Unit 8 Questions (COMFORT PAIN, SLEEP, MOBILITY, SAFETY, CARING INTERVENTION)

Opioids-Three primary types

1. Full agonists: Morphine, Oxycondone, Hydromorphone, Fentanyl 2. Mixed agonists-antagonists: dezocine, pentazocine hydrochloride, butorphanol tartrate, nalbuphine hydrochloride. 3. Partial agonists: buprenorphine

Physiology of Pain/Nociception

* Transduction * Transmission * Perception * Modulation * pain pathway

Roach "Human mode of being"

*All persons are caring and develop by being true to self, being real, and who they truly are. *Box 25-1 6 C's of Caring -Compassion -Competence -Confidence -Conscience -Commitment -Comportment

Ray: Theory of Bureaucratic caring

*Caring in organizations as cultures *Factors that influence the meaning of caring -Educational -Technological -Physical -Social-cultural -Economic -Political -Legal

Transmission

1. Impulses travel from peripheral nerve fibers to spinal cord - C fibers: slow transmission (dull, burning, chronic pain) - A-delta fibers (fast transmission of sharp, localized pain) 2. Transmission from spinal cord threw ascending pathways to brainstem & thalamus Opioids (stops substance P at spinal level) Capsaicin (deplete substance P) 3. Transmission between thalamus to somatic sensory cortex (perception)

21. The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the FLACC assessment as ________. (Record your answer as a whole number.)

ANS: 2

20. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lb. The nurse should administer ______ milligrams of OxyContin. (Record your answer as a whole number.)

ANS: 30 The childs weight is divided by 2.2 to obtain the weight in kilograms. Kilograms in weight are then multiplied by the prescribed 2 mg. 33 lb/2.2 = 15 kg. 15 kg x 2 mg = 30 mg.

19. Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration (Select all that apply)? a. Bran cereal b. Decrease fluid intake c. Prune juice d. Cheese e. Vegetables

ANS: A, C, E To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended.

7. When pain is assessed in an infant, it is inappropriate for the nurse to assess for: a. Facial expressions of pain. c. Crying. b. Localization of pain. d. Thrashing of extremities.

ANS: B Infants are unable to localize pain. Frowning, grimacing, and facial flinching in an infant may indicate pain. Infants often exhibit high-pitched, tense, harsh crying to express pain. Infants may exhibit thrashing of extremities in response to a painful stimulus.

8. Which myth may interfere with the treatment of pain in infants and children? a. Infants may have sleep difficulties after a painful event. b. Children and infants are more susceptible to respiratory depression from narcotics. c. Pain in children is multidimensional and subjective. d. A childs cognitive level does not influence the pain experience.

ANS: B No data are available to support the belief that infants and children are at higher risk of respiratory depression when they are given narcotic analgesics. This is a myth. It is true that infants may have sleep difficulties after a painful event. Pain in children is multidimensional and subjective. The childs cognitive level, along with emotional factors and past experiences, does influence the perception of pain.

4. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine c. Methadone b. Morphine d. Meperidine

ANS: B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief.

11. In which developmental stage is the child first able to localize pain and describe both the amount and the intensity of the pain felt? a. Toddler stage c. School-age stage b. Preschool stage d. Adolescent stage

ANS: B The preschool stage is the period when the child is first able to describe the location and intensity of pain, by stating, for example, Ear hurts bad, when feeling pain. The toddler expresses pain by guarding or touching the painful area, verbalizes words that indicate discomfort such as ouch and hurt, and demonstrates generalized restlessness when feeling pain. The school-age child describes both the location of the pain and its intensity. The adolescent also describes the location and intensity of pain.

5. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: a. 4% Liposomal Lidocaine (LMX) 15 minutes before the procedure. b. A transdermal fentanyl (Duragesic) patch immediately before the procedure. c. Eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure. d. EMLA 30 minutes before the procedure.

ANS: C EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. LMX must be applied 30 minutes before the procedure. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60 minutes in advance.

The patient receives morphine for pain. Which comment by the patient does the nurse assess to be a side effect of morphine? 1. My ears are constantly ringing. 2. My heart feels like it is skipping beats. 3. I feel like I am going to throw up. 4. I feel cold shivers all over.

Correct Answer: 3 Rationale 1: Nausea is a common side effect of morphine. Feeling cold shivers is not associated with morphine. Ringing ears are not associated with morphine. Heart palpitations are not associated with morphine.

A client needs to have soft contact lenses removed. What should the nurse do when removing the lenses? 1. Gently pinch the lens and lift it out. 2. Have the client look up. 3. Pull the lower eyelid upward. 4. Use the pad of the ring finger.

Correct Answer: 1 Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps for removing a clients soft contact lenses. Rationale 2: The nurse should have the client look straight ahead, not up. Rationale 3: The upper eyelid is pulled down gently. Rationale 4: The nurse would use the pad of the index finger, not the ring finger.

The client has a hearing aid with an earpiece that is connected by a cord to a receiver that the client keeps in a shirt pocket. The nurse would document this as which type of hearing aid? 1. Body hearing aid 2. In-the-canal aid 3. Completely-in-the-canal aid 4. Eyeglasses aid

Correct Answer: 1 Rationale 1: A body hearing aid is a pocket-sized aid that clips onto a shirt pocket. The case, containing the microphone and amplifier, is connected by a cord to the receiver, which snaps into the earpiece. Rationale 2: An in-the-canal aid is a hearing aid that fits directly into the clients ear and is barely visible. It is not connected to a receiver worn by the client. Rationale 3: A completely-in-the-canal aid is a hearing aid that fits inside the clients ear canal and is not visible. It is not connected to a receiver worn by the client. Rationale 4: An eyeglass aid has a hearing aid attached to the eyeglasses and is not connected to a receiver worn by the client.

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit.

Correct Answer: 1 Rationale 1: After testing the device and alarm sound, the nurse should place the leg band on the client with the leg in a straight horizontal position. Rationale 2: The sensor should be placed under the mattress at the buttocks area, not the shoulder area. Rationale 3: Time delays should be between 1 and 12 seconds. Rationale 4: Connecting the sensor pad to the control unit is the last step when installing the bed safety-monitoring device.

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

Rationale 1: This is not the priority for the nurse at this time. Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor. Rationale 3: This is important; however, it does not address that the client is falling. Rationale 4: This is important to do after the client has been assisted to the floor.

Transduction

Stimuli trigger release of biochemical mediators & sensitize nociceptors ■ Prostaglandins (ibuprofen, ASA) ■ Bradykinin ■ Serotonin ■ Histamine ■ Substance P (capsaicin)

Watson "Theory of Human Care" Box 25-2

*Care of the whole person and groups *Practice is both transpersonal and metaphysical -Objectivity -Subjectivity: engaged in interpersonal relationship with client *Both seek out harmony within mind, body and soul *Transpersonal contact can reach higher, spiritual sense of self or soul which can generate self- healing.

Swanson "Theory of Caring"

*Client's well-being should be enhanced through the caring of a nurse who understands the common human responses to a specific health problem. (pregnancy, miscarriage & postpartum) *Table 25-1: Caring Processes -Knowing: understanding the event & meaning -Being emotionally present -Doing for the other as you would do for yourself -Enabling: facilitating through life transitions -Maintaining belief: faith to get through an event and face a future with meaning

Boykin & Schoenhofer "Nursing as Caring"

*Developing trust and respect for clients *Feeing oneself to truly be with others *Awareness of self to authentically care for others

Leininger "Cultural Care"

*Understand differences and similarities among persons in diverse cultures -Preserving client's familiar lifeways -Making accommodations in care that are satisfying to the clients -Repatterning nursing care to help the client move toward wellness

MATCHING A patient receiving an intravenous opioid analgesic has become apneic. Match the nursing interventions with the step numbers in order from the highest priority (first intervention) to the lowest priority (last intervention). a. Place the patient on continuous pulse oximetry to assess SaO2. b. Administer the prescribed naloxone (Narcan) dose by slow IV push. c. Ensure oxygen is available. d. Prepare to calm the child as analgesia is reversed.

22. Step 1-b. 23. Step 2-a. 24. Step 3-c. 25. Step 4=d. The Narcan prescribed dose should be given first by slow IV push every 2 minutes until the effect is obtained. The second intervention should be assessment of the patients SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Finally, the child should be calmed as the analgesia is reversed.

12. Which assessment indicates to a nurse that a 2-year-old child is in need of pain medication? a. The child is lying rigidly in bed and not moving. b. The childs current vital signs are consistent with vital signs over the past 4 hours. c. The child becomes quiet when held and cuddled. d. The child has just returned from the recovery room.

ANS: A Behaviors such as crying, distressed facial expressions, certain motor responses such as lying rigidly in bed and not moving, and interrupted sleep patterns are indicative of pain in children. Current vital signs that are consistent with earlier vital signs do not indicate that the child is feeling pain. Response to comforting behaviors does not suggest that the child is feeling pain. A child who is returning from the recovery room may or may not be in pain. Most times the childs pain is under adequate control at this time. The child may be fearful or having anxiety because of the strange surroundings and having just completed surgery.

. The pediatric nurse understands that nonpharmacologic strategies for pain management: a. May reduce pain perception. b. Make pharmacologic strategies unnecessary. c. Usually take too long to implement. d. Trick children into believing they do not have pain.

ANS: A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With severe pain it is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the childs pain severity and taught to the child before the onset of the painful experience. Some of the techniques may facilitate the childs experience with mild pain, but the child will still know that discomfort is present.

10. What medication is the most effective choice for treating pain associated with sickle cell crisis in a newly admitted 5-year-old child? a. Morphine c. Ibuprofen b. Acetaminophen d. Midazolam

ANS: A Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain, including postoperative pain, post-traumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen provides only mild analgesic relief and is not appropriate for a newly admitted child with sickle cell crisis. Ibuprofen is a type of nonsteroidal antiinflammatory drug (NSAID) that is used primarily for pain associated with inflammation. It is appropriate for mild to moderate pain, but it is not adequate for this patient. Midazolam (Versed) is a short-acting drug used for conscious sedation, for preoperative sedation, and as an induction agent for general anesthesia.

6. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to: a. Administer naloxone (Narcan). b. Discontinue the IV infusion. c. Discontinue morphine until the child is fully awake. d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

ANS: A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

18. The nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for (Select all that apply)? a. Diarrhea b. Respiratory depression c. Hypertension d. Pruritus e. Sweating

ANS: B, D, E Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.

13. When assessing pain in any child, the nurse should consider that: a. Any pain assessment tool can be used to assess pain in children. b. Children as young as 1 year old use words to express pain. c. The childs behavioral, physiologic, and verbal responses are valuable when assessing pain. d. Pain assessment tools are minimally effective for communicating about pain.

ANS: C Childrens behavioral, physiologic, and verbal responses are indicative when assessing pain. The use of pain measurement tools greatly assists in communicating about pain. The childs age is important in determining the appropriate pain assessment tool to use. Developmentally appropriate assessment tools need to be used to effectively identify and determine the level of pain felt by a child. Toddlers may use words such as ouch or hurt to identify pain, but infants and young children may not have the language or cognitive abilities to express pain. Pain assessment tools when used appropriately are successful and efficient in identifying and quantifying pain with children. Behavioral and physiologic signs and symptoms in combination with pain assessment tools are most effective in diagnosing pain levels in children.

15. A nurse is gathering a history on a school-age child admitted for a migraine headache. The child states, I have been getting a migraine every 2 or 3 months for the last year. The nurse documents this as which type of pain? a. Acute c. Recurrent b. Chronic d. Subacute

ANS: C Pain that is episodic and that recurs is defined as recurrent pain. The time frame within which episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain. Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily basis, for more than 3 months. Subacute is not a term for documenting type of pain.

16. Which medications are the most effective choices for treating pain associated with inflammation in children (Select all that apply)? a. Morphine b. Acetaminophen (Tylenol) c. Ibuprofen (Advil) d. Ketorolac (Toradol) e. Aspirin

ANS: C, D Ibuprofen, naproxen/naproxen sodium, and ketorolac are all types of NSAIDs, which are used primarily for pain associated with inflammation. Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain, including postoperative pain, post-traumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen lacks the antiinflammatory effects of NSAIDs and provides only minimal antiinflammatory relief. Although aspirin is an antiinflammatory medication, because of its association with Reyes syndrome, its use is not recommended in children.

17. An appropriate tool to assess pain in a 3-year-old child is the (Select all that apply): a. Visual Analog Scale (VAS) b. Adolescent and pediatric pain tool c. Oucher tool d. Poker Chip Tool e. FACES pain rating scale

ANS: C, D, E The Oucher Tool can be used to assess pain in children 3 to 12 years of age. The Poker Chip Tool can be used to assess pain in children 4 to 12 years of age. The FACES pain rating scale can be used to assess pain for children 3 years of age and older. The VAS is indicated for use with older school-age children and adolescents. It can be used with younger school-age children, although less abstract tools are more appropriate. The adolescent and pediatric pain tool is indicated for use with children 8 to 17 years of age.

14. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain? a. FACES pain rating tool c. Oucher scale b. Numeric scale d. FLACC tool

ANS: D A behavioral pain tool should be used when the child is preverbal or does not have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many children are not able to self-report their pain accurately.

9. The nurse caring for the child in pain understands that distraction: a. Can give total pain relief to the child. b. Is effective when the child is in severe pain. c. Is the best method for pain relief. d. Must be developmentally appropriate to refocus attention.

ANS: D Distraction can be very effective in helping to control pain; however, it must be appropriate to the childs developmental level. Distraction can help control pain, but it is rarely able to provide total pain relief. Children in severe pain are not distractible. Children may use distraction to help control pain, although it is not the best method for pain relief.

2. Physiologic measurements in childrens pain assessment are: a. The best indicator of pain in children of all ages. b. Essential to determine whether a child is telling the truth about pain. c. Of most value when children also report having pain. d. Of limited value as sole indicator of pain.

ANS: D Physiologic manifestations of pain may vary considerably and may not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease or stabilize. These signs are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.

Perry-Chapter 30: Pain Assessment and Management in Children 1. Kyle, age 6 months, is brought to the clinic. His parent says, I think he hurts. He cries and rolls his head from side to side a lot. This most likely suggests which feature of pain? a. Type c. Duration b. Severity d. Location

ANS: D The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears indicate pain in the ear. The childs behavior indicates the location of the pain. The behavior does not provide information about the type, severity, or duration.

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling.

Correct Answer: 1 Rationale 1: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Rationale 2: Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Rationale 3: Always avoid overloading outlets at any time because this can cause a fire. Rationale 4: Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote.

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Allow for a toe pleat. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail.

Correct Answer: 1 Rationale 1: Allowing for a toe pleat provides for client comfort. Rationale 2: Placing the bath blanket over the client prevents unnecessary exposure. Rationale 3: Sliding the mattress to the head of the bed makes it easier to tuck in the linens. Rationale 4: Raising the side rail maintains client safety.

The patient is receiving escitalopram (Lexapro) for treatment of generalized anxiety disorder. The patient asks the nurse, I am just nervous, not depressed. Why am I taking an antidepressant medicine? What is the best response by the nurse? 1. The same brain chemicals are involved with anxiety as well as depression, and these medications are very safe. 2. You are really depressed; it is just manifested as anxiety. These medications are safer than benzodiazepines. 3. Your doctor thinks that this is the best treatment for your anxiety, and these medications are safer than benzodiazepines. 4. The two disorders go together, and if you treat depression, the anxiety goes away.

Correct Answer: 1 Rationale 1: Antidepressants are frequently used to treat symptoms of anxiety. They reduce anxiety by altering levels of norepinephrine and serotonin. These neurotransmitters are also involved in depression. Selective serotonin reuptake inhibitors (SSRIs) are safer than benzodiazepines, but depression and anxiety are two separate disorders. The patient is being treated for generalized anxiety, this is different from depression. Telling the patient that the doctor knows best is a condescending reply, and does not answer the patients question.

The parents of a 6-month-old tell the nurse that they are exhausted because their baby wakes up several times every night. What advice should the nurse give these parents? 1. Be certain that the baby is truly awake before picking him up for feeding. 2. Let the baby cry it out for a few nights until he can sleep through the night. 3. Continue to respond to the baby whenever he is restless during the night. 4. Bring the baby in for a possible sleep study to check for sleeping disorders.

Correct Answer: 1 Rationale 1: Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain the baby is awake before picking him up to feed, change, or comfort. Rationale 2: Letting the baby cry it out is not appropriate if he really needs care. Rationale 3: Continuing to respond to the baby whenever he is restless during the night is not necessary and may result in parental exhaustion. Rationale 4: There is no indication for need of a sleep study for this baby.

A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by 1. the registered nurse. 2. unlicensed assistive personnel. 3. no one, because the client cannot assume the prone position. 4. the physician.

Correct Answer: 1 Rationale 1: Because the client is on day 1 in recovery from abdominal surgery, the clients condition might not be stable enough to have unlicensed assistive personnel perform the skill. Rationale 2: Although unlicensed assistive personnel might be able to perform the skill, the clients condition might warrant that the nurse provide the back rub. Rationale 3: The client can assume a side-lying position for the back rub. Rationale 4: The nurse can provide the back rub. The physician does not need to be contacted to do this.

The nurse works with a physician who frequently prescribes benzodiazepines. The use of benzodiazepines in which patient would cause the nurse the most concern? 1. An 87-year-old patient who uses a cane for ambulation 2. A 9-year-old child with panic attacks 3. A 42-year-old businessman who travels internationally 4. A 32-year-old mother of two preschool children

Correct Answer: 1 Rationale 1: Benzodiazepines should be used with caution in elderly patients. Elderly patients are at highest risk because their metabolism and excretion is slowed; and there is a higher potential for overdose and sedation. There have been few studies of benzodiazepine use in the pediatric population; benzodiazepines must be used with caution, but these patients are not at as high risk as the elderly population. There is minimal concern with benzodiazepine use in a 32-year-old patient. There is minimal concern with benzodiazepine use in a 42-year-old patient.

The client scheduled to undergo minor surgery states, The physician will not give me pain medication after surgery because my surgery is only minor. What is the best response by the nurse? 1. You can experience pain after minor surgery, so you can have pain medication. 2. You are correct. The physician will not order any pain medication. 3. You are correct. I will need to teach you nonpharmacologic pain relief measures. 4. You can only have about half the dose because your surgery is minor.

Correct Answer: 1 Rationale 1: Clients can experience intense pain after minor surgery, so pain medication may be ordered. Rationale 2: This is not true. The client can have pain after minor surgery and can receive pain medication. Rationale 3: Nonpharmacologic pain relief measures may not be enough for the pain after surgery. Rationale 4: The nurse has no way of knowing the dose the physician will prescribe for the client.

A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. What is this nurse demonstrating? 1. Compassion 2. Competence 3. Confidence 4. Conscience

Correct Answer: 1 Rationale 1: Compassion is being aware of ones relationship to others; sharing their joys, sorrows, pain, and accomplishments; and participating in the experience of another. The nurse exemplifies this by staying until the delivery is over and the birth is accomplished. Rationale 2: Competence is having the knowledge, skills, energy, experience, and motivation to respond adequately to others, within the demands of the professional responsibilities. Rationale 3: Confidence is the quality that fosters trusting relationships. It is comfort with self, patient, and family. Rationale 4: Conscience is focused on morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility is part of conscience.

