Nursing Fundamentals exam 4 practice test

A patient's spinal cord was severed, causing paralysis from the waist down. When obtaining data about this patient, which component of the sensory experience would be a priority for the nurse to assess? a. Transmission of tactile stimuli b. Adequate stimulation in the environment c. Reception of visual and auditory stimuli c. General orientation and ability to follow commands

a Rationale: Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of less importance at this time.

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate

a Rationale: If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

50 gtts/min. Rationale: When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

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

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

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of what side effect? a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression

d Rationale: Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? a. Remove the IV from the site and start at another location. b. Immediately notify the primary care provider. c. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. d. Aspirate the catheter and attempt to flush again.

a Rationale: If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.

a Rationale: In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? a. No action is necessary as this is a normal finding during sleep. b. Call the primary care provider to report possible neurologic deficit. c. Lower the temperature in the patient's room. d. Awaken the patient as this is an indication of night terrors.

a Rationale: Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.

a Rationale: Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? a. An older adult on bedrest following cervical spine surgery b. A patient with a severe sunburn being treated for dehydration c. An industrial worker who has burns caused by a caustic acid d. A patient experiencing cardiac disturbances from an electrical shock

a Rationale: Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores is a mechanical stimulant. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. An electrical shock is an electrical stimulant.

In a group home in which most patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns? a. Maintaining safety and preventing sensory deterioration b. Insisting that every patient participate in as many self-care activities as possible c. Emphasizing and reinforcing individual patient strengths d. Encouraging reminiscence and life review in groups

a Rationale: Safety is a basic physiologic need that must be met before higher-level needs—such as love and belonging, self-esteem, and self-actualization—can be met.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational

a, b, c Rationale: The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is loss that is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? a. The nurse leaves the patient in a sitting position while the family visits. b. The nurse places identification tags on both the shroud and the ankle. c. The nurse removes soiled dressings and tubes. d. The nurse makes sure a death certificate is issued and signed.

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

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? a. The patient b. The patient's daughter c. The patient's health care provider d. The ethics consult team

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

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

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

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES scale b. COMFORT scale c. FLACC scale d. FACES scale

a Rationale: The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES Scale is used for children who can compare their pain to the faces depicted on the scale.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a. Checking the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

a Rationale: The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife's health care provider about which type of order? a. Comfort Measures Only b. Do Not Hospitalize c. Do Not Resuscitate d. Slow Code Only

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

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

a Rationale: The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? a. Cultural imposition b. Clustering c. Cultural competency d. Stereotyping

a Rationale: The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced sensation of pain b. Inadequate or inconsistent relief of pain is widespread c. Reliable assessment tools are currently unavailable d. Narcotic analgesic use should be avoided

b Rationale: Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. b. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. c. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. d. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

a Rationale: The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed postoperative medications b. Impaired Physical Mobility related to surgical procedure c. Anxiety related to outcome of surgery d. Risk for Infection related to surgical incision

a Rationale: The patient's immediate problem is the pain that is unrelieved because the patient refuses to take pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation.

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? a. Acceptance b. Anger c. Bargaining d. Denial

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

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? a. Remove the catheter. b. Notify the primary care provider. c. Check that the airway is the appropriate size for the patient. d. Place the patient on his or her back.

a Rationale: When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? a. Cultural assimilation b. Cultural imposition c. Culture shock d. Ethnocentrism

a Rationale: When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

Which patient would a nurse assess as being at greatest risk for sensory deprivation? a. An older adult confined to bed at home after a stroke b. An adolescent in an oncology unit working on homework supplied by friends c. A woman in labor d. A toddler in a playroom awaiting same-day surgery

a Rationale: The patient confined to bed rest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate.

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

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

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism. b. A patient with coronary artery disease. c. A patient who has GERD. d. A patient who is HIV positive. e. A patient who is taking corticosteroids for arthritis. f. A patient with a urinary tract infection.

a, b, c Rationale: A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80 to 150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e Rationale: Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a, b, e Rationale: A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.

a, b, e, f Rationale: For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow.

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

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident b. A child is moaning and crying due to a stomachache c. A patient's pulse is increased following a myocardial infarction d. A patient in pain strikes out at a nurse who attempts to provide a bath e. A patient who has chronic cancer pain is depressed and withdrawn f. A child pulls away from a nurse trying to give an injection

a, b, f Rationale: Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to 1 quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

a, c, d, f Rationale: In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. a. A Native American patient b. An African-American patient c. An Alaska Native d. An Asian patient e. A White patient f. A Hispanic patient

a, c, e, f Rationale: Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. a. A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. b. A nurse treats all patients the same whether or not they come from a different culture. c. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. d. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. e. A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. f. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

a, d Rationale: Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping.

