Test 4 Study Set

The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure?

"I will wipe my genital area from front to back before I collect the specimen midstream."

Which urine specific gravity would be expected in a patient admitted with dehydration?

1.030

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)?

6 t o8 glasses a day

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching?

A stoma that is pale, dusky, or black in color

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? 1) Acute 2) Chronic 3) Intractable 4) Neuropathic

ANS: 1 Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves. PTS:1DIF:EasyREF:p. 1092 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document? 1)Injection site 2)Previous site of administration 3)Patient response to medication 4)Heart rate prior to administration

ANS: 1 After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patient's response to medication is recorded in the nurse's narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician's order. Heparin does not affect heart rate.

The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? "An advance directive is a document 1) Specifying your healthcare intentions should you become unable to make self-directed decisions" 2) Identifying the activities considered to be evidence of quality care" 3) Verifying your understanding of the risks and benefits associated with a procedure" 4) Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice"

ANS: 1 An advance directive is a group of instructions stating the patient's healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patient's understanding of risks and benefits associated with a procedure. An "against medical advice" form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient. PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive

Which dysrhythmia confirms death? 1) Asystole (absence of heart activity) 2) Pulseless electrical activity 3) Ventricular fibrillation 4) Ventricular tachycardia

ANS: 1 Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment. PTS:1DIF:EasyREF:p. 365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? 1) Caution the patient against combining acetaminophen with alcohol. 2) Explain that acetaminophen increases the risk for bleeding. 3) Advise taking acetaminophen with meals to prevent gastric irritation. 4) Explain that physical dependence may occur with long-term oral use.

ANS: 1 Even in recommended doses, acetaminophen can cause hepatotoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence. PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1)The Minimum Data Set (MDS) for assessment 2)Situation-background-assessment-recommendation (SBAR) for reporting 3)Healthcare Financing Administration guidelines prior to surgery 4)Joint Commission guidelines for discharge planning

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law.

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1)14 days 2)3 days 3)2 days 4)24 hours

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? 1) Stimulate the patient. 2) Prepare to administer naloxone (Narcan). 3) Administer a dose of pain medication. 4) Notify the physician immediately.

ANS: 1 If the patient's score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patient's respiratory rate is less than 8 breaths/minute; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated. PTS:1DIFgrinifficultREF:p. 1106 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? 1) Distraction 2) Guided imagery 3) Sequential muscle relaxation 4) Hypnosis

ANS: 1 Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state. PTS:1DIF:EasyREF:pp. 1101-1102 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1)"Occurrence reports track problems and identify areas for quality improvement." 2)"Occurrence reports are required by the Food and Drug Administration to report drug errors." 3)"The Joint Commission requires occurrence reports for all client falls." 4)"Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

ANS: 1 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or Joint Commission.

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy

ANS: 1 Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm. PTS:1DIFgrinifficultREF:p. 1108 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain? 1) Selective serotonin reuptake inhibitor 2) Selective norepinephrine reuptake inhibitor 3) Narcotic analgesic 4) Anti-emetic

ANS: 1 The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, such as Atomoxetine (Strattera), are commonly used for attention deficit-hyperactivity disorder. If a narcotic, such as oxycodone (OxyContin), is used for a long time, it may become habit forming (causing mental or physical dependence). Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An anti-emetic, such as ondansetron (Zofran), is used to control for nausea and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an anti-emetic to control the side effect. PTS:1DIFgrinifficultREF:p. 1103; higher-order item, can be inferred from text KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain

ANS: 1 The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia. PTS: 1 DIF: Moderate REF: pp. 1096-1098 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? 1) Monitor the patient's respiratory status. 2) Auscultate the patient's heart sounds. 3) Check blood pressure in supine and sitting positions. 4) Monitor the patient for psychological drug dependence.

ANS: 1 The nurse should assess the patient's respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to check blood pressure while the patient lies down (supine position) and sits up. Psychological dependence occurs rarely even after long-term prescribed use of morphine. Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drug dependence. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1)Repeat the order to the prescriber even if she believes she understood the order correctly. 2)Immediately notify the pharmacy of the order and verify it with a pharmacist. 3)Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4)Transcribe the order onto note paper and verify the dosage in a drug handbook.

ANS: 1 The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient's chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

The patient's medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN Which type of charting has the nurse used? 1)Narrative 2)Focus 3)SOAP 4)PIE

ANS: 1 The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

What is typically the most reliable indicator of pain? 1) Patient's self-report 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues

ANS: 1 The patient's self-report is the most reliable indicator of pain. A patient's facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patient's experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. Sociocultural factors can influence a patient's nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression or anxiety, can influence the perception of pain. PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? 1) Blood pressure 160/82 mm Hg 2) Temperature 100.6°F 3) Heart rate 80 beats/min 4) Oxygen saturation 95%

ANS: 1 This patient has an elevation in blood pressure which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits. PTS: 1 DIF: Moderate REF: pp. 1095-1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing? 1) Environmental loss 2) Internal loss 3) Perceived loss 4) Psychological loss

ANS: 1 This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them. PTS:1DIF:EasyREF:p. 358 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

According to William Worden, which task in the grieving process takes longest to achieve? 1) Accepting that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy

ANS: 1 Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task. PTS:1DIF:EasyREF:p. 359 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

Which action by the nurse breaches patient confidentiality? Select all that apply. 1)Leaving patient data displayed on a computer screen where others may view it 2)Remaining logged on to the computer system after documenting patient care 3)Faxing a patient report to the nurses' station where the patient is being transferred 4) Informing the nurse manager of a change in the patient's condition

ANS: 1, 2 Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses' station receiving a patient does not breach patient confidentiality because it is located at the nurses' station out of others' view. Anyone directly involved in the patient's care has the right to know about the patient's condition without breaching patient confidentiality.

A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might help relieve the patient's constipation? Choose all that apply. 1) "Be sure the amount of fruit, vegetables, and fiber in your diet is adequate." 2) "Drink at least eight 8-ounce glasses of water each day." 3) "Avoid using stool softeners because they may become habit forming." 4) "Increase your exercise routine to include 1 hour of exercise a day."

ANS: 1, 2 The nurse should instruct the patient to be sure the amount of fruit, vegetables, and fiber in his diet is adequate, and increase fluid intake to eight, 8-ounce glasses of water per day. Stool softeners may also be used. The patient should also be encouraged to increase exercise; even walking a short distance may be helpful. It is not necessary to increase exercise to 1 hour of exercise a day. The patient may be physically able to walk only short distances. PTS:1DIF:ModerateREF:p. 1105 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1)"I can wait until the end of the shift to document my care." 2)"Charting every 2 hours is the most appropriate way to document nursing care." 3)"I find it easier to chart before I go to lunch and then after my shift report." 4)"I should chart as soon as possible after nursing care is given."

ANS: 1, 2, 3 Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1)Teaching performed 2)Any change in client status 3)Treatments administered 4)Hygiene measures performed

ANS: 1, 2, 3 Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the client's status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information.

The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1)Facilitate evidence-based nursing practice 2)Promote efficient use of the nurse's documentation time 3)Reduce the opportunity for interdisciplinary collaboration 4)Ensure improved client safety and outcomes

ANS: 1, 2, 4 Electronic health records (EHR) have many advantages, including the facilitation of evidence-based nursing practice, efficient use of the nurse's documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members.

To be eligible for insurance benefits covering hospice care, a physician must certify that which of the following apply to the patient? Choose all that apply. 1) Life expectancy is not more than 6 months. 2) Life expectancy is not more than 12 months. 3) Condition is expected to improve slightly. 4) Condition is not expected to improve.

ANS: 1, 4 For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6 months. PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Choose all correct answers. 1)"The Kardex® pulls data from multiple areas of the patient's chart." 2)"The Kardex® is usually kept at the patient's bedside." 3)"The Kardex® is used to document patient response to interventions." 4)"The Kardex® summarizes the plan of care and guides nursing care."