1. Go to your physician for a physical examination. 2. Go to a mental health professional for evaluation of possible depression. 3. Purchase an over-the-counter sleep aid to deepen nighttime sleep. 4. Drink more caffeinated beverages in the daytime to stay awake.

Correct Answer: 1 Rationale 1: Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances. The nurse should suggest that the client be evaluated by a physician. Rationale 2: Daytime hypersomnia is rarely caused by psychologic issues. Rationale 3: An over-the-counter sleep aid is not a good choice, as the client already sleeps well at night and sleep aids can sometimes cause future sleep disturbances. Rationale 4: Caffeinated beverages may increase daytime wakefulness, but will not help any underlying problem that may be present.

A nurse is providing bathing assistance to a young client who was seriously injured and is unable to care entirely for herself. Which action demonstrates the nurse implementing the doing for process in Swansons theory of caring? 1. Allowing the client to wash her perineal area 2. Drying the client completely 3. Seeing the client is uncomfortable with the whole bathing process 4. Touching the clients shoulder when she starts to cry

Correct Answer: 1 Rationale 1: Doing for is providing for the client as she would do for herself if it were possible. Subdimensions of this process include preserving dignity. Rationale 2: Drying the client completely, if she is able to do some herself, would not be part of doing for. Rationale 3: Sensing that the client is uncomfortable fits in the subdimension of knowing (sensing cues). Rationale 4: Touching the clients shoulder is comforting, a subdimension of being with.

A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process? 1. Transduction 2. Transmission 3. Perception 4. Modulation

Correct Answer: 1 Rationale 1: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane. Rationale 2: The transmission of pain includes three segments. During the first segment, the pain impulses travel from the peripheral nerve fibers to the spinal cord. The second segment is transmission from the spinal cord, and ascension, via spinothalamic tracts, to the brainstem and thalamus. The third segment involves transmission of signals between the thalamus to the somatic sensory cortex, where pain perception occurs. Pain control can take place during this second process of transmission. Opioids block the release of neurotransmitters, which stops the pain at the spinal level. Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows. Rationale 4: Modulation is often described as the descending system, and occurs when neurons in the thalamus and brainstem send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit the ascending painful impulses in the dorsal horn. In contrast, excitatory amino acids and the upregulation of excitatory glial cells can amplify these pain signals. The effects of excitatory amino acids and glial cells tend to persist, whereas the effects of the inhibitory neurotransmitters tend to be short-lived because they are reabsorbed into the nerves. Tricyclic antidepressants block the reuptake of norepinephrine and serotonin, and may be used to help diminish the pain signals.

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail.

Correct Answer: 1 Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the clients perception of the quality of care being provided and the nurses concern about infection control. Rationale 2: This action is done later in the procedure. Rationale 3: This action is done later in the procedure. Rationale 4: This action is done later in the procedure.

Safety Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 32 Question 1 The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation

Correct Answer: 1 Rationale 1: Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults. Rationale 2: Drowning and poisoning are seen in the toddler-age client. Rationale 3: Drowning and poisoning are seen in the toddler-age client. Rationale 4: Suffocation is a hazard in newborns and infants.

During the morning bath of a client, the nurse identifies areas of erythema below the clients breasts. What should the nurse do to enhance comfort and healing for the client? 1. Wash the skin carefully. 2. Apply alcohol-free lotion. 3. Wash the area without soap. 4. Remove hair in the area.

Correct Answer: 1 Rationale 1: For areas of erythema, the nurse should wash the area carefully to remove microorganisms. Rationale 2: Alcohol-free lotion would be applicable for excessively dry skin areas. Rationale 3: Washing without soap would be applicable for excessively dry skin areas. Rationale 4: Removing the hair would be applicable for hirsutism.

Comfort/Pain/Sleep Adams, Chapter 14 The patient tells the nurse he worries about everything all day, feels confused, restless, and just cant stop worrying. What is the best response by the nurse? 1. You have generalized anxiety; I will teach you some relaxation techniques. 2. This sounds like social anxiety. You need to calm down and youll be fine. 3. You have posttraumatic stress disorder (PTSD), and it is time for your therapy session. 4. This is called panic disorder; Ill get your medication for you.

Correct Answer: 1 Rationale 1: Generalized anxiety disorder is characterized by excessive anxiety, but not to panic levels. Other symptoms include restlessness, muscle tension, and loss of focus and ability to concentrate. Relaxation techniques are effective in reducing anxiety. Panic disorder is characterized by intense feelings of apprehension, terror, and impending doom, and increased autonomic nervous system anxiety; the patient does not have these symptoms. Posttraumatic stress disorder is situational anxiety that develops in response to re-experiencing a previous traumatic life event; there is no information that the patient has experienced a trauma. Social anxiety disorder is characterized by performance anxiety, i.e., extreme fear when a patient is in a social situation; there is no information to support that this is what the patient is experiencing. Also, telling the patient to calm down is non-therapeutic.

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

Correct Answer: 1 Rationale 1: High-topped shoes will place the clients feet in the anatomical position of dorsal flexion. Rationale 2: Turning the linens back will keep the weight of the linens off of the feet but will not prevent foot drop. Rationale 3: The prone and Sims positions are implicated in the development of foot drop. Rationale 4: A device to elevate the linens off of the feet will not prevent foot drop.

The patient has been treated by the same physician for 2 years and has had insomnia the entire time. Many different medications have been tried with limited success. What should be the nurses primary assessment at this time? 1. Assess for a primary sleep disorder such as sleep apnea. 2. Assess if the patient has been selling his medications to addicts. 3. Assess if the patient has an addictive personality disorder. 4. Assess the patient for a primary personality disorder.

Correct Answer: 1 Rationale 1: If the patient has a primary sleep disorder such as sleep apnea, this must be treated to relieve the insomnia. Also, medications such as benzodiazepines depress respiratory drive and would aggravate the sleep apnea. There is no information that the patient might have a personality disorder. If he did, the nurse would most likely recognize this after 2 years of treatment. While it is remotely possible that the patient is selling his medication; it is not likely for a patient with an anxiety disorder to do this. There is no information that the patient might have an addictive personality disorder. If he did, the nurse would know this after 2 years of treatment.

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

Correct Answer: 1 Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility. Rationale 2: There are NANDA levels of activity intolerance, but not of immobility. Rationale 3: Describing what happens when the client attempts mobility might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section. Rationale 4: Strength assessment data might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section.

The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard that taking an antacid with this medication will help decrease the incidence of upset stomach. What is the nurses best response? 1. Antacids reduce the absorption and therefore the effectiveness of the NSAID. 2. Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs. 3. Antacids should never be taken with an NSAID. 4. Antacids help to reduce the incidence of pain.

Correct Answer: 1 Rationale 1: It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication. Rationale 2: Antacids can reduce the likelihood of gastric bleeding; however, antacids will interfere with the absorption of the medication in the client. Rationale 3: This statement is not correct. Rationale 4: Antacids may reduce the pain associated with gastric distress; however, antacids are not a category of pain medication.

The nurse educator teaches students about caring nursing practice. Which situation demonstrates a nurse implementing the whole idea of caring? 1. The nurse who takes time for a favorite hobby, at least once a week 2. The nurse who volunteers at church and school events 3. The nurse who makes lists every morning so the day stays organized and planned 4. The nurse who takes care of his elderly parents as well as providing care to his immediate family

Correct Answer: 1 Rationale 1: It is imperative that nurses attend to their own needs, because caring for self is central to caring for others. Rationale 2: As nurses take on multiple commitments to family, work, school, and community, they risk exhaustion, burnout, and stress. Rationale 3: This nurse is trying to stay on top of the many tasks involved in a daily routine. Rationale 4: This nurse is caring for other people.

A clients hearing aid needs to be cleaned. What action should the nurse take to complete this task? 1. Clean with a dry, soft cloth. 2. Leave the battery in place when not in use. 3. Store the aid in the bathroom cabinet. 4. Use alcohol to remove any earwax.

Correct Answer: 1 Rationale 1: It is recommended by the manufacturers to clean the aid with a dry, soft cloth to prevent any damage to the aid. Rationale 2: The aid should be turned off and the battery removed to preserve the life of the battery. Rationale 3: The aid should be stored in a safe place where it will not get damaged. It should not be stored in the bathroom cabinet. Rationale 4: Alcohol is not recommended to be used on an aid because it could damage the aid.

The nurse is emulating the characteristics of caring, as described by Mayeroff. Which action demonstrates knowing, in relationship to caring? 1. Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments 2. Understanding the reason a clients lab values are elevated 3. Seeing the connection between the pathophysiology of the cardiac condition and treatment and giving the rationale for certain medications when the client asks 4. Getting an extra blanket when the client says he is cold

Correct Answer: 1 Rationale 1: Knowing means understanding the others needs and how to respond to those needs. Sensing that a client is withdrawn and sullen, the nurse knows that spending extra time can sometimes allow the client to feel comfortable in talking about what might be bothering him. Rationale 2: Understanding the reason for elevated lab values is an example of knowing in the didactic sense. Rationale 3: Seeing the connection between the pathophysiology and treatment of a condition is an example of knowing in the didactic sense. Rationale 4: Getting an extra blanket is responding to client needs after being told what those needs are, not sensing or understanding them.

The nurse working on an acute psychiatric unit learns that a client with bipolar disorder is being admitted and says to a coworker, We better be ready for a busy night. This nurse is exemplifying which process of Swansons theory of caring? 1. Knowing 2. Being with 3. Doing for 4. Enabling

Correct Answer: 1 Rationale 1: Knowing, according to Swanson, is striving to understand an event as it has meaning in the life of the other. A subdimension of this process is avoiding assumptions. The nurse in this situation made an assumption about clients with bipolar disorder. Rationale 2: Being with is being emotionally present to another person. Rationale 3: Doing for is providing for others as they would do for themselves if it were possible. Rationale 4: Enabling is facilitating the others passage through life transitions and unfamiliar events.

