after this procedure.

Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye."

ANS: D The eye with the better sight is left alone until the outcome of the first surgery is known to reduce the chance that the client will lose sight in both eyes if complications arise from the surgery.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.

After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

Which health care worker should be referred for critical incident stress debriefing?

An emergency medical technician (EMT) who treated victims of a car bombing at a mall Although each of the individuals mentioned experiencing job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to trauma victims.

An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.

The nurse discusses the disease process of multiple sclerosis with the patient and caregiver. The patient will begin taking glatiramer (Copaxone), and then nurse is teaching the patient about the drug. Which of the following points should be include? 1. Drink extra fluids while this drug is given. 2. Local injection site irritation is a common effect. 3. Take the drug with plenty of water and remain in an upright position for at least 30 minutes. 4. The drug causes a loss of vitamin C so include extra citrus and foods containing vitamin C in the diet.

Answer: 2 Rationale: Glatiramer (Copaxone) is given by injection and often causes injection site irritation. Options 1, 3, and 4 are incorrect. Extra fluids do not need to be included and the drug is not given orally. It does not deplete vitamin C from the body.

The patient asks what can be expected from the levodopa/carbidopa (Sinemet) he is taking for treatment of Parkinson's Disease. What is the best response by the nurse? 1. "A cure can be expected within 6 months." 2. "Symptoms can be reduced and the ability to perform ADLs can be improved." 3. "Disease progression will be stopped." 4. "Extrapyramidal symptoms will be prevented."

Answer: 2 Rationale: Pharmacotherapy does not cure or stop the disease process but does improve the patient's ability to perform ADLs such as eating, bathing, and walking. Options 1, 3, and 4 are incorrect. Drug therapy for PD does not cure or halt progression of the disease. Depending on the drug therapy, EPS may be an adverse effect.

The nurse knows that which of the following are major disadvantages for the use of donepezil (Aricept) to treat the symptoms of early Alzheimer's disease? (Select all that apply.) 1. It must be administered four times per day. 2. It may cause significant weight loss. 3. It may cause potentially fatal cardiac dysrhythmias. 4. It may cause serious hepatic damage. 5. It results in only modest cognitive improvement and results do not last.

Answer: 2, 3, 4, 5 Rationale: Donepezil (Aricept) may cause serious liver damage and potentially fatal dysrhythmias including severe bradycardia and heart block. It may also cause significant weight loss, and the patient's weight should be monitored. While cognitive improvement may be observed in as few as 1 to 4 weeks, patients should receive pharmacotherapy for at least 6 months prior to assessing maximum benefits of drug therapy. Unfortunately, cognitive improvement is only modest and short-term. Option 1 is incorrect. Donepezil is taken once per day usually at bedtime.

An early sign(s) of levodopa toxicity is (are) which of the following? 1. orthostatic hypotension 2. drooling 3. spasmodic eye winking and muscle twitching 4. nausea, vomiting, and diarrhea

Answer: 3 Rationale: Blepharospasm (spasmodic eye winking) and muscle twitching are early signs of potential overdose or toxicity. Options 1, 2, and 4 are incorrect. Orthostatic hypotension is a common adverse effect of both PD and many drugs used to treat the condition but is not a symptom of overdosage or toxicity. Drooling, nausea, vomiting, and diarrhea are also not symptoms of overdose or toxicity.

A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane? 1. Apply a transfer belt around the client's waist. 2. Move the cane and left leg forward at the same time. 3. Guide the client to a standing position. 4. Move the right leg one step forward. 5. Place the cane in the client's right hand. 6. Check balance and repeat the sequence. a. 3, 1, 5, 4, 2, 6 b. 1, 3, 5, 2, 4, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 5, 1, 4, 2, 6

A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities? a. "Use analgesics before and after activity, even if you are not experiencing pain." b. "Let me know if you start to experience shortness of breath, chest pain, or fatigue." c. "Do not take your prescribed beta blocker until after you exercise with physical therapy." d. "If you experience knee pain, ask the physical therapist to reschedule your therapy."

A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise

A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown? a. Place pillows under the client's heels. b. Have the client do wheelchair push-ups. c. Perform wound care as prescribed. d. Massage the client's calves and feet with lotion.

A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach? a. Use the bear-hug method to transfer the client safely. b. Ask several members of the health care team to carry the client. c. Utilize the facility's mechanical lift to move the client. d. Consult physical therapy before performing all transfers.