ANS: 1, 4 The Kardex® is a tool that pulls data from multiple areas of the patient's health record and helps guide nursing care. Responses to interventions are documented on flow sheets and in nurses' notes. Kardexes® are paper forms that are kept together in a portable file at the nurses' station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there, as a general rule.

A patient refuses a dose of medication. How should the nurse document the event? 1)Patient is uncooperative and refuses the prescribed dose of digoxin. 2)Patient refuses the 0900 dose of digoxin. 3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4)0900 dose of digoxin not given.

ANS: 2 "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given" provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

According to the Uniform Determination of Death Act, which bodily function must be lost to declare death? 1) Consciousness 2) Brain stem function 3) Cephalic reflexes 4) Spontaneous respirations

ANS: 2 According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations. PTS:1DIF:ModerateREF:p. 362 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall

Which patient is at most risk for experiencing difficult grieving? 1) The middle-aged woman whose grandmother died of advanced Parkinson's disease 2) The young adult with three small children whose wife died suddenly in an accident 3) The middle-aged person whose spouse suffered a slow, painful death 4) The older adult whose spouse died of complications of chronic renal disease

ANS: 2 Although it is impossible to predict with certainty and the grieving process is highly individual and personal, in general those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g., cancer) have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs. PTS: 1 DIF: Moderate REF: p. 360 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1)Patient found on floor in pain after falling out of bed. 2)Patient found on floor after falling out of bed; found by NAP Smith. 3)Patient fell out of bed but is currently in bed. 4)Patient reminded to not climb OOB after falling.

ANS: 2 Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

he nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4)09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS: 2 Correct documentation of a telephone order is as follows: "09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurse's name and title.) The other options demonstrate incomplete documentation of a telephone order.

Which side effects associated with opioid use may improve after taking a few doses of the drug? 1) Constipation 2) Drowsiness 3) Dry mouth 4) Difficulty with urination

ANS: 2 Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a "death rattle"? 1) Perform nasotracheal suctioning of secretions. 2) Turn the patient on his side and raise the head of the bed. 3) Insert a nasopharyngeal airway as needed. 4) Administer morphine sulfate intravenously.

ANS: 2 If a "death rattle" occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a "death rattle" and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a "death rattle." This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest. PTS:1DIF:ModerateREF:p. 376 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, "Tell my wife to stop hovering and go home. I'm going to be fine." How should the nurse respond? 1) "Your physical signs indicate that you will likely not live more than a few more days." 2) "You seem very sure that you are not going to die. Please tell me more about what you are feeling." 3) "It seems to me you would be feeling some anger and wondering why all this is happening to you." 4) "It would be best for your family if you were able to work through this and come to accept the reality of your situation."

ANS: 2 Not all patients go through all the traditional stages of grieving. It is not the nurse's responsibility to move patients sequentially through each stage of the dying and grieving process with the goal that everyone ends life accepting death. It is a nursing responsibility to accept and support people "where they are" and help them to express their feelings. Nurses need to understand patients, not change them. In this situation, denial may be very important to this patient, as an emotional defense and coping strategy. "You seem sure . . . tell me . . . what you are feeling" restates what the patient has said (indicating understanding) and encourages expression of feelings—both are supportive. Even though moving him through stages is not the goal in this situation, support does facilitate that. Telling the patient that his physical signs indicate that death is imminent is presenting truth and reality; however, the exact time of death is not always predictable. Forecasting the hour of death can have negative impact on the family as they anticipate the event with emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier in the dying process, but not in this situation because it has already been tried with no change in the patient. Presenting reality does not support the patient's needs at this time. Saying "It seems to me you would be feeling some anger . . ." is directed toward moving the patient from denial and suggesting he should feel something he has not yet expressed. This is not therapeutic. Saying "It would be best for your family . . ." presumes that the nurse knows more about what is "best" for the patient's family than the patient himself. This statement is also judgmental. PTS: 1 DIF: Difficult REF: pp. 362-363 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

he surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse 1)Performs oral care 2)Assists the patient out of bed 3)Assists the patient with bathing 4)Changes the patient's operative dressings

ANS: 2 OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient's postoperative dressings.

What is the purpose of completing an occurrence report? 1)Provide a legal defense should the patient seek legal action after an unusual occurrence 2)Track problems and identify areas for quality improvement 3)Report errors to the Food and Drug Administration 4)Report medical errors to the Joint Commission

ANS: 2 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal defense should a patient seek legal action or to report errors to the FDA or Joint Commission.

In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? 1) Transduction 2) Transmission 3) Perception 4) Modulation

ANS: 2 Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed. PTS:1DIFgrinifficultREF:p. 1092 KEY:Nursing process: NA | Client need: PHSI | Cognitive level: Recall

When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? 1) To prevent blood from settling in the head, neck, and shoulders 2) To perform these actions more easily before rigor mortis develops 3) To set the mouth in a natural position for viewing by the family 4) To prevent discoloration caused by blood settling in the facial area

ANS: 2 Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patient's eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patient's mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area. PTS: 1 DIF: Moderate REF: p. 378 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will 1) Request pain medication when needed 2) Report or demonstrate satisfactory pain control 3) Use only nonpharmacological measures to control pain 4) Verbalize understanding that it may not be possible to control his pain

ANS: 2 The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an "as needed" basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain-control medications are available and can be administered by several routes; it should be possible to control the pain. PTS: 1 DIF: Moderate REF: p. 369 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain? 1) Psychogenic 2) Phantom 3) Referred 4) Radiating

ANS: 2 The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person which does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations. PTS:1DIF:EasyREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? 1) Acute pain secondary to surgery 2) Acute pain (abdominal) secondary to surgery for colon cancer 3) Chronic pain secondary to cancer diagnosis 4) Chronic pain (abdominal) secondary to abdominal surgery

ANS: 2 The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic. PTS: 1 DIF: Moderate REF: p. 1100 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patient's condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? 1) "I'll call your physician right away so he can discuss this with you." 2) "You have the right to change your decision about treatment at any time." 3) "Are you sure you want to change your decision?" 4) "We must follow whatever is written in your living will."

ANS: 2 The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patient's decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patient's decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it. PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do? 1) Notify the prescriber immediately. 2) Take the medication with food. 3) Take the medication with 8 ounces of water. 4) Take the medication before bedtime.

ANS: 2 The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen. PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient complaining of a severe headache. When should the nurse reassess the patient's pain? 1) 15 minutes after administration 2) 60 minutes after administration 3) 90 minutes after administration 4) Immediately before the next dose is due

ANS: 2 The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due. PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

A patient's wife tells the nurse that she wants to be with her husband when he dies. The patient's respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? 1) "Certainly, go ahead; your husband will most likely hold on until you return." 2) "Your husband could live for days or a few hours; you should do whatever you are comfortable with." 3) "You need to take care of yourself; go home and shower, and I'll stay at his bedside while you are gone." 4) "Don't worry. Your husband is in good hands; I'll look out for him."

ANS: 2 The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband's bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wife's return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wife's concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death. PTS:1DIF:ModerateREF:pp. 367-368 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A home health patient previously lived with her sister for more than 20 years. Although it has been over a year since her sister died, the patient tells the nurse, "It's no worse now, but I never feel any relief from this overwhelming sadness. I still can't sleep a full night. The house is a mess; I feel too tired, even to take a bath. But, sometimes at night, she comes to me and I can see her plain as can be." The patient's clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably 1) Grieving longer than usual because of the closeness of the relationship with her sister 2) Experiencing a depressive disorder rather than simply grieving the loss of her sister 3) Feeling guilt and worthlessness because her sister died and she is still alive 4) Interpreting the holiday as a trigger event, which is causing her to hallucinate event, which is causing her to hallucinate

ANS: 2 The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no "correct" timeline for what constitutes "longer than usual" grieving; however, the patient's symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said that the holiday has not made her feel any worse—that is, it has not been a trigger event. PTS: 1 DIF: Difficult REF: pp. 367-368 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse? 1) Oral pain medication once every 6 to 8 hours 2) Patient-controlled analgesic 3) Oral pain medications instead of the IM form 4) Only nonpharmacological pain measures

ANS: 2 The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse. PTS:1DIF:EasyREF:pp. 1109-1110 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. 2) Cannot communicate the character of his pain effectively. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking.