A patient taking which of the following medications should avoid foods high in tyramine? 1. MAOIs 2. SSRIs 3. Beta blockers 4. Benzodiazepines

Correct Answer: 1 Rationale 1: MAOIs and foods high in tyramine can produce a hypertensive crisis, and therefore should not be taken together.

The patient has been taking lorazepam (Ativan) for 2 years. The patient stopped this medication after a neighbor said the drug manufacturers plant was contaminated with rat droppings. What best describes the nurses assessment of the patient when seen 3 days after stopping his medication? 1. Increased heart rate, fever, and muscle cramps 2. Nothing different; it is safe to abruptly stop lorazepam (Ativan) 3. Pinpoint pupils, constipation, and urinary retention 4. A sense of calmness and lack of anxiety

Correct Answer: 1 Rationale 1: Many central nervous system (CNS) depressants can cause physical and psychological dependence. The withdrawal syndrome for some central nervous system (CNS) depressants can include fever, seizures, increased pulse, anorexia, muscle cramps, disorientation, etc. It is not safe to abruptly stop lorazepam (Ativan); withdrawal symptoms will occur. Pinpoint pupils, constipation, and urinary retention are signs of opioid use. The patient would be anxious, not calm, during benzodiazepine withdrawal.

The nurse is caring for a client who is using morphine through patient-controlled analgesia (PCA). What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

Correct Answer: 1 Rationale 1: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid. Rationale 2: Tylenol would not be helpful to have available for a client who is receiving morphine through PCA administration. Rationale 3: Benadryl would not be helpful to have available for a client who is receiving morphine through PCA administration. Rationale 4: Normal saline would not be helpful to have available for a client who is receiving morphine through PCA administration.

The patient tells the nurse that she is interested in the human brain, and questions which parts of the brain control anxiety and insomnia. What is the best reply by the nurse? 1. The limbic system and reticular activating system control anxiety and insomnia. 2. The frontal lobes and limbic system control anxiety and insomnia. 3. The thalamus and reticular activating system control anxiety and insomnia. 4. The limbic system and hypothalamus control anxiety and insomnia.

Correct Answer: 1 Rationale 1: Neural systems associated with anxiety and restlessness includes the limbic system and the reticular activating system. The reticular activating system is responsible for sleeping and wakefulness and performs an alerting function for the entire cerebral cortex. The limbic system and the reticular activating system, not the hypothalamus, are responsible for anxiety and sleep. The limbic system and the reticular activating system, not the frontal lobes, are responsible for anxiety and sleep. The limbic system and the reticular activating system, not the thalamus, are responsible for anxiety and sleep.

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

Correct Answer: 1 Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the clients central blood pressure drops when moving from supine to sitting or to standing. Rationale 2: Orthostatic hypotension is a drop in blood pressure not a drop in heart rate. Rationale 3: Paleness of the legs is not significant. Rationale 4: The blood pressure drops, the heart rate increases, and the client may complain of dizziness or may faint upon arising.

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

Correct Answer: 1 Rationale 1: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities. Rationale 2: Additional calcium in the diet after osteoporosis has begun is not thought to be effective. Rationale 3: Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity. Rationale 4: Assisted range-of-motion exercises are not weight-bearing activities and do not help delay or reverse osteoporosis.

A client experiencing pain after surgery says Something must be wrong because the pain is so severe. What is the best response for the nurse to make to the client? 1. The amount of tissue disrupted from the surgery is not related to the degree of pain you feel. 2. That could be so. 3. Taking pain medication for many years has made the medication ineffective now. 4. Are you sure the pain is as bad as you are saying it is?

Correct Answer: 1 Rationale 1: Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. The amount of tissue damaged or disrupted is not related to the amount of pain experienced. Rationale 2: This is not true. Rationale 3: This statement assumes the client was taking pain medication for years, and would be incorrect and inappropriate for the nurse to make. Rationale 4: This response is questioning the clients experience of pain, and would be incorrect and inappropriate for the nurse to make.

A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain? 1. Phantom limb pain 2. Acute pain 3. Chronic pain 4. Narcotic-induced pain

Correct Answer: 1 Rationale 1: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone. Rationale 2: Acute pain is directly related to tissue injury and resolves when tissue heals. Rationale 3: Chronic pain persists beyond 3 to 6 months secondary to chronic disorders or nerve malfunctions that produce ongoing pain after healing is complete. Rationale 4: There is no such type of pain.

Which patient would be at greatest risk for developing opioid dependence? 1. 24-year-old with sickle-cell anemia 2. 33-year-old with diabetes 3. 17-year-old with a broken arm 4. 75-year-old with congestive heart failure

Correct Answer: 1 Rationale 1: Sickle-cell anemia is a chronic and painful disorder, and is often treated with opioids. Diabetes and congestive heart failure are chronic disorders, but are not typically managed with opioids. Broken bones are painful, and opioids may be used. However, broken bones and the associated pain are acute events.

The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one clients personal hygiene? 1. A client has a newly formed ileostomy. 2. A client performs meticulous foot care. 3. A German client refuses to bathe everyday. 4. The room temperature is set at 72F.

Correct Answer: 1 Rationale 1: Some of the factors that influence ones personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change, which can greatly influence whether he will care for it or rely on others. This can pose a threat if the client chooses not to care for it. Rationale 2: Performing meticulous foot care does not pose a threat to ones hygiene. Rationale 3: Bathing every other day does not pose a threat to ones hygiene. Rationale 4: Room temperature of 72F does not pose a threat to ones hygiene.

A labor and delivery nurse wants to conduct research focused on the response of new parents toward their babies. The approach the nurse would like to use suggests that caring is a nurturing process. The nurse should review the ideas of which theorist because they are best in line with this research? 1. Swanson 2. Watson 3. Roach 4. Benner

Correct Answer: 1 Rationale 1: Swanson defines caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Rationale 2: Watson views caring as the essence and moral ideal of nursing. Rationale 3: Roach identifies caring as a philosophical concept and proposes that caring is the human mode of being. Rationale 4: Benner describes caring as the essence of excellence in nursing.

Kozier & Erbs Fundamentals of Nursing, 9/E Chapter 46 Question 1 The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant? 1. FLACC scale 2. Wong-Baker FACES 3. Visual analog scale 4. Numeric rating scale

Correct Answer: 1 Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old. Rationale 2: This pain scale would not be appropriate for a client of this age. Rationale 3: This pain scale would not be appropriate for a client of this age. Rationale 4: This pain scale would not be appropriate for a client of this age.

The client reports difficulty sleeping and awakening several times during the night. What intervention should the nurse recommend for the client when unable to sleep? 1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy. 2. Get out of bed, go into another room, and exercise until tired before trying to go back to sleep. 3. Sit in bed and watch the bedroom television until drowsy. 4. Stay in bed with eyes closed and do some mental arithmetic until sleepy.

Correct Answer: 1 Rationale 1: The bed should be used only for sleep or sexual activity, so it is associated with sleep. The client should get up, go into a different room, and pursue some relaxing activity until drowsiness returns. Rationale 2: Exercise within 2 hours of attempting to sleep may cause wakefulness. Rationale 3: Sitting in the bed while watching television will strengthen the association between wakefulness and bed. Rationale 4: Lying awake in bed will strengthen the association between wakefulness and bed.

The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful? 1. Maintain a regular bedtime and wake-up time for all days of the week. 2. If bedtime is delayed on one night, go to bed that much earlier the next night. 3. If daytime drowsiness occurs, go to bed earlier that night. 4. Sleep at least 1 hour later on mornings you dont have to go to work.

Correct Answer: 1 Rationale 1: The best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week. Rationale 2: Moving bedtime according to previous delays does not promote a sleep routine. Rationale 3: Moving bedtime according to drowsiness does not promote a sleep routine. Rationale 4: Changing awake times according to work schedules does not promote a sleep routine.

A client with diabetes asks the nurse why his blood glucose level is higher on days when he sleeps less. What should the nurse explain to the client? 1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels will remain elevated, impacting blood glucose. 2. Because the client is awake more, it is likely the client is eating more, which is impacting the blood glucose level. 3. There is no relationship between sleep and blood glucose levels. 4. The body needs cortisol for the extra energy created by the lack of sleep.

Correct Answer: 1 Rationale 1: The cortisol level falls during sleep. With waking, the cortisol level peaks. If the client with diabetes is not getting sufficient rest, the cortisol level will stay elevated, which will impact the control of blood glucose. Rationale 2: The nurse has no way of knowing what the client is ingesting that would impact blood glucose level and sleep. Rationale 3: There is a relationship between sleep and blood glucose levels. Rationale 4: The body does not use cortisol for energy.

A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety 2. Ineffective Coping 3. Deficient Knowledge 4. Hopelessness

Correct Answer: 1 Rationale 1: The diagnosis of Anxiety would be appropriate for the client, as the client has past experiences of poor pain control and is anticipating pain. Rationale 2: The diagnosis of Ineffective Coping would be applicable if the client were experiencing prolonged pain because of ineffective pain management. Rationale 3: The diagnosis of Deficient Knowledge would be applicable if the client had a lack of exposure to information regarding pain management. Rationale 4: The diagnosis of Hopelessness would be appropriate if the client were experiencing continuous pain.

An individual who has difficulty sleeping due to two final examinations scheduled for the same day later in the week most likely would be suffering from 1. situational anxiety. 2. social anxiety. 3. obsessive-compulsive disorder. 4. performance anxiety.

Correct Answer: 1 Rationale 1: The final examination is a temporary event that is the cause of the anxiety. Once the examination is over, it is likely that the situational anxiety will end. Social anxiety is a fear of crowds. Performance anxiety is frequently referred to as stage fright. Although the situation presented required the student to perform on the exam, it is best defined as situational anxiety.

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions.