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply. a. A patient is receiving chemotherapy for bladder cancer b. An adolescent is admitted to the hospital for an appendectomy c. A patient is experiencing a ruptured aneurysm d. A patient who has fibromyalgia requests pain medication e. A patient has back pain related to an accident that occurred last year f. A patient is experiencing pain from second-degree burns

a, d, e Rationale: Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns.

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

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

A nurse is diagnosing an 11-year-old student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Based on this assessment data, which alteration would the nurse document for this patient? a. Self-care deficit b. Altered Role Performance (Student) c. Disturbed Body Image d. Delayed Growth and Development

b Rationale: An important role for an 11 year old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may also represent accurate diagnoses for this patient, they do not flow from the data presented.

A nurse observes that a patient who has cataracts is sitting closer to the television than usual. Which alteration would the nurse suspect is causing this patient behavior? a. Altered stimulation b. Altered sensory reception c. Altered nerve impulse conduction d. Altered impulse translation

b Rationale: Cataracts are interfering with the patient's ability to receive visual stimuli, causing altered sensory reception. The nature of incoming stimuli (e.g., environmental stimuli), the conduction of nerve impulses, and the translation of incoming impulses in the brain are not problematic in this situation.

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? a. "I can expect my newborn to sleep an average of 16 to 24 hours a day." b. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." c. "I will place my infant on his back to sleep." d. "I will not place pillows or blankets in the crib to prevent suffocation."

b Rationale: Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? a. 1 b. 2 c. 3 d. 4

b Rationale: Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. b. Keeping fluids readily available for the patient. c. Emphasizing the long-term outcome of increasing fluids when the patient returns home. d. Planning to offer most daily fluids in the evening.

b Rationale: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. Circadian rhythm sleep-wake disorder b. Narcolepsy c. Enuresis d. Sleep apnea

b Rationale: Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? 1. Encourage foods and fluids with high sodium content. 2. Administer oral K supplements as ordered. 3. Caution the patient about eating foods high in potassium content. 4. Discuss calcium-losing aspects of nicotine and alcohol use.

b Rationale: Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication

b Rationale: Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory.

Which action would be most important for a nurse to include in the care plan for a patient diagnosed with presbycusis? a. Obtaining large-print written material b. Speaking distinctly, using lower frequencies c. Decreasing tactile stimulation d. Initiating a safety program to prevent falls

b Rationale: Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. Obtaining large-print written material is appropriate for visual alterations. Decreasing tactile stimulation is appropriate for a patient with an alteration in touch, and initiating a safety program to prevent falls is appropriate for a patient experiencing kinesthetic alterations.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? a. Thoracentesis b. Pulse oximetry c. Diffusion capacity d. Maximal respiratory pressure

b Rationale: Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse is assessing a patient receiving a continuous opioid infusion. For which related condition would the nurse immediately notify the primary care provider? a. A respiratory rate of 10/min with normal depth b. A sedation level of 4 c. Mild confusion d. Reported constipation

b Rationale: Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the health care provider, but is not the priority in this situation.

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? a. How do you get your medications? b. How does having COPD affect your lifestyle? c. Are you concerned about the side effects of your medications? d. Can you describe how you will take your medications?

b Rationale: The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

b Rationale: The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative adult b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia

c Rationale: Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? a. Use short words and talk more loudly. b. Ask an interpreter for help. c. Explain why care can't be provided. d. Provide instructions in writing.

b Rationale: The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c. Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis.

b Rationale: The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

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

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

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b Rationale: The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

A patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial d. Somatic

b Rationale: The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the nurse would be most appropriate? a. "You can't be feeling this way. You know you are going to die." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll be all right; who knows how much time any of us has." d. "Tell me about your pain. Did it keep you awake last night?"

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

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? a.. "Oh, don't worry about that now. You need to sleep." b. "What seems to be concerning you the most?" c. "I have talked to your wife and she told me she will be fine." d. "I'm not qualified to advise you, I suggest you discuss this with your wife."

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

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient.

b Rationale: With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia. b. A patient with Parkinson's disease who is taking dopamine. c. An older adult taking diuretics for congestive heart failure. d. A patient who is taking antibiotics for an ear infection. e. A patient who is prescribed antidepressants. f. A patient who is taking low-dose aspirin prophylactically.

b, c, e Rationale: Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a. Pain is whatever the health care provider treating the pain says it is b. Pain exists whenever the person experiencing it says it exists c. Pain is an emotional and sensory reaction to tissue damage d. Pain is a simple, universal, and easy-to-describe phenomenon e. Pain that occurs without a known cause is psychological in nature f. Pain is classified by duration, location, source, transmission, and etiology

b, c, f Rationale: Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

A nurse is assessing a patient in a long-term care facility. The nurse notes that the patient is at risk for sensory deprivation due to limited activity related to severe rheumatoid arthritis. Which interventions would the nurse recommend based on this finding? Select all that apply. a. Use a lower tone when communicating with the patient. b. Provide interaction with children and pets. c. Decrease environmental noise. d. Ensure that the patient shares meals with other patients. e. Discourage the use of sedatives. f. Provide adequate lighting and clear pathways of clutter.