ANS: 2 There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to ask for it out of habit or reliance on others; rather, it is likely due to inability to effectively express to the caregiver that analgesia is needed. PTS:1DIF:ModerateREF:p. 1095 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patient's pain? 1) Encourage the client to ambulate to promote flow of spinal fluid. 2) Offer caffeinated beverages to constrict blood vessels in his head. 3) Encourage coughing and deep breathing to increase CSF pressure. 4) Restrict oral fluid intake to prevent excess spinal pressure.

ANS: 2 Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a "spinal headache" after epidural anesthesia. PTS:1DIFgrinifficultREF:p. 1108 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient's care? 1)Every 2 weeks 2)Every shift 3)Every week 4)Every 3 months

ANS: 2 When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require wound care. The Minimum Data Set must be updated every 3 months.

Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Choose all that apply. 1) Interest in his usual activities 2) Extended regression 3) Withdrawal from friends 4) Inability to sleep 5) Intermittent sadness

ANS: 2, 3, 4 The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over a long period of time, so they would not indicate a need for professional help. PTS:1DIF:EasyREF:p. 380 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

which of the following is a disadvantage of paper health records? 1)Assist collaboration 2)Provide cautionary reminders 3)Are sometimes illegible 4)Serve as a resource

ANS: 3 A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors, as well as taking nurses' time to decipher handwriting and call providers.

Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. 2) The patient will rest quietly when undisturbed. 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. 4) The patient will receive pain medication every 2 hours as prescribed.

ANS: 3 A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numeric score gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patient's pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome. PTS:1DIFgrinifficultREF:p. 1100 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1)It involves a cooperative effort among various disciplines. 2)The system requires diligence in maintaining a current problem list. 3)Data may be fragmented and scattered throughout the chart. 4)It allows the nurse to provide information in an unorganized manner

ANS: 3 A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

Which intervention takes priority for the patient receiving hospice care? 1) Turning and repositioning the patient every 2 hours 2) Assisting the patient out of bed into a chair twice a day 3) Administering pain medication to keep the patient comfortable 4) Providing the patient with small frequent, nutritious meals

ANS: 3 A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the body's need for nutrition and hydration is reduced as the body begins the desiccation process. PTS:1DIFgrinifficultREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur 1) Moments before death 2) Days to hours before death 3) 1 to 2 weeks before death 4) 1 to 3 months before death

ANS: 3 Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened. PTS:1DIF:ModerateREF:p. 367 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Which intervention should be included in the plan of care for a patient in the end-stage death process? 1) Encourage the patient to accept as much help as possible. 2) Avoid administering laxatives. 3) Wet the lips and mouth frequently. 4) Administer pain medication on an as-needed basis.

ANS: 3 If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them. PTS:1DIF:ModerateREF:p. 375 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication? 1)Every hour around-the-clock 2)Immediately after taking off the order 3)As needed, but not more than once per hour 4)1 hour after the last administered dose

ANS: 3 PRN is the abbreviation for "as needed." The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? 1) Metabolic alkalosis 2) Pneumothorax 3) Pneumonia 4) Hemothorax

ANS: 3 Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting. PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

Which set of topics makes up a hand-off report given in a recommended format? 1)Data-action-response 2)Subjective-objective-assessment-plan 3)Situation-background-assessment-recommendation 4)Patient-diagnosis-medications-activity

ANS: 3 The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

Which pain management task can be safely delegated to nursing assistive personnel? 1) Assessing the quality and intensity of the patient's pain 2) Evaluating the effectiveness of pain medication 3) Providing a therapeutic back massage 4) Administering oral dose of acetaminophen

ANS: 3 The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patient's pain, monitoring the patient's response to pain management strategies, administering medications (including over-the-counter preparations), or evaluating the pain management plan. PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child? 1) Take the child to the funeral even if he is frightened. 2) Notify the physician immediately if the child shows signs of regression. 3) Spend as much time as possible with the child. 4) Provide distraction whenever the child begins to express feelings of sadness.

ANS: 3 The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears. PTS:1DIF:ModerateREF:p. 380 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? 1) Physostigmine (Antilirium) 2) Flumazenil (Romazicon) 3) Naloxone (Narcan) 4) Protamine sulfate

ANS: 3 The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous system depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1)Use an opaque white fluid to cover the documentation error. 2)Completely cover the documentation error with black ink. 3)Draw a line through the error and initial the change. 4)Use correction tape to make the documentation correct.

ANS: 3 The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words "error" or "mistaken entry" above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient's health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened.

How should the nurse respond to a family immediately after a patient dies? 1) Ask the family to leave the patient's room so postmortem care can be performed. 2) Leave tubes and IV lines in place until the family has the opportunity to view the body. 3) Express sympathy to the family (e.g., "I am sorry for your loss"). 4) Tell the family that they will have limited time with their loved one.

ANS: 3 The nurse should express sympathy to the family immediately after the patient's death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready. PTS:1DIF:ModerateREF:p. 378 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. 2) Apply the cold pack to the ankle for 30 minutes at a time. 3) Check the skin frequently for extreme redness. 4) Keep the cold pack in place for at least 24 hours.

ANS: 3 The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time. The patient should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur. PTS:1DIF:ModerateREF:p. 1101 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for 1)Acute interventions 2)Patient teaching 3)Discharge needs 4)Family health data

ANS: 3 The patient's potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient's hospitalization.

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1)Hypertension 2)Rheumatoid arthritis 3)Postoperative colon resection 4)Follow all three plans

ANS: 3 The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient's other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care.

At 1000 on 11/14/10, the nurse takes a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? 1)11/14/13 at 1200 2)11/14/13 at 2200 3)11/15/13 at 1000 4)11/16/13 at 1000

ANS: 3 The prescriber must countersign all verbal and telephone orders within 24 hours.

The nurse uses his hands to direct energy fields surrounding the patient's body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention? 1) Tactile distraction was performed and appeared effective in reducing pain. 2) Guided imagery was effective to relax the patient and reduce the pain. 3) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. 4) Sequential muscle relaxation was performed; patient states pain is less.

ANS: 3 Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain. PTS:1DIF:ModerateREF:p. 1102 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, "I just can't make up my mind about it." Which nursing diagnosis is most appropriate for this patient? 1) Deficient Knowledge 2) Spiritual Distress 3) Decisional Conflict 4) Death Anxiety

ANS: 3 This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict. PTS:1DIF:ModerateREF:pp. 367-368; high-level question, not stated verbatim in text | V2, pp. 168-169; high-level question, not stated verbatim in text KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level: Analysis

A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response? 1) Histamine 2) Prostaglandin 3) Bradykinin 4) Serotonin

ANS: 3 Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not involved in the inflammatory response. PTS:1DIFgrinifficultREF:p. 1092 KEY: Nursing process: NA | Client need: PHSI | Cognitive level: Application

How should the nurse classify pain that a patient with lung cancer is experiencing? 1) Radiating 2) Deep somatic 3) Visceral 4) Referred

ANS: 3 Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the source and extends to other locations. Deep somatic pain is typically caused by fracture, sprain, arthritis, and bone cancer. Referred pain occurs in an area distant from the original site. PTS:1DIF:ModerateREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

Which intervention is appropriate for a client receiving palliative care? Choose all that apply. 1) Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation 2) Administering IV dopamine to raise blood pressure of a patient with end-stage lung cancer 3) Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4) Administering a medication to relieve the nausea of a patient with end-stage leukemia

ANS: 3, 4 Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops and administering antinausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures. PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate? 1) Shock and numbness 2) Yearning and searching 3) Disorganization and despair 4) Reorganization

ANS: 4 According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase. PTS:1DIF:ModerateREF:p. 359 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

What emotional response is typical during the Rando's confrontation phase of the grieving process? 1) Anger and bargaining 2) Shock with disbelief 3) Denial 4) Emotional upset

ANS: 4 During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities. PTS:1DIF:ModerateREF:p. 359 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall

During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate? 1) Delayed 2) Chronic 3) Disenfranchised 4) Masked

ANS: 4 Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported. PTS: 1 DIF: Moderate REF: p. 361 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? 1) Perception 2) Transduction 3) Transmission 4) Modulation

ANS: 4 Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation). PTS:1DIF:ModerateREF:pp. 1093, 1100; synthesis of information required KEY:Nursing process: Planning | Client need: PHSI | Cognitive level: Recall

A patient with Raynaud's disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief? 1) Cordotomy 2) Rhizotomy 3) Neurectomy 4) Sympathectomy

ANS: 4 Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynaud's disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission. PTS:1DIF:ModerateREF:p. 1108 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Recall

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1)Study the discharge plan. 2)Check the graphic data for vital signs. 3)Examine the history and physical. 4)Look for an advance directive.