Correct Answer: 1 Rationale 1: The first step is to ask if the person is choking. Rationale 2: Five back blows are reserved for an infant who is choking. Rationale 3: If he indicates he is choking, the next step would be to perform the Heimlich maneuver. Rationale 4: Chest compressions would be given if the person was unconscious; this person is not. He is clutching his throat.

The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room

Correct Answer: 1 Rationale 1: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective. Rationale 2: Scatter rugs would indicate that instruction on home safety has not been effective. Rationale 3: Cords for appliances stretching across major walkways would indicate that instruction on home safety has not been effective. Rationale 4: Inadequate lighting in major rooms of the home would indicate that instruction on home safety has not been effective.

The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash

Correct Answer: 1 Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion. Rationale 2: Shakiness is not a common side effect of NSAIDs. Rationale 3: Tremors are not a common side effect of NSAIDs. Rationale 4: A rash is not a common side effect of NSAIDs.

A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep? 1. Illness 2. Stimulant 3. Diet 4. Lifestyle

Correct Answer: 1 Rationale 1: The need to urinate during the night disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep. Rationale 2: Caffeinated beverages and alcohol are stimulants that influence sleep. Rationale 3: Body weight and the use of beverages that contain l-tryptophan are dietary influences of sleep. Rationale 4: Hours of work, activity, and exercise are lifestyle influences of sleep.

Which area of the brain is primarily responsible for maintaining sleep and wakefulness? 1. Reticular activating system 2. Cerebral cortex 3. Limbic system 4. Cerebellum

Correct Answer: 1 Rationale 1: The reticular activating system is responsible for sleeping and wakefulness. The limbic system is responsible for emotional expression, learning, and memory. The primary functions of the cerebral cortex and cerebellum do not include sleep and wakefulness.

A clients hearing aid needs to be removed. What action should the nurse perform? 1. Assist the client with removal when necessary. 2. Instruct the client to remove the aid in the sunroom. 3. Leave the aid in place when bathing. 4. Send the aid home with the family.

Correct Answer: 1 Rationale 1: The small size of hearing aids may make it difficult for older adults to manipulate, so they may need assistance in the aids removal. Rationale 2: Clients are instructed not to remove their aids in common rooms like a sunroom. Rationale 3: The removal of the aid is necessary before bathing so that it is not damaged. Rationale 4: The aid should always be stored in the clients bedside tablenot sent home with the familyso it is available for later use.

An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the clients bathing needs? 1. Obtain a shower chair and assist the client in the shower. 2. Document that the client refused a morning bath in the medical record. 3. Tell the client that shower shoes can be worn to prevent falls. 4. Hold the client during the shower.

Correct Answer: 1 Rationale 1: To provide person-centered care with bathing, the nurse should obtain a shower chair. This should eliminate the clients fear of falling when in the shower. Rationale 2: The client did not refuse a morning bath but rather explained why showers are not used. Rationale 3: Shower shoes may not be sufficient to eliminate the clients fear of falling when in the shower. Rationale 4: The nurse would not be able to hold the client during the shower.

A client is diagnosed with chronic low back pain syndrome. The nurse realizes that which analgesic delivery route might be beneficial for this client? 1. Topical 2. Rectal 3. Transmucosal 4. Transdermal

Correct Answer: 1 Rationale 1: Topical medications work directly at the point of application on the body. They are useful for painful procedures such as lumbar punctures or bone marrow biopsies, or for injections. These products can also offer effective pain relief for chronic pain syndromes such as low back pain. Rationale 2: The rectal route is useful for clients who have difficulty swallowing, or nausea and vomiting. Rationale 3: The transmucosal route is helpful for breakthrough pain because the oral mucosa is well vascularized, which facilitates rapid absorption. Rationale 4: The transdermal approach delivers a relatively stable plasma drug level, and is noninvasive. The medication, however, is systemic, which might not be what is necessary for the client with chronic low back pain syndrome.

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the clients pain was influenced by which type of distraction? 1. Visual 2. Tactile 3. Intellectual 4. Behavioral

Correct Answer: 1 Rationale 1: Visual distraction includes watching television. Rationale 2: Tactile distraction includes slow, rhythmic breathing or a massage. Rationale 3: Intellectual distraction includes crossword puzzles or engaging in hobby. Rationale 4: Behavioral is not a type of distraction.

The patient comes to the emergency department after an overdose of lorazepam (Ativan). The nurse will plan to administer which medication? 1. Pralidoxime (Protopam) 2. Naloxone (Narcan) 3. Flumazenil (Romazicon) 4. Nalmefene (Revex)

Correct Answer: 3 Rationale 1: Should an overdose of benzodiazepines occur, flumazenil (Romazicon) is a specific benzodiazepine receptor antagonist that can be administered to reverse central nervous system (CNS) depression. Naloxone (Narcan) is indicated for treatment of opiate overdose. Nalmefene (Revex) is indicated for treatment of opiate overdose. Pralidoxime (Protopam) is indicated for treatment of organophosphate poisoning.

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth.

Correct Answer: 1 Rationale 1: When implementing seizure precautions, the nurse should place oral suction equipment in the clients room because suctioning might be needed to prevent aspiration of oral secretions. Rationale 2: If the client were having difficulty swallowing liquids, oral suction already would be in the clients room. Rationale 3: Placing a piece of equipment in a clients room that is not needed is not a good utilization of resources. Rationale 4: Having oral suction equipment available for teeth brushing is not the best use of the equipment.

The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this clients sleep history? 1. No questions should be asked. 2. When do you usually go to sleep? 3. Do you have any problems with sleeping? 4. What are your bedtime rituals?

Correct Answer: 1 Rationale 1: When the client is critically ill or being admitted for an outpatient procedure, sleep history can be omitted or deferred. Rationale 2: Because the client is critically ill, the sleep assessment can be done at a later time. Rationale 3: Because the client is critically ill, the sleep assessment can be done at a later time. Rationale 4: Because the client is critically ill, the sleep assessment can be done at a later time.

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.

Correct Answer: 1 Rationale 1: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface. Rationale 2: It is easier for the client to move down a slant to the new surface than to move up to a higher surface. Rationale 3: It is easier for the client to move down a slant to the new surface than to move up to an even surface. Rationale 4: It is easier for the client to move down a slant to the new surface than to move up to a higher surface.

The client has been prescribed zolpidem (Ambien) for the short-term management of insomnia. What information should the nurse include when teaching the client about this medication? 1. For best results, take the medication just prior to bedtime. 2. Take the medication at dinnertime to avoid gastric upset. 3. Do not take the medication with any liquid that contains calcium. 4. Drink an entire glass of water with the dose to avoid kidney stones.

Correct Answer: 1 Rationale 1: Zolpidem (Ambien) has a rapid onset of action, so for best results and decreased sedation while awake, the client should take the medication just prior to bedtime. Rationale 2: The client should not take the medication at dinnertime, which is probably some hours before bedtime. Rationale 3: There is no reason to avoid calcium when taking this medication. Rationale 4: There is no need for extra water when taking this medication.

The nurse is completing the admission assessment on a client who has obstructive sleep apnea. Which findings should the nurse expect when assessing this client? Standard Text: Select all that apply. 1. Reddened uvula 2. Large soft palate 3. Obesity 4. Short neck 5. Deviated septum

Correct Answer: 1, 2, 3 Rationale 1: Clients with obstructive sleep apnea are likely to have a reddened uvula. Rationale 2: Clients with obstructive sleep apnea are likely to have an enlarged soft palate. Rationale 3: Clients with obstructive sleep apnea are likely to be obese. Rationale 4: A large, thick neck (over 17.5 inches) is more likely to be problematic than is a short neck. Rationale 5: Deviated septum is an unlikely cause of obstructive sleep apnea.

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Standard Text: Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications

Correct Answer: 1, 2, 3 Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom. Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor. Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly. Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension. Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.

The nurse is reviewing Mayeroffs philosophy of caring prior to providing care to a client. What should the nurse include to demonstrate caring to the client? 1. Honesty 2. Trust 3. Humility 4. Professionalism 5. Courtesy

Correct Answer: 1, 2, 3 Rationale 1: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Honesty includes awareness and openness to ones own feelings and a genuineness in caring for the other person. Rationale 2: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Trust involves letting go, to allow the other to grow in his or her own way and own time. Rationale 3: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 4: Professionalism and courtesy are not ingredients described by Mayeroff. Rationale 5: Professionalism and courtesy are not ingredients described by Mayeroff.

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? Standard Text: Select all that apply. 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status

Correct Answer: 1, 2, 4, 5 Rationale 1: When changing the linen of an unoccupied bed the nurse should assess the clients pulse. Rationale 2: When changing the linen of an unoccupied bed the nurse should assess the clients respirations. Rationale 3: Urine output does not need to be assessed prior to assisting a client out of the bed to change the linen. Rationale 4: When changing the linen of an unoccupied bed the nurse should assess the clients blood pressure. Rationale 5: When changing the linen of an unoccupied bed the nurse should assess the clients mobility status.

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time? Standard Text: Select all that apply. 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine)

Correct Answer: 1, 2, 3 Rationale 1: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as acetaminophen (Tylenol). Rationale 2: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as ibuprofen (Motrin). Rationale 3: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as naproxen (Naprosyn). Rationale 4: Hydrocodone (Vicodin) would be provided if the client were experiencing moderate pain. Rationale 5: Methadone (Dolophine) would be provided if the client were experiencing severe pain.

A client has not had uninterrupted sleep for several nights, and is irritable. What other assessment findings should the nurse associate with the clients lack of REM sleep? Standard Text: Select all that apply. 1. Depression 2. Confusion 3. Disorientation 4. Impaired memory 5. Muscle weakness

Correct Answer: 1, 2, 3, 4 Rationale 1: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as depression. Rationale 2: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as confusion. Rationale 3: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as disorientation. Rationale 4: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as impaired memory. Rationale 5: Muscle weakness is not associated with a loss of REM sleep.