b, d, e Rationale: For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit. Decreasing environmental noise is an intervention for sensory overload. Providing adequate lighting and removing clutter is an intervention for a vision deficit.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b, d, e Rationale: When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

c Rationale: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c Rationale: A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is caring for a man with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would best prevent sensory alterations for this patient? a. Turn the radio or television volume up very loud and close the door to his room. b. Prevent embarrassment and emotional discomfort as much as possible. c. Provide daily opportunity for him to participate in a social hour with 6 to 8 people. d. Encourage daily participation in exercise and physical activity.

c Rationale: Although all the options listed are appropriate, providing daily opportunities for this patient to participate in a social hour builds on his strength of being able to lip-read and provides sufficient sensory stimulation to prevent sensory deprivation resulting from his hearing loss, thereby meeting his needs.

A nurse assessing an 8-month-old infant suspects the infant is experiencing sensory deprivation related to inadequate parenting. Since this assessment, both parents have attended parenting classes. However, both parents work while the infant stays with a grandparent, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor, rocking back and forth and has a dull facial expression with few vocalizations. Which nursing action would be appropriate for this patient and family? a. Explore why the infant's parents lack motivation to provide necessary stimulation. b. Remove the infant from the grandmother's care as the child has not progressed. c. Suggest counseling since the infant's sensory deprivation is still severe. d. No action is needed, as this is normal behavior for an 11-month-old infant.

c Rationale: Although the data show that the parents have been motivated to improve their parenting skills, it is clear from the data that the infant's sensory deprivation is still severe. The data suggest that the grandmother is not improving the infant's care, but there is nothing to suggest that she is unable to do so if shown how.

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? a. "Do you think you will be able to eat the food we have here?" b. "Do you understand that we can't prepare special meals?" c. "What types of food do you eat for meals?" d. "Why can't you just eat our food while you are here?"

c Rationale: Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? a. The use of a central nervous system stimulant b. Continuous positive airway pressure machine (CPAP) c. Chronotherapy d. The application of heat or cold therapy to promote sleep

c Rationale: Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? a. Somatic grief b. Anticipatory grief c. Unresolved grief d. Inhibited grief

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

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in the patient's legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin

c Rationale: Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? a. Learning the predominant language of the community b. Obtaining significant information about the community c. Treating each patient at the clinic as an individual d. Recognizing the importance of the patient's family

c Rationale: In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? a. A pinched and drawn facial expression b. Deep, rapid respirations. c. Moist crackles heard upon auscultation d. Tachycardia

c Rationale: Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method? a. Using the highest effective dose of an opioid on a PRN (as needed) basis b. Using nonopioid drugs conservatively c. Using consistent nonpharmacologic and nonopioid pharmacologic therapies d. Administering a continuous intravenous infusion on a regular basis

c Rationale: Nonpharmacologic and nonopioid pharmacologic therapies are the preferred choices for chronic pain that is not related to active cancer, palliative care, or end-of-life care. If progression to opioids becomes necessary, the lowest effective dose of an immediate-release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PRN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a PRN schedule may be acceptable to relieve occasional pain episodes.

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? a. Preparing the family for a diagnosis of insomnia and related treatments. b. Preparing the family for a diagnosis of narcolepsy and related treatments. c. Anticipating the scheduling of polysomnography to confirm OSA. d. No action would be taken, as this is a normal finding for hospitalized children.

c Rationale: OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a. The nurse assures that the oxygen is flowing into the prongs. b. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c. The nurse encourages the patient to breathe through the nose with the mouth closed. d. The nurse adjusts the flow rate to 6 L/min or more.

c Rationale: The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. d. Exercising right before bedtime can hinder sleep.

c Rationale: The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct the assistant to notify the primary care provider. b. Assess the patient's vital signs. c. Remove the tape, adjust the depth to ordered depth and reapply the tape. d. No action is required as depth will adjust automatically.

c Rationale: The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

A nurse is assessing a patient for tactile disturbances. Which question asked by the nurse would be appropriate for this assessment? a. "Have you been experiencing any strange tastes lately?" b. "Have you smelled odors lately that other cannot smell?" c. "Can you tell me what I am placing in your hand right now?" d. "Have you found it difficult to communicate verbally?"

c Rationale: When the nurse asks: "Can you tell me what I am placing in your hand right now?" the nurse is assessing for tactile disturbances. When the nurse asks: "Have you been experiencing any strange tastes lately?" the nurse is assessing for gustatory disturbances. The question: "Have you smelled odors lately that others cannot smell?" assesses for olfactory disturbances. The question: "Have you found it difficult to communicate verbally?" assesses for transmission-perception-reaction.