ANS: 4 The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? 1) Use nonpharmacological therapy while waiting 3 more hours before the next dose. 2) Administer an additional 800 mg oral dose of ibuprofen right away. 3) Do nothing because the patient's facial expression indicates he is comfortable. 4) Notify the prescriber that the current pain management plan is ineffective.

ANS: 4 The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescriber's order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is. PTS:1DIF:ModerateREF:pp. 1110-1111 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which nursing intervention should be included in the plan of care for a patient dying of cancer? 1) Encourage at least one family member to remain at the bedside at all times. 2) Follow-up with other healthcare team members during weekly meetings. 3) Avoid discussing the dying process with family (to reduce sadness). 4) Encourage family members to participate in care of the patient when possible

ANS: 4 The plan of care should include encouraging family members to help with the patient's care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns. PTS: 1 DIF: Moderate REF: pp. 369-371 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, "I hate this place; nobody knows how to take care of me or I'd be home by now." Which response by the nurse is best in this situation? 1)"You seem angry; what's going on that makes you hate this place?" 2)"I'm sorry that we aren't caring for you according to your expectations." 3)"You were very sick; don't be angry; you're lucky to be alive." 4)"You shouldn't be angry with us; we're trying to help you."

ANS:1 "You seem angry; what's going on . . ." encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patient's anger by apologizing ("I'm sorry . . ."). Advising the patient "don't be angry" or "you shouldn't be angry" diminishes the patient's right to be angry. PTS:1DIF:ModerateREF:p. 266

What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome? 1)Promotes fluid retention by increasing the reabsorption of water by kidney tubules 2)Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle 3)Increases the use of fats and proteins for energy and conserves glucose for use by the brain 4)Promotes fluid excretion by causing the kidneys to reabsorb more sodium

ANS:1 Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium. PTS:1DIF:ModerateREF:p. 252

The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess? 1)Depression 2)Hypochondriasis 3)Somatization 4)Malingering

ANS:1 Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger. PTS:1DIF:EasyREF:p. 256

You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation? 1)Epinephrine 2)Corticotrophin-releasing hormone 3)Aldosterone 4)Antidiuretic hormone

ANS:1 During the shock phase of the general adaptation syndrome, large amounts of epinephrine prepare the body to react in an emergency situation. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.

At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful? 1)Decreased blood pressure 2)Decreased peripheral skin temperature 3)Increased heart rate 4)Increased respiratory rate

ANS:1 Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate. PTS:1DIF:ModerateREF:pp. 266-267

Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope 1)Could be used by the patient to hurt her 2)Might cause the patient not to trust her 3)Would distract her from focusing on the patient 4)Will function as another stressor for the patient

ANS:1 When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse should be removed before entering the patient's room. It is unlikely that a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely don't even notice their presence. PTS:1DIF:ModerateREF:p. 266

A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." You recognize this reaction as Anxiety rather than Fear because (choose all that apply) 1)It concerns future or anticipated events 2)It concerns anticipation of danger rather than a present danger 3)There is no shakiness or tearfulness present 4)There is a psychological rather than a physical threat

ANS:1, 2, 4 Anxiety is an emotional response related to future or anticipated events. Fear is a cognitive response to a present, usually identifiable, source. Anxiety results from psychological conflict, whereas fear can result from either a psychological or physical threat. Shakiness and tearfulness may occur in both anxiety and fear, which share several defining characteristics. PTS:1DIF:ModerateREF:p. 256

After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting? 1)Reaction formation 2)Displacement 3)Denial 4)Conversion

ANS:2 This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis. PTS:1DIF:ModerateREF:p. 257

Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Choose all that apply. 1)The wound is most likely infected. 2)This is a vascular response to inflammation. 3)Damaged cells are being regenerated. 4)Exudate formation is occurring.

ANS:2, 4 During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonly appears at surgical incisions. When a wound becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here. PTS:1DIF:ModerateREF:pp. 254-255

During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply. 1)Rate of metabolism decreases. 2)Liver converts more glycogen to glucose. 3)Use of amino acids decreases. 4)Amino acids and fats are more available for energy.

ANS:2, 4 The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: The rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of amino acids and mobilization of fats for energy. PTS:1DIF:ModerateREF:pp. 252-253

When released in response to alarm, which of the following substances promotes a sense of well-being? 1)Aldosterone 2)Thyroid-stimulating hormone 3)Endorphins 4)Adrenocorticotropic hormone

ANS:3 Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralocorticoids. PTS:1DIF:ModerateREF:p. 253

A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient? 1)Anger 2)Fear 3)Anxiety 4)Hopelessness

ANS:3 NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely feeling anxious. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf. PTS:1DIF:ModerateREF:p. 256

After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing? 1)Alarm 2)Resistance 3)Exhaustion 4)Recovery

ANS:3 Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place. PTS:1DIFgrinifficultREF:p. 254

When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan? 1)"The patient will limit his intake of fat to no more than 15% of the daily calories consumed." 2)"The patient will eat three meals per day at approximately the same time each day." 3)"The patient will limit his intake of sugar and salt, as well as sweet and salty foods." 4)"The patient will consume no more than three alcoholic beverages a day."

ANS:3 The nurse should advise the client to limit the intake of sugar and salt; limit the intake of fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals (not three meals a day); and consume no more than two alcoholic beverages per day but not necessarily every day. PTS:1DIF:ModerateREF:p. 265 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea? 1)Monitor and record the frequency of stools on the graphic record. 2)Administer prescribed antidiarrheal medications as needed. 3)Encourage the patient to verbalize about stressors and anxiety. 4)Provide oral fluids on a regular schedule.

ANS:3 The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patient's diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea. PTS: 1 DIF: Moderate REF: p. 259

A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first? 1)Cellular inflammation 2)Exudate formation 3)Tissue regeneration 4)Vascular response

ANS:4 Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate-formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase. PTS:1DIF:ModerateREF:p. 254

You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing? 1)Hypochondriasis 2)Somatization 3)Somatoform pain disorder 4)Malingering

ANS:4 Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically. PTS:1DIF:ModerateREF:p. 259

A patient is in crisis. After assessing the situation, what should the nurse do first? 1)Determine the imminent cause of the crisis. 2)Intervene to relieve the patient's anxiety. 3)Decide on the type of help the patient needs. 4)Ensure the safety of both the nurse and patient.

ANS:4 The first goal of crisis intervention is to assess the situation. Then ensure safety of self and patient, defuse the situation, decrease the person's anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost. PTS:1DIF:ModerateREF:p. 269

A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? 1)Precrisis 2)Impact 3)Crisis 4)Adaptive

ANS:4 When a patient begins to think rationally and problem-solve, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase. PTS: 1 DIF: Moderate REF: pp. 259-260

Which of the following structures is considered a vestigial organ

Appendix

The nurse is obtaining a bowel elimination history from her 80 year old patient. The patient states, "Sometimes when I go to the bathroom I push real hard, hold my breath, and plug my nose." Which action should the nurse take first?