The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? Standard Text: Select all that apply. 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety.

Correct Answer: 1, 2, 3, 4 Rationale 1: Nursing interventions to assist with pain management for an adolescent client include talking with the client about the pain. Rationale 2: Nursing interventions to assist with pain management for an adolescent client include providing privacy. Rationale 3: Nursing interventions to assist with pain management for an adolescent client include presenting choices for dealing with the pain. Rationale 4: Nursing interventions to assist with pain management for an adolescent client include encouraging distraction with music or television. Rationale 5: Allaying fears and anxiety would be a nursing intervention to assist with pain management for an adult.

The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology

Correct Answer: 1, 2, 3, 4 Rationale 1: Pain may be described in terms of duration. Rationale 2: Pain may be described in terms of location. Rationale 3: Pain may be described in terms of intensity. Rationale 4: Pain may be described in terms of etiology. Rationale 5: Pain is not described in terms of neurology.

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

Correct Answer: 1, 2, 3, 4 Rationale 1: Prior to applying the wrist restraint, the clients bony prominences should be padded. Rationale 2: The nurse should apply the padded portion of the restraint around the wrist. Rationale 3: The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Rationale 4: The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

The nurse is determining a clients risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake

Correct Answer: 1, 2, 3, 4 Rationale 1: The ability of a person to protect him- or herself from injury is dependent upon age. Rationale 2: The ability of a person to protect him- or herself from injury is dependent upon mobility. Rationale 3: The ability of a person to protect him- or herself from injury is dependent upon hearing. Rationale 4: The ability of a person to protect him- or herself from injury is dependent upon vision. Rationale 5: The ability of a person to protect him- or herself from injury is not dependent upon dietary intake.

During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this clients risk? Standard Text: Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward

Correct Answer: 1, 2, 3, 4 Rationale 1: Unscreened windows would be a safety hazard for a toddler. Rationale 2: Uncovered electrical outlets would be a safety hazard for a toddler. Rationale 3: Having a backyard pool without a fence is a safety hazard for a toddler. Rationale 4: Cleaning solution in the bottom cabinet can be easily reached by a toddler, creating a safety hazard. Rationale 5: Pots on stove with the handles turned inward is the appropriate way to maintain safety in a home with a toddler.

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

Correct Answer: 1, 2, 5 Rationale 1: Hot baths can cause venous pooling in the lower extremities. Rationale 2: Heavy meals divert blood to the gastrointestinal organs. Rationale 3: Use of a rocking chair can be good for the client, as the rocking action exercises the legs. Rationale 4: Moving in bed is not likely to cause postural hypotension. Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again.

A client tells the nurse about having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem? Standard Text: Select all that apply. 1. How often does this happen? 2. How much coffee do you drink each day? 3. How do you feel when you wake up in the morning? 4. When do you eat your evening meal? 5. What have you done to deal with this sleeping problem?

Correct Answer: 1, 2, 3, 5 Rationale 1: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How often does this happen? Rationale 2: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How much coffee do you drink each day? Rationale 3: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How do you feel when you wake up in the morning? Rationale 4: Asking when the client ingests the evening meal might not be appropriate with the client who is experiencing a sleep disturbance. Rationale 5: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include What have you done to deal with this sleeping problem?

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion? Standard Text: Select all that apply. 1. Enrolled in online classes 2. Raising two children ages 4 and 8 3. Experiences chronic pain from sciatica 4. Attends religious services every Sunday and Wednesday 5. Works one job steady night turn and another part-time late afternoon

Correct Answer: 1, 2, 3, 5 Rationale 1: The National Sleep Foundation reports that certain adults, such as students, are vulnerable for not getting enough sleep. Rationale 2: A womans sleep pattern is more commonly affected by the birth of a child. However, both parents of infants and young children experience fatigue related to interrupted sleep or sleep deprivation. Rationale 3: The National Sleep Foundation reports that certain adults, such as those experiencing chronic pain, are vulnerable for not getting enough sleep. Rationale 4: Attending religious services is not identified as contributing to vulnerability for not getting enough sleep. Rationale 5: The National Sleep Foundation reports that certain adults, such as shift workers, are vulnerable for not getting enough sleep. Adults working long hours or multiple jobs may find their sleep less refreshing.

The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? Standard Text: Select all that apply. 1. Move slowly. 2. Be flexible. 3. Help the client feel in control. 4. Avoid stopping once the bath is started. 5. Be prepared.

Correct Answer: 1, 2, 3, 5 Rationale 1: When bathing a client with dementia, the nurse should move slowly. Rationale 2: When bathing a client with dementia, the nurse should be flexible to adapt the approach to meet the needs of the client. Rationale 3: When bathing a client with dementia, the nurse should offer the client choices in order for the client to feel in control. Rationale 4: When bathing a client with dementia, the nurse should stop if the client begins to feel distressed. Rationale 5: When bathing a client with dementia, the nurse should be prepared with all items prior to starting the bath.

The nurse is identifying strategies to support a clients empowerment. What strategies should the nurse use? Standard Text: Select all that apply. 1. Making it possible for the client diagnosed with mild Alzheimers disease to continue to dance regularly, as it has always been a passion of hers 2. Being sure to polish the clients nails now that she is not able to do it herself, as it has always been important to her that she have pretty hands 3. Suggesting to a clients family members that they should insist that the client move into an assisted living facility so as to ensure her safety 4. Helping the clients family identify community support services that will make it possible for the client to remain in her own home 5. Encouraging the client to use a walker and stay indoors, just in case she might fall

Correct Answer: 1, 2, 4 Rationale 1: This nursing intervention supports and thus empowers the client to continue expressing herself and experiencing life in spite of a chronic disease. Rationale 2: This nursing intervention supports and thus empowers the client by helping her to maintain her self-esteem and pride in her appearance. Rationale 3: This nursing intervention might be premature, and so might deny the client the independence and autonomy she is due. Rationale 4: This nursing intervention supports and thus empowers the client by helping her to maintain her autonomy and independence longer. Rationale 5: This nursing intervention might be premature, and so might deny the client the independence and autonomy she is due.

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision? Standard Text: Select all that apply. 1. Is wide awake around 3 am 2. Takes a nap after lunch every day 3. Returns to sleep after using the bathroom 4. Goes to sleep before 9 pm most evenings 5. Wakes up and looks at the clock every hour

Correct Answer: 1, 2, 4, 5 Rationale 1: A hallmark change with age is a tendency toward earlier wake times. Rationale 2: Many older adults report daytime napping, which may contribute to reduced nocturnal sleep. Rationale 3: Older adults have difficulty falling back to sleep after awakening. Rationale 4: A hallmark change with age is a tendency toward earlier bedtime. Rationale 5: Older adults may awaken an average of six times during the night.

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions? Standard Text: Select all that apply. 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements

Correct Answer: 1, 2, 4, 5 Rationale 1: Massage is a nonpharmacologic intervention that targets the body for pain control. Rationale 2: Acupressure is a nonpharmacologic intervention that targets the body for pain control. Rationale 3: Self-hypnosis is a nonpharmacologic intervention that targets the mind for pain control. Rationale 4: Exercise is a nonpharmacologic intervention that targets the body for pain control. Rationale 5: Nutritional supplements are a nonpharmacologic intervention that target the body for pain control.

A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client? Standard Text: Select all that apply. 1. Nortriptyline 2. Amitriptyline 3. Tramadol 4. Meloxicam 5. Gabapentin

Correct Answer: 1, 2, 5 Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 2: Amitriptyline a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 3: Tramadol is an opioid analgesic used for moderate pain. Rationale 4: Meloxicam is a nonopioid analgesic used for mild pain. Rationale 5: Gabapentin is an anticonvulsant used as a coanalgesic to treat pain.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

Correct Answer: 1, 2, 5 Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Rationale 2: Using two personnel will allow a lift and move rather than pulling or sliding the client over linens. Rationale 3: The personnel should stand on either side of the bed and use the turn sheet to move the client. Rationale 4: Sliding the client causes friction. The client should be moved using the turn sheet. Rationale 5: Encouraging the client to assist as much as possible will lighten the workload.

The new graduate nurse has committed to improving self-care activities. Which behaviors exemplify that the nurse is following through on this personal commitment? Standard Text: Select all that apply. 1. Using meditation to de-stress at the end of a long day at work 2. Eating a low fat-diet, as there is a family history of heart disease 3. Attending workshops designed to enhance professional skills at least twice yearly 4. Volunteering to cover a friends weekend shifts so the friend can fully recover from a sprained ankle 5. Making sure to reserve the time to read a favorite book between 12 hours of shift work

Correct Answer: 1, 2, 5 Rationale 1: Self-care is described as helping oneself grow and actualize ones possibilities. Managing stress in a healthy manner is certainly a positive behavior directed at self-care. Rationale 2: Self-care is described as helping oneself grow and actualize ones possibilities. Eating a low-fat diet, especially when one has an increased risk for heart disease, is certainly a positive behavior directed at self-care. Rationale 3: Although self-care is described as helping oneself grow and actualize ones possibilities, this action is more related to ones professional, not personal, life. Rationale 4: Although this action reflects caring, it is directed at another rather than toward the self. Rationale 5: Self-care is described as helping oneself grow and actualize ones possibilities. Engaging in enjoyable activities in a healthy manner is certainly a positive behavior directed at self-care.

The nurse is preparing to remove ticks from a clients scalp. Which actions should the nurse perform to safely remove these pathogens from the client? Standard Text: Select all that apply. 1. Grasp the tick with blunt tweezers. 2. Apply heat to the tick with a match. 3. Wash the area with antibacterial soap. 4. Pull the tick away in a perpendicular movement. 5. Apply petroleum jelly to the surface of the tick.