A rehabilitation nurse is caring for an older adult client who states, "I tire easily." How should the nurse respond? (Select all that apply.) a. "Schedule all of your tasks for the morning when you have the most energy." b. "Use a cart to push your belongings instead of carrying them." c. "Your family should hire someone who can assist you with daily chores." d. "Plan to gather all of the supplies needed for a chore prior to starting the activity." e. "Try to break large activities into smaller parts to allow rest periods between activities."

B D E

A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? (Select all that apply.) a. Achieving mobility b. Attaining independence with dressing c. Using a walker in public d. Learning techniques for transferring e. Performing activities of daily living (ADLs) f. Completing job training

B E

A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse's role? (Select all that apply.) a. Maintain the safety of adaptive devices by monitoring their function and making repairs. b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. c. Assist clients to identify support services and resources for the coordination of services. d. Counsel clients and family members on strategies to cope with disability. e. Support the client's choices by acting as an advocate for the client and family.

B E

Which statement about handwashing is in accordance with recommendations by the Centers for Disease Control and Prevention? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary.

B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Microorganisms that can be transmitted to another client can be found on intact skin. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, any equipment connected to the client, and contaminated items; immediately after removing gloves; and between client contacts.

A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply.) A. If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. E. Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels.

B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. Dantrolene (Dantrium) may cause hepatotoxicity with the greatest risk occurring for women over age 35, and periodic laboratory tests will be required for monitoring. Estrogen taken concurrently with dantrolene may increase this risk. The drug may cause dry mouth and sucking on hard candy, sucking ice chips, or sipping water may help relieve the dryness. Options 1 and 5 are incorrect. Dantrolene may cause erratic blood pressure, including hypotension, and hot baths or showers cause vasodilation, increasing the risk for syncope and falls. The drug may cause photosensitivity and direct exposure to the sun should be avoided.

Which actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed. F. Remove unnecessary medical devices.

B. Promote sufficient nutritional intake. E. Obtain cultures as needed. F. Remove unnecessary medical devices. Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection. Inspecting the skin does not prevent or detect systemic infections. Fluid intake is important but does not directly relate to prevention or detection of infection. Monitoring the RBC count does not prevent, nor would it detect, infection.

Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A. Encourage family and friends to call the client. B. Provide education on the mode of transmission of infection. C. Encourage the client to watch television. D. Ask a certified hospital chaplain to visit the client.

B. Provide education on the mode of transmission of infection. Education is the most appropriate and main intervention for addressing a client's feeling of isolation when placed on Transmission-Based Precautions. It is important to teach the client and family about the mode of transmission and mechanisms that prevent spread to others. The nurse needs to assess coping mechanisms that the client has used in the past. Encouraging phone calls and distraction activities like watching television may be effective interventions. Engaging a certified hospital chaplain to visit the client may help alleviate the client's stress, anxiety, or depression.

A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily. B. Taking the antibiotic most days. C. Taking the antibiotic as prescribed. D. Taking the antibiotic with a full glass of water.

B. Taking the antibiotic most days. Antibiotics not taken as prescribed can result in recurring symptoms, as well as the development of drug-resistant infections and other emerging infections. Taking the antibiotic before jogging is not a contributing factor to the client's relapse. The client who is taking antibiotics as prescribed is not likely to develop recurring symptoms. Taking antibiotics with a full glass of water is a positive action and neither hinders nor promotes antimicrobial therapy.

Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years. B. An RN with experience in the operating room who transferred a month ago to the medical unit. C. A float RN with 7 years of experience on the inpatient oncology unit. D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago.

C. A float RN with 7 years of experience on the inpatient oncology unit. The float RN with experience on the inpatient oncology unit would be familiar with complications and assessment for IV fluids and pneumonia. LPN/LVNs do not have the scope of practice to provide care to this client. The RN with experience in the operating room or the RN who has worked mostly on the same-day surgery unit does not have the experience needed to care for an unstable client on an unfamiliar unit.

A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? A. Monitoring hepatic laboratory work B. Encouraging fluid intake to prevent dehydration C. Assessing for drowsiness and implementing safety measures D. Providing social services referral for patient concerns about the cost of the drug

C. Assessing for drowsiness and implementing safety measures Clonazepam (Klonopin) is a benzodiazepine; because it works on the C N S, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options 1, 2, and 4 are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety.

A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Decreased mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate

C. Decreased neutrophil count In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils. An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis.

Which statement about the transmission of hepatitis C is correct? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors.

C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection. Feces are not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors, so these items should be disinfected regularly.