Check the patient's medical history for heart disease, glaucoma, increased intracranial pressure, or a new surgical wound

The nurse is preparing a patient for an invasive diagnostic test that will provide direct visualization of the rectum, entire large intestine, and the distal small bowel. The nurse should teach and give the patient written instructions about which of the following tests?

Colonoscopy

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to his mother?

Consume a diet consisting of bananas, white rice, applesauce, and toast

A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took his medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?

Consume yogurt daily while taking the antibiotic.

When changing a diaper, the nurse observes that a 2 day old infant has passed green-black, tarry stool. What should the nurse due?

Do nothing, this is normal

What position should the patient assume before the nurse inserts an indwelling urinary catheter?

Dorsal recumbent

A bowel prep "until clear" is prescribed for a female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?

Explain that diarrhea is expected

A patient is prescribed furosemide (Lasix), a loop diuretic. For treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug

Hypokalemia

The nurse is planning care for a renal patient who is prescribed a diuretic medication. In planning care, what is the most appropriate time of day to administer this medication?

In the morning

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1)Reduces the time nurses spend charting 2)Addresses the patient's concerns holistically 3)Establishes an ongoing care plan from admission 4)Is most useful when constructing a timeline of events

NS: 1 An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient's concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

he patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1)Progress notes 2)Graphic record 3)Narrative notes 4)MAR

NS: 3 The nursing narrative note will contain documentation about the time the medication was administered and the patient's response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient's response. The physician's progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient's output.

The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?

Notify the provider about the patient's oliguria

Which action should the nurse take when beginning bladder training using scheduled voiding?

Offer the patient a bedpan every 2 hours while she is awake.

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication?

Paralytic ileus

A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis?

Renal Failure

The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication?

Skin breakdown

A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patient's healthcare record?

Stress incontinence

The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient:

Takes measures to reduce her stress level

The students nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because:

They are the leading cause of nosocomial infection

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test?

Vitamin C

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to these complaints? a) "Are you worried about failing your exams?" b) "Have you been staying up late studying?" c) "Are you using any recreational drugs?" d) "Do you have trouble managing your time?"

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

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? b) "Listing alternatives is the initial step." c) "I will list alternatives after I develop the plan." d) "I do not need to evaluate the outcome of my plan."

a) "I need to identify the problem first." Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified.

Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse? a) A graduate nurse working on a telemetry unit b) A nurse who is an editor of a nursing journal c) A nurse with one year of experience working on an oncology unit d) A nurse with 10 years of experience working as a nurse educator

a) A graduate nurse working on a telemetry unit Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care.

The client is a single mother of two children who attends college and works full time. She is seeing the college nurse due to a crying outburst in class. The first step of crisis intervention that the nurse employs is what? a) Assisting the client to identify the reason for her outburst b) Asking the client, "What would happen if you did this solution?" c) Having the client select an acceptable solution to her problem. d) Outlining several solutions to the crisis with the client

a) Assisting the client to identify the reason for her outburst Crisis intervention is a five-step problem-solving technique. The first step is to identify the problem. The other options follow problem identification.

A 78-year-old widower was recently relocated to an assisted living facility. His aunt used to live in this facility and always talked fondly about her fellow residents and the staff. However, the nurse has noticed that the client has spent most of his time in his room alone. What type of stress is the nurse most concerned about with this client? a) Environmental stress b) Psychological stress c) Physiologic stress d) Sociocultural stress

a) Environmental stress Environmental stress is common when individuals move to a new location, even if that move is voluntary. It is associated with a lack of familiarity with the sights, smells, and sounds of the location. Relocation also requires alteration in daily routine which is in itself stressful.

A nurse assesses patients in a long-term care facility for diseases that are exacerbated by stressors. What is an autoimmune disease that is related to stress? a) Grave's disease b) Hypertension c) Asthma d) Esophageal reflux

a) Grave's disease The cumulative negative effects of stress on the body can cause the exacerbation of autoimmune disorders, including Grave's disease. Asthma, hypertension, and esophageal reflux are diseases associated with stress but are not autoimmune in nature.

A nurse working on an oncology floor often sits with her clients in a calm, quiet, dimly lit environment and describes a walk along the ocean's shore. The nurse provides details of the walk and verbally paints a picture for the client. What best defines this form of stress management? a) Guided imagery b) Anticipatory guidance c) Meditation d) Biofeedback

a) Guided imagery Guided imagery involves creating a mental image based upon a verbal description offered by another individual. Biofeedback is a method of gaining mental control of the autonomic nervous system and regulating body responses. Meditation involves relaxing major muscle groups and repeating a word silently during exhalation. Anticipatory guidance focuses on physiologically preparing a person for an unfamiliar or painful event.

A withdrawn and isolated patient is most likely suffering from what type of stressors on basic human needs? a) Love and belonging needs b) Self-esteem needs c) Physiologic needs d) Safety and security needs

a) Love and belonging needs Effects of stress on basic human needs varies with each individual, but there are certain characteristics that are commonly seen with stressors on the basic human needs. Withdrawal and isolation from others is commonly seen when stressors are placed on love and belonging needs. Stressors on physiologic, safety and security, and self-esteem needs have other common characteristics.

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms? a) Moderate anxiety b) Obstructive sleep apnea c) Herniated lumbar disc d) Type 2 diabetes

a) Moderate anxiety This client may have increased anxiety from adjusting to retirement, a significant life stressor.

A school nurse is listening to a teen describe symptoms related to his schoolwork. The boy states he can't focus when studying, is unable to eat and sleep, and felt like he was going to "pass out" the other day during a geometry test. The nurse believes the teen is experiencing which disorder? a) Moderate anxiety response b) Panic attacks c) Psychological alarm reaction d) Obsessive-compulsive disorder (OCD)

a) Moderate anxiety response Inability to concentrate, nausea, insomnia, dizziness, and hyperventilation are all symptoms of moderate-level anxiety. Alarm reaction is the initial physiologic response to a stressor described in Selye's general adaptation syndrome theory. OCD is a psychiatric pathology. Panic attacks go a step further in the anxiety cascade; the client is unable to function at this level.

A nurse is caring for an older male patient in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on this patient data, what would be a priority intervention for this patient? a) Monitoring food and drink temperatures to prevent burns b) Providing adequate pain relief measures to reduce stress c) Monitoring for depression related to social isolation d) Providing meals high in carbohydrates to promote healing

a) Monitoring food and drink temperatures to prevent burns A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the ChooseMyPlate dietary guidelines.

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as: a) severe. b) mild. c) moderate. d) panic.

a) severe. Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.

A 55-year-old widow recently assumed care of her 85-year-old mother. She had to cut back on her hours at work in order to be present in the home because she is concerned about her mother's safety. She is struggling to make mortgage payments as a result. Which is an applicable NANDA-I nursing diagnosis for this situation? Select all that apply. a) Compromised Family Coping r/t change in family dynamics b) Caregiver Role Strain r/t change in family dynamics c) Anxiety r/t change in family dynamics d) Readiness for Enhanced Family Process r/t change in family dynamics

a, b There is no evidence that this family is ready to change its family process. There is also no evidence of anxiety.

A nurse is assessing a 49-year-old male patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a) Changes in appetite b) Changes in elimination patterns c) Decreased pulse and respirations d) Use of ineffective coping mechanisms e) Withdrawal f) Attention-seeking behaviors

a, b Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

Which behaviors represent effective coping mechanisms? Select all that apply. a) setting limits with family members who upset you b) learning relaxation techniques c) sleeping 14 hours a night d) taking a vacation e) denying responsibility for a DUI conviction f) sleeping 3 hours a night

a, b, d Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective.

A client asks about general adaptation syndrome (GAS). Which of the following details provided by the nurse are correct? (Select all that apply.) a) There are three stages to GAS. b) The alarm stage of GAS can last from minutes to hours. c) The resistance stage usually lasts for less than a day. d) GAS requires psychological hospitalization for treatment. e) It can be a response to physiological or psychological stress.

a, b, e There are three stages to GAS: the alarm stage, the resistance stage, and the exhaustion stage. GAS can be in response to a physiological or psychological stressor. The alarm stage is usually the shortest stage, lasting minutes to hours. Individuals progress through the resistance and exhaustion phase at different speeds depending on coping mechanisms and situations. Hospitalization is generally not required to treat GAS, but the nurse must recognize that GAS can impact all clients.