An older adult in a long-term care facility walked out the door unobserved and was lost for several hours. Upon assessment, the nurse notes that the patient is confused and documents: chronic sensory deprivation related to the effects of aging. Which interventions would be most effective for this patient? Select all that apply. a. Ignore the patient's confusion, or go along with it to prevent embarrassment. b. Reduce the number and type of stimuli in the patient's room. c. Orient the patient to time, place, and person frequently. d. Provide daily contact with children, community people, and pets. e. Decrease background or loud noises in the environment. f. Provide a radio and television in the patient's room.

c, d, f Rationale: Even if well motivated, ignoring a patient's confusion to prevent embarrassment may be dangerous, as it was in this case in which the appropriate safety precautions were never implemented. Reducing the type of stimuli in the room and decreasing environmental noise is appropriate for a patient who is experiencing sensory overload. The other options are related to sensory deprivation and are appropriate for this patient.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c. It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage.

c, e Rationale: This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

A nurse is assessing an older adult patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. a. The nurse asks the patient if he is bored, and if so, why. b. The nurse asks the patient if anything interferes with the functioning of his senses. c. The nurse asks the patient if he noticed any changes in the way he perceives his body. d. The nurse asks the patient if he has found it difficult to communicate verbally. e. The nurse notes if the patient withdraws from being touched. f. The nurse notes if the patient seems unsure of his body parts or position.

c, e, f Rationale: To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation. Asking if anything interferes with his senses assesses reception. Asking about difficulty communicating assesses for transmission-perception-reaction.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output. b. Testing skin turgor. c. Reviewing the complete blood count. d. Measuring weight daily.

d Rationale: Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A patient is in the late stages of AIDS, with alterations to the brain as well as other major organ systems. The patient complains of loneliness because of friends being "afraid to visit." Based on this data, what would the nurse determine to be the least likely underlying etiology for this patient's sensory problems? a. Stimulation b. Reception c. Transmission-perception-reaction d. Emotional responses

d Rationale: Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for the patient's condition. This patient is receiving decreased environmental stimuli (e.g., from lack of friends), and is more than likely experiencing problems with reception because of major organ involvement. In addition, impaired brain function will impair impulse transmission-perception-reaction.

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. c. Teach the patient to take short shallow breaths when performing hygiene measures. d. Group personal care activities into smaller steps, allowing rest periods between activities.

d Rationale: For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? a. "It's not a good idea to ask for pain medication regularly as it can be addictive." b. "It is better to wait until the pain is severe before asking for pain medication." c. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." d. "Your doctor has prescribed pain medications for you, which you should request when you have pain."

d Rationale: Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time.

A patient who is having a myocardial infarction reports pain that is situated in the neck. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain

d Rationale: Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.

A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? a. Cultural imposition b. Clustering c. Cultural competency d. Stereotyping

d Rationale: Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.

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

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

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a. Reposition the extremity and raise the height of the IV pole. b. Apply pressure to the dressing on the IV. c. Pull the catheter out slightly and reinsert it. d. Put on gloves; remove the catheter

d Rationale: This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 1800, 1900, and 2000. A heart monitor beeps for a patient on one side, and another patient moans frequently. Which patient assessment would the nurse make based on this data? a. Sufficient sensory stimulation b. Deficient sensory stimulation c. Excessive sensory stimulation d. Both sensory deprivation and overload

d Rationale: This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the health care provider. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline.

d Rationale: When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

An older patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient? a. Assist the patient to ambulate by walking slightly behind her and grasping the arm. b. Concentrate on the patient's sense of sight and limit diversions that involve other senses. c. Stay outside of the patient's field of vision when performing personal hygiene for her. d. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.

d Rationale: When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when he or she is leaving the room. When assisting with ambulation, the nurse should walk slightly ahead of (rather than behind) the patient and allow her to grasp the nurse's arm. The nurse should provide, rather than limit, diversions using other senses, and stay in the person's field of vision if she has partial or reduced peripheral vision.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. A nosebleed is noted with continued suctioning.

d Rationale: When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in 0.9% NaCl b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (⅓-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 5% dextrose in Lactated Ringer's solution

d, e Rationale: 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. a. The United States has become less inclusive of same-sex couples b. Cultural diversity is limited to people of varying cultures and races c. Cultural diversity is separate and distinct from health and illness d. People may be members of multiple cultural groups at one time e. Culture guides what is acceptable behavior for people in a specific group f. Cultural practices may evolve over time but mainly remain constant

d, e, f Rationale: A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

d, e, f Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f Rationale: Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.