The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents

C. Reinforcing the need for handwashing after caring for clients All caregivers have a responsibility to reinforce basic handwashing, including that provided for nursing assistants. A higher level of administration is required to evaluate the performance of another worker. Deciding which brand of handwashing soap to use is done at the facility level by the infection control department. Determining which clients are most likely to infect other residents requires a higher level of education for client management.

A nurse teaches a client about performing intermittent self-catheterization. The client states, "I am not sure if I will be able to afford these catheters." How should the nurse respond? a. "I will try to find out whether you qualify for money to purchase these necessary supplies." b. "Even though it is expensive, the cost of taking care of urinary tract infections would be even higher." c. "Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each." d. "You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable."

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully wash hands that are visibly soiled. B. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. C. Wear a mask with eye protection and perform proper handwashing. D. Wear gloves when contact with body secretions or body fluids is expected.

D. Wear gloves when contact with body secretions or body fluids is expected. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires contact precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile. Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile.

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists?

Situational (Adventitious) Situation crisis arises from events that are extraordinary, external rather than internal and often unanticipated. An adventitious crisis is a crisis of disaster that is not a part of everyday life. It is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. "Organic" is not a type of crisis.

revictimization

The nurse is explaining the forensic exam to a patient who was just sexually assaulted. The patient does not want to be examined and says, "I feel like my body just keeps getting violated more and more." Which is the best term used to describe this feeling?

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me get my life back in balance." The nurse responds, "I think we should have two more sessions to explore why your reactions were so intense." Which analysis applies?

The nurse is having difficulty terminating the relationship. The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient shows no need for continuing support. The scenario does not describe dependency needs.

abd

The nurse is planning care for a patient diagnosed with a dissociative disorder. Which intervention is directed primarily towards minimizing the patient's anxiety level? Select all that apply. a. Provide a simple, predictable daily routine. b. Teach and reinforce relaxation and deep breathing techniques. c. Work with the patient and involved parties to reestablish relationships. d. Allow the patient to progress at his or her own pace as memories are recovered. e. Provide support through empathetic listening during disclosure of painful experiences.

The nurse is providing discharge teaching to a patient who was recently raped. What should the nurse say regarding the psychological effects of the assault? a. "You may feel hyperactive and notice an increased surge of energy." b. "It is normal to experience depression after being sexually assaulted." c. "People often report the need to be social after a sexual assault incident." d. "Let the healthcare provider know immediately if you feel scared or worried."

The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? a. "So if you dress conservatively, your risk of being raped is small." b. "Who would have guessed that most rape victims know the rapist?" c. "It makes sense that rape is a crime of violence, not a crime of sex." d. "I always thought rapes happened at night, but now I know that isn't true."

ade

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

Which assessment tool does the nurse use while assessing a patient with dissociative identity disorder? a. Somatoform questionnaire b. Child dissociative checklist c. Child sexual behavior inventory d. Posttraumatic stress disorder screening

bcd

Which behavior would support a diagnosis of posttraumatic stress disorder (PTSD) in a preschool child? Select all that apply. a. Engages in specific, ritual behaviors b. Frequent displays of irritability and negativity c. Reluctant to engage in previously enjoyed activities d. Expresses concern that "something bad is going to happen" e. Shares that he or she "hears voices when there is no one there"

bcde

Which child should be assessed for possible posttraumatic stress disorder (PTSD) as a result of exposure to major trauma in his or her life? Select all that apply. a. A 3-year-old whose older sibling was born with both physical and cognitive impairments. b. A 4-year-old who was hospitalized for two months after being injured in an automobile accident. c. An 8-year-old child who has a medical history that includes several broken bones and a dislocated shoulder. d. A 5-year-old child who lives with grandparents since his or her single parent was deployed by the military 10 months ago. e. A 12-year-old who has been in cancer remission for three years since finishing both chemotherapy and radiation treatments.

Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used."

cde

Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks

Which nursing action has priority for a patient immediately following a reported rape? a. Provide written follow-up instructions. b. Document the debris and dirt on the patient's clothing. c. Give the patient alone time to recover after the incident. d. Give the patient prophylactic analgesics after the incident.

Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

acd

Which scenarios describe completed rape? (Select all that apply.) a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.

Which statement about structural dissociation of the personality is true? a. An organic basis exists for this type of disorder. b. Nurses perceive patients with this disorder as easy to care for. c. No known link exists between this disorder and early childhood loss or trauma. d. This disorder results in a split in the personality, causing a lack of integration.