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a) Progressive muscle relaxation b) Meditation c) Anticipatory socialization d) Biofeedback e) Rhythmic breathing f) Guided imagery

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

A nurse witnesses a street robbery and is assessing a 26-year-old female patient who is the victim. The patient has minor scrapes and bruises and tells the nurse, "I've never been so scared in my life." What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a) Increased heart rate b) Decreased muscle strength c) Increased mental alertness d) Increased blood glucose levels e) Decreased cardiac output f) Decreased peristalsis

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

The nurse provides education about physiological stressors. The nurse recognizes the education to be effective when the client identifies which of the following as physiological stressors? (Select all that apply.) a) Outside temperature of 100 degrees b) Accidental death of a child c) Excessive protein in the diet d) Upper respiratory infection e) Rheumatoid arthritis

a, c, d, e A physiological stressor can include excessive temperatures, infections, illness, and imbalances in nutrition. The death of a child would be a psychological stressor.

A nurse is providing a seminar about stress. Which information should the nurse include? (Select all that apply.) a) People can have a positive or negative reaction to stress. b) One effective coping mechanism will inhibit stressors. c) Adaptation occurs to maintain balance from stress. d) Stressors are either positive or negative. e) Stress can be physical and psychological.

a, c, e Stress can be both physical and psychological. Stressors are neither positive nor negative but can cause a person to react either positively or negatively. The body seeks homeostasis by adapting to stress. Stress cannot be inhibited by one coping mechanism.

The nurse educator is preparing a teaching plan on preventing urinary tract infections for a group of female college students. What information will the nurse include in the plan?

a. Empty the bladder soon after sexual intercourse. b. Urinate when you first feel the urge to void. c. Use tampons instead of sanitary napkins while menstruating

A patient has a history of chronic constipation. Which of the following medications prescribed for the patient would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventative measures?

a. Iron b. Pain medications

Which of the following task may be delegated to a certified nursing assistant?

a. Measuring and recording intake and output b. Performing a bedside dipstick urine test c. Applying a condom catheter to a male patient

Which of the following are considered normal processes and changes in the urinary system that occur with aging in older adults? Select all that apply.

a. The number of functional nephrons decreases with age. b. The volume of urine that the bladder can hold lessens with age. c. d. Loss of bladder elasticity leads to urinary retention.

The nurse would expect which of the following signs and symptoms for a patient with a suspected urinary tract infection?

a. Urinary frequency b. Urinary urgency

The nurse is caring for a patient with suspected kidney dysfunction. In reviewing the patient's home medication list, the nurse is most altered to which medications?

a. aspirin b. gentamicin d. ibuprofen

The pediatric nurse educator is teaching a group of parents about distinguishing between food allergies and food intolerance. The nurse should teach parents that which of the following is/are true food allergens?

a. egg whites b. shellfish c. peanuts

A teen is worried that her boyfriend is under "a lot of stress" with his home life, classes, clubs, community service, and part-time work. She asks the nurse what medication he should take to "calm down." Which response would be best? a) "Isn't he passing his classes? Did you tell his parents this was happening?" b) "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives." c) "What medication is he taking now? I can recommend something, but we need to make sure there won't be an interaction with something else." d) "It sounds like he is in too many extracurricular activities. Can you convince him to drop out of some of those clubs?"

b) "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives." The most therapeutic approach would be to enlist the girl's help in getting the boy to sit down and discuss what is happening with someone trained in therapeutic communication. Decreasing the activities may help but may be unacceptable to the young man. Directing attention to his academic problems, asking the girlfriend about health issues and medications, and asking about parental involvement at this stage may damage the trust relationship the nurse has with them.

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for more teaching? a) "I must breathe in and out in rhythm." b) "I should take my pulse and expect it to be faster." c) "I can expect my muscles to feel less tense." d) "I will be more relaxed and less aware."

b) "I should take my pulse and expect it to be faster." No matter what the technique, relaxation involves rhythmic breathing, a slower pulse, reduced muscle tension, and an altered state of consciousness.

A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client? a) Exercise b) Alcohol abuse c) Cocaine use d) Projection

b) Alcohol abuse Alcohol abuse is a common altered coping pattern for individuals with poor coping skills. It is legal and easily accessible. Phrases such as "I just cannot cope" and "I need to numb the pain" are common among those who abuse alcohol.

Which statement correctly explains a person's interactions with basic human needs? a) Stress affects all people in their attainment of basic human needs in the same manner. b) As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. c) Basic human needs and responses to stress are generalized. d) Basic human needs and responses to stress are unaffected by sociocultural backgrounds, priorities, and past experiences.

b) As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. Both the attainment of basic human needs and the adaptation to stress require energy and motivate behaviors. As a person strives to meet basic human needs at each level, stress can be either a stimulus or a barrier. How basic human needs are met and responses to stress are unique to the person, depending on the individual's sociocultural background, priorities, and past experiences. In all people, the failure to meet needs results in an imbalance in homeostatic mechanisms and, eventually, illness.

When nurses become overwhelmed in their jobs and develop symptoms of anxiety and stress, they are experiencing what condition? a) Culture shock b) Burnout c) Ineffective coping d) Adaptation syndrome

b) Burnout The feeling of being overwhelmed in one's job and development of symptoms of anxiety and stress is referred to as burnout. Burnout can be compared with the exhaustion stage of anxiety and is characterized by a wide range of behaviors. Culture shock is a feeling of uneasiness or uncertainty in different and unfamiliar surroundings. The change that takes place as a result of the response to a stressor is adaptation. Ineffective coping means that a person does not deal effectively with stressors.

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario? a) Reaction formation b) Compensation c) Projection d) Sublimation

b) Compensation Compensation is overcoming a perceived weakness by emphasizing a more desirable trait or achieving in a more comfortable area. Sublimation involves a person substituting a socially acceptable goal for one whose normal channel of expression is blocked. Projection is a person's thoughts or impulses attributed to someone else. Reaction formation is the development of conscious attitudes and behavior patterns that are opposite to what he would prefer to do.

A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response? a) Defense mechanism b) Coping mechanism c) Withdrawal behavior d) Stress adaptation

b) Coping mechanism Coping mechanisms are immediate responses and are often involuntary. The heart beating rapidly and hands that are shaking are considered coping mechanisms. The change that takes place as a result of the response to a stressor is stress adaptation. Defense mechanisms protect one's self-esteem and are useful in mild to moderate anxiety; if they are used to an extreme, however, they distort reality and create problems with relationships. Withdrawal is a type of coping mechanism.

A nurse is interviewing a patient who just received news that he has pancreatic cancer. The patient tells the nurse that getting cancer could never happen to him. Which defense mechanism is this patient demonstrating? a) Projection b) Denial c) Displacement d) Repression

b) Denial Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing.

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? a) Resistance stage b) Exhaustion stage c) Secondary stage d) Alarm stage

b) Exhaustion stage

A 35-year-old woman comes to the local health center with a large mass is her right breast. She has felt the lump for about a year but was afraid come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this client? a) Chronic Confusion b) Ineffective Individual Coping c) Self-Esteem Disturbance d) Altered Family Process

b) Ineffective Individual Coping Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case the client was unable to access health care even when she was aware the disorder could be life threatening. Self-Esteem Disturbance and Altered Family Process are nursing diagnoses that are often associated with breast cancer, but her ineffective individual coping has created a significant safety risk and is therefore the most appropriate nursing diagnosis. The client's behavior was motivated by fear, not confusion.