Correct Answer: 1, 3, 4 Rationale 1: To remove a tick, grasp the tick as close to the skin as possible with blunt tweezers. Rationale 2: Applying heat to the tick with a match is a dangerous practice and should not be done. Rationale 3: After the tick is removed, wash the area with antibacterial soap. Rationale 4: Gently pull the tick away using a perpendicular motion. Rationale 5: Applying petroleum jelly to the surface of the tick is an ineffective approach to remove a tick.

The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? Standard Text: Select all that apply. 1. Skin status 2. Financial status 3. Psychosocial needs 4. Learning needs 5. Physical conditions

Correct Answer: 1, 3, 4, 5 Rationale 1: Assessment of the skin can be done during the morning bath. Rationale 2: The clients financial status is an area not usually assessed during the morning bath. Rationale 3: The clients psychosocial needs can be assessed during the morning bath. Rationale 4: The clients learning needs regarding hygienic care can be assessed during the morning bath. Rationale 5: Assessing the clients physical conditions can be done during the morning bath.

The health care provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client? Standard Text: Select all that apply. 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid)

Correct Answer: 1, 3, 4, 5 Rationale 1: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 2: Hydrocodone (Vicodin) is an opioid analgesic for moderate pain. Considering that the client rates pain as being severe, this medication would not sufficiently control the clients pain. Rationale 3: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 4: Morphine sulfate (morphine) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 5: Hydromorphone hydrochloride (Dilaudid) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate.

The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications

Correct Answer: 1, 3, 4, 5 Rationale 1: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include lifting. Rationale 2: Inadequate lighting would be a safety issue in a home or community neighborhood. Rationale 3: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include bending and walking. Rationale 4: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to infectious agents. Rationale 5: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to hazardous compounds.

Which statement is accurate concerning the use of aspirin (ASA) to treat pain? 1. High doses are necessary (1 gram) to achieve anticoagulant effects. 2. Enteric-coated capsules are available to reduce GI side effects. 3. Increase consumption of herbs such as garlic and ginger to potentiate the anti-inflammatory effects. 4. In low doses (325 mg), it significantly reduces inflammation.

Correct Answer: 2 Rationale 1: Aspirin can cause bleeding in low doses. Enteric-coated capsules can help prevent bleeding, and avoiding certain herbs such as ginger and garlic should be advised. The anti-inflammatory effects of aspirin occur in high doses.

The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether Standard Text: Select all that apply. 1. unlicensed assistive personnel know how to perform a back rub. 2. there any clients who have intravenous fluids infusing. 3. there any clients who should not have a back rub performed. 4. there any clients who are prescribed to take nothing by mouth. 5. there any clients who do not want a back rub done by unlicensed assistive personnel.

Correct Answer: 1, 3, 5 Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for the UAPs comfort and ability. Rationale 2: An intravenous infusion is not a contraindication for a back rub. Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications. Rationale 4: Being prescribed nothing by mouth is not a contraindication for a back rub. Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate.

The patient is to start on sumatriptan (Imitrex) for migraine headaches. What will the best plan of the nurse include as it relates to this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Plan to teach the patient not to drive until the effects of the medication are known. 2. Plan to teach the patient to avoid pseudoephedrine (Sudafed) with this medication. 3. Plan to teach the patient the importance of taking the medication with protein. 4. Plan to instruct the patient to take the medication with food to avoid ulcers. 5. Plan to teach the patient to increase fluid intake with this medication.

Correct Answer: 1,2 Rationale 1: Drowsiness and dizziness can occur with sumatriptan (Imitrex). Pseudoephedrine (Sudafed) is a vasoconstrictor as is sumatriptan (Imitrex). The combination could dramatically increase the patients blood pressure. There isnt any relationship between sumatriptan (Imitrex) and ulcers. Sumatriptan (Imitrex) does not need to be taken with protein. There is no need to increase fluid intake with sumatriptan (Imitrex).

The patient has been keeping a headache diary of her migraines. Upon review of this diary, the nurse notes that the headaches are described as mild and have happened four times in the last 3 months. The patient reports that she generally just lies down until they pass but that her new job will not allow that time. She is requesting information about pain medication. What medications would the nurse expect to be prescribed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ibuprofen 2. Acetaminophen and caffeine 3. Sumatriptan (Imitrex) 4. Ergotamine (Ergostat) 5. Amitriptyline (Elavil)

Correct Answer: 1,2 Rationale 1: NSAIDs are often effective for the mild migraines this patient experiences. Rationale 2: Acetaminophen and caffeine together are used for treatment of mild migraines. Rationale 3: Sumatriptan is a serotonin receptor agonist and is usually used only for moderate to severe migraines. Rationale 4: Ergotamine is an ergot alkaloid that is a serotonin receptor agonist. This drug is used only with moderate to severe migraines. Rationale 5: Amitriptyline is used to prevent migraines, not to reduce pain once they occur.

A patient whose spouse recently died is having difficulty falling asleep and does not want to take any prescription medications to induce sleep. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Walking 2-3 miles or engaging in some other exercise every morning can enhance sleep. 2. There are alternative methods to treat insomnia, such as yoga, meditation, and massage therapy. 3. Eating a large meal at bedtime will help induce sleep. 4. Avoid caffeinated beverages, nicotine, and alcohol immediately prior to bedtime. 5. Count sheep after lying down in order to enhance sleep.

Correct Answer: 1,2,4 Rationale 1: Exercise therapy (except just prior to sleeping), nutrition therapy, and deep breathing are alternative treatments for insomnia. Rationale 2: Acupuncture, aromatherapy, yoga, prayer, massage, meditation, biofeedback therapy, hypnosis, guided imagery, and music therapy are alternative treatments for anxiety and insomnia. Rationale 3: Eating a large meal prior to bedtime is a secondary cause of insomnia. Rationale 4: Amphetamines, cocaine, caffeinated beverages, corticosteroids, sympathomimetics, antidepressants, alcohol use, nicotine, and tobacco use are secondary causes of insomnia. Rationale 5: There is no evidence that counting sheep at bedtime helps to induce sleep.

The home hospice nurse is completing the initial assessment of a patient who is has terminal congestive heart failure. The patient frequently has pain with breathing. What questions should the nurse ask? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. How much pain are you willing to tolerate? 2. What do you like to do throughout the day? 3. Have you ever been addicted to a pain medication? 4. Are there any pain medications you would like to avoid? 5. What things besides drugs help with your pain?

Correct Answer: 1,2,4,5 Rationale 1: It is sometimes impossible to eliminate all pain and all adverse medication effects. The nurse needs to know how much pain and how many of the effects the patient is willing to tolerate. Rationale 2: Knowing what the patient likes to do and when it is important for the patient to be most awake and alert helps the nurse create a pain management plan. Rationale 3: Addiction is not a concern at the end of life. Many patients are already concerned about becoming addicted and the nurse should not reinforce this myth. Rationale 4: Some patients cannot tolerate the side effects of some medications. It is important for the nurse to assess for these preferences. Rationale 5: Nonpharmacologic pain relief strategies should also be investigated.

The patient receives aspirin. The nurse assesses an adverse effect to this drug when the patient makes which response? 1. My stools have been gray in color. 2. There is a constant ringing in my ears. 3. Bright lights give me a headache. 4. I have to get up a lot at night to urinate.

Correct Answer: 2 Rationale 1: Aspirin is ototoxic, and may cause ringing in the ears. Aspirin does not cause photophobia. A decrease in bilirubin (gray stools) is not caused by aspirin. There isnt any relationship between aspirin and nocturnal renal output.

The patient has been started on morphine sulfate (MS Contin) for chronic back pain resulting from inoperable disk degeneration. What nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Use the prn order of docusate (Dulcolax) routinely every night. 2. Ask the dietary department to add bran cereal to the patients breakfast trays. 3. Ask the health care provider to write an order for an indwelling urinary catheter. 4. Review the trending of the patients hemoglobin and hematocrit levels. 5. Check the medical record for a prn order for an antiemetic.

Correct Answer: 1,2,4,5 Rationale 1: One of the adverse effects of morphine therapy is constipation. The nurse should be proactive by giving the docusate every night. Rationale 2: Intake of additional fiber, as long as sufficient fluid is taken, is useful in preventing the constipation that is common with the use of morphine. Rationale 3: While morphine may promote urinary retention, other methods of controlling this adverse effect should be used initially. Rationale 4: Morphine should not be administered to those who are hypovolemic due to the risk of hypotension. Rationale 5: Nausea and vomiting are adverse effects of the use of morphine. Until the patient becomes tolerant of this effect, an antiemetic may be necessary.

The patient is diagnosed with post-traumatic stress disorder. What will the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Tachycardia 2. Extreme nervousness or panic attacks 3. A fear of crowds 4. A fear of exposure to germs 5. Hallucinations, nightmares, or flashbacks

Correct Answer: 1,2,5 Rationale 1: Tachycardia is a symptom of post-traumatic stress disorder. Rationale 2: Extreme nervousness or panic attacks are symptoms of post-traumatic stress disorder. Rationale 3: A fear of crowds is typical in social anxiety disorder. Rationale 4: A fear of exposure to germs is typical of obsessive-compulsive disorder. Rationale 5: In post-traumatic stress disorder the person re-experiences traumatic events, which can take the form of nightmares, hallucinations, or flashbacks.

It is important for the nurse to obtain a thorough history from a patient who is experiencing anxiety. This history will help to distinguish Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. the best method of pharmacotherapy. 2. whether the patient might benefit from individual or group therapy. 3. the category of anxiety disorder. 4. the region of the brain that is causing the anxiety disorder. 5. substances that might worsen anxiety.