The nurse reviews the discharge and home care instructions with a pt who had conventional open back surgery. Which statement by the patient indicates further teaching is needed? a. "I will drive myself to the doctor's office next week." b. "I guess my wife will have to walk to dog for 6 more weeks." c. "I will try to increase fruits and vegetables and decrease fats." d. "I plan to get a new ergonomic chair at work."

a. "I will drive myself to the doctor's office next week."

Which disorder could have similar clinical presentation to multiple sclerosis? a. Amyotrophic lateral sclerosis b. Spinal cord tumor c. Guillan-Barre d. Quadriplegia

a. Amyotrophic lateral sclerosis

The nurse is participating in a committee to decrease back injuries among the staff. What recommendations should the nurse suggest? Select all that apply. a. Assign committee members to review OSHA guidelines for the prevention of back injuries. b. Develop policies and procedures for the therapeutic use of patient handling equipment c. Train all staff and family caregivers in the safe operation of all ergonomic-appropriate equipment. d. Assign all pts the responsibility for learning how to use assistive equipment e. Develop competency based assessments that demonstrate proficiency in patient handling. f. Encourage quality improvement projects and research that support safe and effective patient handling.

a. Assign committee members to review OSHA guidelines for the prevention of back injuries. b. Develop policies and procedures for the therapeutic use of patient handling equipment c. Train all staff and family caregivers in the safe operation of all ergonomic-appropriate equipment. e. Develop competency based assessments that demonstrate proficiency in patient handling. f. Encourage quality improvement projects and research that support safe and effective patient handling.

The nurse is teaching a pt with multiple sclerosis and her family about her exercise program. Which points must the nurse include? Select all that apply. a. ROM exercises are an important component b. Stretching should precede rigorous activity c. Increased body temperature can lead to increased fatigue d. Steadily increasing walking distances can lead to jogging e. Stretching and strengthening exercises will be part of your program f. Take your pain medication at least 30 mins prior to exercise

a. ROM exercises are an important component c. Increased body temperature can lead to increased fatigue e. Stretching and strengthening exercises will be part of your program

A pt is scheduled for lumbar surgery. Which key points must the nurse include in a pre-operative teaching plan for this patient? Select all that apply. a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. d. Restricted to bed rest for at least 48 hrs e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

The nurse is caring for a patient who is experiencing spinal shock. What are the expected findings that occur with the condition? a. Temporary loss of motor, sensory, reflex and autonomic functions. b. Stridor, garbled speech, or inability to clear airway c. Hypotension and a decreased LOC d. Bradycardia and decreased UO

a. Temporary loss of motor, sensory, reflex and autonomic functions.

A teenager dove head first into a rock quarry pond and is brought to the emergency department by EMS. Which questions will the nurse ask the EMS? Select all that apply. a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? c. Have the parents been notified to get permission for treatment? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

Which position is therapeutic and comfortable for a patient with acute lower back pain from a herniated disc? a.Semi-Fowler's position with a pillow under the knees to keep them flexed. b. Supine position with arms and legs in a correct anatomical position. c. Orthopneic position; sitting with trunk slightly forward; arms supported with a pillow d. Modified Sim's position with upper arm and leg supported by pillows.

a.Semi-Fowler's position with a pillow under the knees to keep them flexed.

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past, but they resolved and no medication attention was sought. Which question does the nurse ask to assess whether the symptoms may be associated with MS? Select all that apply. a. "Are you having persistent headaches that occur with stress?" b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" d. "Are you having trouble breathing with minimal exertion?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

A pt with MS is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug? a. "You must be carefully monitored for allergic reactions bc the drug tends to build up in the body." b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate." c. "This drug will decrease the frequency of clinical relapses, but there is an increased risk for stroke." d. "The medication will improve your ability to walk, but it also increases the risk for seizures."

b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate."

The nurse is caring for several patients on an orthopedic surgical unit. Which pt has the greatest risk for fat embolism syndrome? a. 66 year old who had laser-assisted laparoscopic lumbar discectomy b. 46 year old who had a spinal fusion for spine stabilization c. 52 year old who had a laminectomy to relieve back pain d. 62 year old who had minimally invasive surgery

b. 46 year old who had a spinal fusion for spine stabilization

The nurse is preparing to physically assess a pt's report of parasthesia in the lower extremities. To accomplish this assessment, which assessment technique does the nurse use? a. Use a doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse. b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball. c. Use a reflex hammer to test for deep tendon patellar or Achilles reflexes. d. Ask the patient to walk across the room and observe gait and equilibrium.

b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball.