A teenager is unable to eat breakfast and is pacing in the house 2 hours before his appointment for his driving road test. He takes the test and passes. The driving test administrator says to the teen, "You did very well. You weren't nervous at all, were you?" What level of anxiety was the teen experiencing prior to and during his road test? a) Panic b) Mild anxiety c) Moderate anxiety d) Severe anxiety

b) Mild anxiety The teenager was exhibiting symptoms of mild anxiety, which includes increased focus and alertness, leading to positive effects. Moderate, severe, and panic levels of anxiety produce negative symptoms ranging from poor concentration to inability to function.

A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in? a) Reflex pain response b) Resistance c) Alarm reaction d) Exhaustion

b) Resistance This client's situation is an example of the resistance stage of the GAS. Stress is continuing, but the client is maintaining homeostasis. Alarm is the initial stage when major stress is encountered. Exhaustion is when homeostasis can no longer be achieved. The reflex pain response is part of the local adaptation syndrome.

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention? a) Tense and relax muscle groups systematically. b) Seek assistance from family and friends. c) Perform meditation to relax. d) Keep the home environment noise free.

b) Seek assistance from family and friends. The nurse should suggest that the client seek assistance from family and friends as a crisis intervention. Adequate support during a crisis and its resolution can help clients realistically perceive the problem and reinstitute coping strategies. Performing meditation, tensing and relaxing muscle groups systematically for progressive relaxation, and keeping the home environment noise free are methods to calm and relax the client that may not necessarily help in crisis intervention.

In contrast to anxiety, fear is characterized by: a) short-term resolution. b) a cognitive response to a known threat. c) the creation of an action plan to deal with a perceived threat. d) a real, rather than perceived, threat.

b) a cognitive response to a known threat. Fear is a cognitive response to a known threat, while anxiety is the emotional response to that threat. Fear does not necessarily resolve in the short term, and an action plan may or may not be formulated by the individual. The fact that fear involves the identification of a known threat does not necessarily mean that the object of fear is objectively real.

An intensive care unit (ICU) nurse with 11 years of experience has been frequently absent or late for shifts, has been verbally abusive with coworkers she feels are unskilled at the technological tasks of the job, and cursed under her breath at a distraught family member today. The nurse manager is threatening to suspend her if it happens again. The ICU nurse may be experiencing: a) allostatic load. b) burnout. c) sleep deprivation. d) repression.

b) burnout. Burnout is the term used to describe behaviors that occur when a person is overwhelmed with the demands of a situation and is similar to the exhaustion stage of anxiety. This is commonly seen in nurses who work in high-stress environments. The individual in this scenario may have a great allostatic load and/or sleep deprivation, but there is no evidence of this in the given scenario. Repression is when a person copes by unconsciously denying the occurrence of a stressful event.

A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? a) stabilizes mood and regulates temperature b) heightens arousal and increases energy c) transmits sensation of pain d) promotes coordinated movement

b) heightens arousal and increases energy Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.

A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an): a) concern. b) stressor. c) adjustment. d) threat.

b) stressor.

The client is a 33-year-old secondary education teacher. Lately, he tells his nurse, there were several incidences of violence in the school where he teaches. What symptoms during the client history and physical examination would indicate that the client is experiencing physical manifestations of stress? Select all that apply. a) difficulty viewing objects more than 100 feet away b) an extra heart sound every fourth to sixth beat c) report of frequent evening headaches relieved by sleep d) a blood pressure of 110/68

b, c Palpitations are a common manifestation of stress. They may be auscultated during exam or detected on an EKG. Tension headaches frequently manifest in the evening and are always relieved. A headache that does not go away is an ominous sign. A blood pressure of 110/68 is normal for an adult man. Problems with distance vision are not associated with stress.

A nurse is assessing a client for anxiety. Which questions should the nurse ask to elicit subjective data related to anxiety? (Select all that apply.) a) "How often do you have sex?" b) "Has your heart felt like it was racing or skipping a beat?" c) "Have there been any changes in your appetite?" d) "Do you feel like you get angry or upset easily?" e) "Do you wake easily from sleep?"

b, c, d Anxiety can manifest in different ways. To obtain subjective data the nurse should ask about appetite, changes in heart rhythms or breathing, and anger or sadness issues. Anxiety usually causes a lack of sleep, not waking easily from sleep. Changes in sexual desire may be a reaction to anxiety, but asking how often one has sex does not gather the needed information about anxiety.

Which of the following tasks may be delegated to a CAN or NAP?

b. collecting and testing a stool sample for occult blood d. assisting with placing a fracture pan on an immobile patient

A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities? a) "I get so tired from working long hours at the site." b) "I need to get back to work here at home. That will get me back into a routine." c) "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." d) "I guess the smoke in the air brought out my mental addiction to cigarettes."

c) "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." This person is exhibiting a physiologic response to stress, while also taking up a negative coping solution to diminish the symptoms. Reliving the events that were stressful is a common complaint when under anxiety. The other statements do not demonstrate the burden of role strain.

A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because "I got mad at her and wished she would go away." Based on this information, the nurse would estimate the sister's age to be: a) 15 years b) 3 years c) 7 years d) 21 years

c) 7 years

A nurse is assessing the developmental levels of patients in a pediatric office. Which individual would a nurse document as experiencing developmental stress? a) An infant who learns to turn over b) A school-aged child who learns how to add and subtract c) An adolescent who is a "loner" d) A young adult who has a variety of friends

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

A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? a) Meditation b) Biofeedback c) Anticipatory guidance d) Guided imagery

c) Anticipatory guidance

Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique? a) Guided imagery b) Relaxation c) Anticipatory guidance d) Normalization

c) Anticipatory guidance Anticipatory guidance involves preparing a client psychologically for an event in the knowledge that familiarity reduces anxiety. Guided imagery involves the creation of mental image, not education. Relaxation focuses on the control of the body's responses to stress. Normalization is not a specific stress management technique.

A nurse is performing an assessment of a female patient who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a) Ineffective Coping related to the new parenting role b) Ineffective Denial related to ability to care for a newborn c) Anxiety related to change in role status d) Situational Low Self-Esteem related to fear of parenting

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

A nurse is working with a 67-year-old Asian American woman on diet changes to help with weight loss. She is explaining her role in the family as the one who prepares the meats for the family, while her daughter is responsible for preparing vegetables. Based on the nurse's knowledge of traditional Asian cultures, the nurse knows what to be true? a) Family is the only thing that is important. b) Older adults never change their eating patterns. c) Families operate in a collectivistic manner. d) Families operate in an individualistic manner.

c) Families operate in a collectivistic manner.

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a) Decreasing pulse b) Increasing sleepiness c) Increasing energy levels d) Decreasing respirations

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

A 15-year-old student is on the high school soccer team. She tells a nurse how she has really started to take a leadership role on the team. When the nurse talks with the client's mother, the mother tells the nurse that her daughter's best friend is a natural leader and may be voted team captain next year. The client's behavior is an example of what defense mechanism? a) Lying b) Denial c) Introjection d) Projection

c) Introjection Introjection is when an individual adapts a characteristic of someone else.

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing? a) Alarm stage b) Primary stage c) Resistance stage d) Exhaustion stage

c) Resistance stage The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress.

A client who has been working with an organization for several years did not get a promotion. As a result, the client has gone into depression. Which suggestion should the nurse make in order to help the client with his stress? a) Change the job. b) Take a break from the job. c) Seek professional help. d) Accept the changes.

c) Seek professional help. The client should seek professional help, where he can talk freely about his anger and sense of betrayal. The client should then explore other options in a calmer frame of mind. Changing jobs, compromising, or taking a break from the job will not help the client solve the problem.

A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors? a) Personal hygiene b) Economic status c) Social support d) Eating habits

c) Social support A person's response to stressors depends on social support, intensity of the stressor, number of stressors, duration of the stressor, physical health status, life experiences, coping strategies, personal beliefs, attitudes, and values. A person's response to stressors is independent of education, eating habits, economic status, or personal hygiene.

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress? a) Endocrine system b) Parasympathetic nervous system c) Sympathetic nervous system d) Respiratory system

c) Sympathetic nervous system

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which instruction would the nurse provide in this type of stress management? a) The nurse teaches patients rhythmic breathing to perform prior to the procedure. b) The nurse tells patients to focus on a pleasant place, mentally place themselves in it, and breathe slowly in and out. c) The nurse teaches patients about the pain involved in the procedure and methods to cope with it. d) The nurse teaches patients to create and focus on a mental image during the procedure to become less responsive to the pain.

c) The nurse teaches patients about the pain involved in the procedure and methods to cope with it. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, their anxiety is reduced, which occurs when teaching about the pain involved and related pain relief measures. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.

The nurse is providing care to the following clients. The nurse assesses the client exhibiting maladaptive behavior as the client who is: a) participating in a smoking cessation program after her father was diagnosed with lung cancer. b) 84 years old with multiple health problems and requesting to see an end-of-life care specialist. c) experiencing a terminal illness and states, "If I pray to God and go to church each week, I will live." d) overweight, consumes 1,600 calories/day, and exercises 30 minutes a day 5 times each week.

c) experiencing a terminal illness and states, "If I pray to God and go to church each week, I will live."

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? a) a focus of attention b) a quiet environment c) soft music d) an open attitude

c) soft music Music may be helpful for some, but is not essential for meditation.

A medical student is experiencing major life changes—the board exam, an internship, and a wedding all within 2 months of graduation. She is particularly susceptible to which conditions? Select all that apply. a) Acute narrow-angle glaucoma b) Mitral valve prolapse c) Asthma d) Bipolar depression e) Psoriasis f) Rheumatoid arthritis

c, e, f Increased stress (allostatic load) can predispose a person to illness, even if the stressor is a positive event. Psoriasis, rheumatoid arthritis, and asthma are examples of stress-related illness.

A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement? a) "It's so hard to get them into a routine after summer break. I go through this every year with all my kids." b) "We've all been talking to him about what school will be like; his brother had the same teacher and really liked her." c) "I am bringing him to the orientation so he can meet his teacher and some classmates." d) "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

d) "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

A nurse interviews a woman who was abused by her partner and is staying at a women's shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a) "Patient displays moderate anxiety related to her situation." b) "Patient manifests panic related to feelings of impending doom." c) "Patient describes severe anxiety related to her situation." d) "Patient expresses fear of her husband."

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

Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? a) Mild anxiety b) Moderate anxiety c) Severe anxiety d) A panic attack

d) A panic attack Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living, and it increases alertness and perceptual fields.

A freshman college student comes to the health clinic reporting insomnia and difficulty concentrating in class. The student has three red, scaly patches of skin on his arms and chest. The nurse believes the primary nursing diagnosis for this client is: a) Sleep Deprivation related to change in living arrangements b) Impaired Skin Integrity related to psoriasis c) Disturbed Thought Processes related to increased scholastic workload d) Anxiety related to stress of achievement in school

d) Anxiety related to stress of achievement in school This student, new to college, is demonstrating classic anxiety symptoms stemming from high stress levels. The best nursing diagnosis would be Anxiety. Sleep deprivation, impaired skin integrity, and disturbances of thought are applicable, but these diagnoses do not address the primary problem.

Aleah is a 22-year-old college student who recently engaged in sexual intercourse with a new partner. When the nurse tells her that she is pregnant, she states, "That's not possible, I got my period last week." This is an example of what defense mechanism? a) Regression b) Rationalization c) Suppression d) Denial

d) Denial Aleah is exhibiting denial by refusing to accept something as is.

A child has been admitted to the medical center with severe depression and stress, and has been avoiding going to school for these reasons. How should the nurse attempt to treat the child? a) Administer therapy that alters the child's mood and feelings. b) Administer antidepressants to counter stress. c) Teach the child the importance of being happy and unstressed. d) Find the factors that have caused stress and depression.

d) Find the factors that have caused stress and depression. The nurse in this case should try to find the factors that have caused stress and depression in the child. The nurse should calmly talk to the child and find the reason for his avoiding going to school. The child will not understand the importance of being happy and unstressed. Also, administering therapies or antidepressants is inappropriate.

A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be appropriate for these patients? a) Discouraging over-verbalization of fears and anxieties b) Focusing on the outcome as opposed to the details of the surgery c) Providing time alone for reflection on personal strengths and weaknesses d) Mutually determining expected outcomes of the plan of care

d) Mutually determining expected outcomes of the plan of care Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. Explain all procedures including sensations likely to be experienced during the procedure, and stay with the patient to promote safety and reduce fear.

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt, the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a) Arrange to have the infant removed from the home. b) Inform other members of the family of the situation. c) Increase the number of visits by the visiting nurse. d) Notify the care provider and recommend respite care for the mother.

d) Notify the care provider and recommend respite care for the mother. Reactions of family members to home health care for long periods of time, called caregiver burden, include chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker and/or arrange for respite care for the family.

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation? a) Adaptation often fails during stressful events and results in homeostasis. b) Stress is a part of our lives and eventually this young woman will adapt c) Acute anxiety and depression are seldom associated with stress. d) Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease.

d) Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. When adaptation fails, the result is disease. If a person is overwhelmed by stress that person may never adapt. Acute anxiety and depression are frequently associated with stress.

Which client would the nurse expect to have negative coping skills? a) a 37-year-old factory worker who is laid off for the summer b) a 13-year-old diabetic who joins a softball league c) a 72-year-old retiree who needs to take an expensive new chemotherapeutic agent d) a 19-year-old diagnosed with schizophrenia who is heading off to college

d) a 19-year-old diagnosed with schizophrenia who is heading off to college All of these clients will be facing stressors and need to develop adaptation skills. The client with schizophrenia, a chronic but manageable psychiatric illness, is most at risk for reacting negatively to the new life stressor. Clients with mental illness may have decreased physiologic reserve with which to effectively cope and adapt.

Many families are sheltering in the local middle school gymnasium during a severe tornado outbreak. Many homes have been destroyed and lives lost. The community health nurse expects to see negative stress reactions to the crisis, such as: a) a man enlisting others to help him look for lost pets. b) a young boy asking everyone if they need some water or food. c) an older adult couple staying near each other constantly. d) a young wife asking everyone repeatedly if they know where her husband is.

d) a young wife asking everyone repeatedly if they know where her husband is. Disasters are considered adventitious crises. Those who are affected will utilize coping skills, good or bad, to maintain homeostasis. Positive coping might involve supporting loved ones and helping others adapt. Negative coping might include denial, anger, withdrawal, and panic.

A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using: a) adaptation technique. b) withdrawal behavior. c) defense mechanism. d) coping mechanism.

d) coping mechanism.

A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using: a) defense mechanism. b) adaptation technique. c) withdrawal behavior. d) coping mechanism.

d) coping mechanism. Anxiety often is managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. Coping mechanisms are immediate responses and are often involuntary. Crying is considered a coping mechanism. The change that takes place as a result of the response to a stressor is adaptation. Withdrawal is a type of coping mechanism. Defense mechanisms protect one's self-esteem and are useful in mild to moderate anxiety; if they used to an extreme, however, they distort reality and create problems with relationships.

A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? a) transmits sensation of pain b) stabilizes mood and regulates temperature c) promotes coordinated movement d) heightens arousal and increases energy

d) heightens arousal and increases energy Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.

In evaluating the therapeutic outcome of using biofeedback to help a client work through a stressful situation, the nurse would expect the client to: a) identify support personnel and services. b) verbalize the actions and side effects of his medications. c) re-demonstrate a home care procedure properly. d) maintain vital signs within normal limits.

d) maintain vital signs within normal limits. Biofeedback is the relaxation technique that involves clients learning to use mental processes to control their physiologic responses to events. Clients can learn to alter their autonomic nervous system and control their vital signs and uncomfortable symptoms. Identifying support services, re-demonstrating procedures, and understanding medications can reduce stressful feelings, but they are not biofeedback principles.

What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter?

use a needle to withdraw urine from the catheter port

Which intervention should the nurse take fist to promote micturition in a patient who is having difficulty voiding?

utilizing the power of suggestion by turning on the faucet and letting the water run