Which patient behavior is most likely to occur with spinal shock? a. Demonstrates restlessness and is easily agitated b. Displays inability or difficulty moving extremities c. Is disoriented to person, place, and time d. Reports severe pain that radiates down the spine

b. Displays inability or difficulty moving extremities

The nurse is planning care for a 66 year old pt with SCI. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend? a. Increase calcium intake and exercise against resistance b. Ensure influenza and pneumococcus vaccinations are current c. Drink adequate liquids and eat a high-fiber diet d. Practice meticulous skin care; including frequent repositioning

b. Ensure influenza and pneumococcus vaccinations are current

The nurse is caring for a pt with recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? Select all that apply. a. Frequently perform passive ROM exercises b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program d. Keep the pt immobilized with neck or back braces e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

The nurse is assessing a pt with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. Check for bladder distention b. Raise the head of bed c. Administer an anti-hypertensive med d. Notify the provider

b. Raise the head of bed

The nurse and nursing student are working together to bathe and reposition a pt who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? a. Uses the log-roll technique to clean the pt's back and buttocks b. Turns the pt by grasping the top of the halo device c. Positions the pt with the head and neck in alignment d. Supports the head and neck area during the repositioning

b. Turns the pt by grasping the top of the halo device

The home health nurse reads in the pt's chart that he has a spinal cord stimulator. What question would the nurse ask to evaluate the efficacy of the treatment? a. "Has the device helped you to gain control over the urinary incontinence?" b. "Does the device allow you to have sexual arousal that is satisfying?" c. "Have you been able to program the device to achieve maximum comfort?" d. "Have you programmed the device to achieve various levels of mobility?"

c. "Have you been able to program the device to achieve maximum comfort?"

The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The pt has a dopamine drip, but the systolic blood pressure is 88 mmHg. there is a new order to infuse 500 mL of dextran-40 over 4 hrs. At what rate does the nurse set the infusion pump? a. 75 mL/hr b. 100 mL/hr c. 125 mL/hr d. 150 mL/hr

c. 125 mL/hr

The pt with MS states she is bothered by diplopia. Which intervention does the nurse expect to implement? a. Obtain an order for consultation or referral for corrective lenses b. Teach the pt scanning techniques, moving her head from side to side c. Application of an eye patch alternating from eye to eye every few hours d. Prophylactic bilateral patches to both eyes at night.

c. Application of an eye patch alternating from eye to eye every few hours

An adolescent pt has quadriplegia as a result of a diving accident. The UAP reports that the pt starting yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "Nobody is going to do anything else to me! I'm going to get out of this place!" What is the priority patient problem? a. Noncompliance with treatment plan b. Self-care deficit for hygeine c. Difficulties with situational coping d. Feelings of hopelessness

c. Difficulties with situational coping

A patient tells the nurse, "I have symptoms of multiple sclerosis, and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employ first? a. Help the patient to locate and make an appointment with a specialist b. Ask the patient to describe the symptoms and past treatments c. Encourage the patient to verbalize feelings and frustrations d. Give the patient a brochure about the diagnosis and treatment of MS.

c. Encourage the patient to verbalize feelings and frustrations

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? a. Heatstroke b. Paralytic ileus c. Hypertensive stroke d. Aspiration and pneumonia

c. Hypertensive stroke

A pt has been talking to the provider about drugs that could potentially be used in the treatment of low back pain. Which statement by the pt indicates a need for additional teaching? a. "The doctor may prescribe a muscle relaxant, so I should not drive or operate machinery until I see how it will affect me." b. "The doctor may suggest OTC ibuprofen; therefore I should watch for and report dark or tarry stools." c. "The doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy, and the dose would gradually taper off." d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it."

d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it."

A patient had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment? a. Assess for gag reflex and ability to swallow own secretions. b. Check for bleeding and drainage at the incision site. c. Monitor vital signs and check neuro status. d. Assess for patency of airway and respiratory effort.

d. Assess for patency of airway and respiratory effort.

An adult has cared for a debilitated parent for 10 years. The parent's condition recently declined, and the health care provider recommended placement in a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to:

resolving the feelings associated with the threat to the person's self-concept. The patient's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors will not be helpful. Automatic relief behaviors are part of the fourth phase of crisis.

While conducting the initial interview with a patient in crisis, the nurse should:

speak in short, concise sentences. Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is non-therapeutic.

A victim of spousal violence comes to the crisis center seeking help. Crisis intervention strategies the nurse uses will focus on:

supporting emotional security and reestablishing equilibrium. Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable.

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