Correct Answer: 1,2,5 Rationale 1: The health care provider must accurately diagnose the anxiety disorder, because treatment differs among the various types of anxiety disorders. Some anxiety disorders are debilitating and require effective pharmacotherapy. Rationale 2: Some patients benefit from individual or group psychotherapy, which can help them identify and overcome the root causes of their worry and fear. Rationale 3: A thorough health history is not used to determine the category of anxiety disorder. Rationale 4: A thorough health history is not used to determine the region of the brain that is causing the anxiety disorder. Rationale 5: When obtaining a comprehensive medication history during the initial patient assessment, the nurse should observe any substances the patient is taking that might worsen or cause anxiety symptoms. Sometimes discontinuing or substituting an alternate drug for these anxiety-promoting medications can lessen patient symptoms.

The patient tells the nurse, I am really confused after talking to my doctor. He said I would be taking different kinds of medications for my anxiety and insomnia. Will you please explain it? What is the best response by the nurse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. You will be taking medications known as sedative-hypnotics. 2. You will be taking medications known as antidepressants. 3. You will be taking a medication known as paraldehyde. 4. You will be taking medications known as barbiturates. 5. You will be taking medications known as benzodiazepines.

Correct Answer: 1,2,5 Rationale 1: The three categories of medications used to treat anxiety and sleep disorders include the benzodiazepines, antidepressants, and sedative-hypnotics. Barbiturates are no longer used for anxiety or insomnia because of significant side effects and the availability of more effective medications. Paraldehyde is no longer used for anxiety or insomnia because of significant side effects and the availability of more effective medications.

Adams Chapter 18 The nurse teaches patients about nonpharmacological techniques for pain management. The nurse determines learning has occurred when the patients make which statement(s)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Nonpharmacological techniques are a good adjunct to pharmacotherapy. 2. Nonpharmacological techniques have not reached mainstream yet. 3. Nonpharmacological techniques may be used in place of drugs. 4. Nonpharmacological techniques include an aerobic exercise. 5. Nonpharmacological techniques are not usually valued by nurses.

Correct Answer: 1,3 Rationale 1: Nonpharmacological techniques may be used in place of drugs, or as an adjunct to pharmacotherapy. An aerobic exercise is not considered a nonpharmacological technique for relief of pain. Nonpharmacological techniques have reached mainstream and are commonly used. Nonpharmacological techniques are valued and used by most nurses.

The nurse has completed group education for patients with anxiety disorders. The education is evaluated as successful when the patients make which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Relaxation techniques will often decrease anxiety. 2. Antianxiety medicine should be used until our anxiety is gone. 3. Antianxiety medicine should not be used indefinitely. 4. We need therapy to learn where this anxiety comes from. 5. We need different medicines for anxiety, and for difficulty in sleeping.

Correct Answer: 1,3,4 Rationale 1: Patients with anxiety disorders should be encouraged to uncover the cause of the anxiety through cognitive-behavioral therapy or other counseling techniques. Nonpharmacological techniques such as relaxation techniques are effective in reducing some levels of anxiety. For most patients, anti-anxiety medication is intended for short-term use. Absence of anxiety is an unrealistic goal because all individuals will have some level of anxiety during their lifetime. Often, the same medication can be used for anxiety as well as insomnia.

The patient rings the nurse call button and requests pain medication. Upon assessment, the nurse finds the patient sitting up in a chair, watching television with a friend. Vital signs are normal and the patients skin is warm and dry. Which nursing actions are appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ask the patient to rate his pain on the pain scale. 2. Tell the patient that he does not look as if he is in pain. 3. Have the patient go back to bed and ask the visitor to leave. 4. Check to see when the patient last received pain medication. 5. Have another nurse assess the patient.

Correct Answer: 1,4 Rationale 1: When the patient complains of pain, the nurse should always ask for a pain rating. Rationale 2: Patients respond to pain differently. For example, this patient may be trying to hide the intensity of his pain from his friend. Rationale 3: Having the patient go back to bed and asking the visitor to leave is punitive and could be interpreted as the nurse not believing the patient. Being active and having diversions can help with pain management. Rationale 4: The nurse should check to see when the patient last had pain medication, what drug was given, what dose was given, and by what route it was administered. Rationale 5: There is no reason to have another nurse assess the patient. This action may imply that the nurse does not trust the patient.

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once.

Correct Answer: 2 Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, at naptime or bedtime, if the child is still crawling out of the crib. Rationale 2: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib. Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib.

Identify the correct statement regarding the neural mechanism of pain 1. Once the pain impulse reaches the spinal cord, neurotransmitters inhibit the signal. 2. Alpha fibers are wrapped in myelin; C fibers are not. 3. When tissues are damaged, pain impulses go directly to the brain via alpha and beta fibers. 4. Myelin is a substance that slows nerve transmission.

Correct Answer: 2 Rationale 1: A pain impulse travels to the spinal cord via alpha and C fibers. The alpha fibers are wrapped in myelin (a lipid substance that speeds nerve transmission); the C fibers are not. Once the impulse reaches the spinal cord, neurotransmitters pass the message along to the next neuron.

A client with a skin rash is prescribed a bath in which medication is added to the bath water. The nurse should plan for the client to receive which type of bath? 1. Shower 2. Tub 3. Partial 4. Complete

Correct Answer: 2 Rationale 1: A shower would not permit the medication to be in contact with the clients skin long enough. Rationale 2: Therapeutic baths are given for physical effects, such as to soothe irritated skin or to treat an area. Medications may be placed in the water. A therapeutic bath is generally taken in a tub one-third or one-half full. The client remains in the bath for a designated time, often 20 to 30 minutes. If the clients back, chest, and arms are to be treated, these areas need to be immersed in the solution. Rationale 3: A partial bath would not permit the medication to be in contact with the clients skin long enough. Rationale 4: A complete bath would not permit the medication to be in contact with the clients skin long enough.

The nurse working with students on a medical unit describes the pathophysiology of a client with a respiratory acidosis condition as well as specific assessment findings. Which type of knowledge is the nurse demonstrating? 1. Aesthetic 2. Empirical 3. Personal 4. Creative

Correct Answer: 2 Rationale 1: Aesthetic knowledge is the art of nursing and is expressed by nurses in their creativity and style in meeting the needs of clients. Rationale 2: Empirical knowing ranges from factual, observable phenomena to theoretical analysis. Empirical knowledge is systematic and helps to describe, explain, and predict phenomena. Rationale 3: Personal knowledge is concerned with the knowing, encountering, and actualizing of the concrete, individual self. Rationale 4: Creativity is part of aesthetic knowledge.

A student asks the nursing instructor which types of knowledge are important in the clinical area. How should the instructor respond to the student? 1. Empirical knowledgeyou have to know the physiology of the problem before you decide which interventions to use. 2. A good nurse will have a mix of all four types of knowledge. 3. Ethical knowledgenurses must be able to identify principles and norms, handle conflicts, and be sensitive to sensitive issues. 4. Aesthetic knowledgea nurse must appreciate the special qualities of each client and the individual situation.

Correct Answer: 2 Rationale 1: All options are true, but a nurse must possess all four types of knowledge. Rationale 2: The nurse who practices effectively is able to integrate all types of knowledge to understand situations more holistically. Rationale 3: All options are true, but a nurse must possess all four types of knowledge. Rationale 4: All options are true, but a nurse must possess all four types of knowledge.

Which of the following common adverse effects of selective serotonin reuptake inhibitors (SSRIs) would be stressed by the nurse during patient discharge? 1. Drowsiness and coma 2. Weight gain and sexual dysfunction 3. Headache and nausea 4. Dry mouth and urine retention

Correct Answer: 2 Rationale 1: Although anticholinergic effects such as dry mouth and urine retention could occur, they are not as common as weight gain or sexual dysfunction. Headache is not a common adverse effect, and neither is drowsiness or coma. Overdoses will cause anxiety and restlessness (not drowsiness).

The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication? 1. Take an antihistamine three times per day. 2. Drink 6 to 8 glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication.

Correct Answer: 2 Rationale 1: Antihistamines do not prevent constipation. Rationale 2: Increasing fluid intake can help prevent constipation. Rationale 3: Assessing respiratory rate will not help prevent constipation. Rationale 4: Assessing heart rate will not impact the development of constipation.

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses station. 2. Place a rocking chair in the clients room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed.

Correct Answer: 2 Rationale 1: Assigning the client to the farthest room from the nurses station would be an unsafe move for the client; closer would be safer than farther. Rationale 2: Placing a rocking chair in the clients room will help her to expend some of her energy so that she will be less inclined to walk and wander. Rationale 3: Pulling up all of the side rails is a restraint, so that action would not be an alternative. Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed.

Benzodiazepines are often the drug of choice for managing anxiety and insomnia. Which statement best explains why? 1. Benzodiazepines are the most effective. 2. Benzodiazepines have the lowest risk of dependency and tolerance. 3. Benzodiazepines are most likely to be covered under insurance premiums. 4. Benzodiazepines are the most affordable.

Correct Answer: 2 Rationale 1: Benzodiazepines have a lower risk of dependency and tolerance than do other drugs used for anxiety and insomnia (such as the barbiturates). They are not necessarily more effective, affordable, or likely to be covered under insurance premiums. Although economics is an important factor in pharmacology, drug safety is essential for widespread use.

The nurse has completed medication education for the anxious patient who is receiving buspirone (BuSpar). The nurse determines that the patient needs additional instruction when the patient makes which statement? 1. Side effects I might experience include dizziness, headache, and drowsiness. 2. I can take this medication when I feel anxious and it will relax me. 3. I have to take this medicine on a regular basis for it to help me. 4. I dont need to worry about becoming dependent on this medication.

Correct Answer: 2 Rationale 1: Buspirone (BuSpar) works by altering levels of neurotransmitters and takes a few weeks to achieve optimal anxiety reduction. It cannot be used as an as needed (prn) medication. Side effects of buspirone (BuSpar) include dizziness, headache, and drowsiness. Dependence and withdrawal are less of a concern with buspirone (BuSpar) than with some other antianxiety drugs. Buspirone (BuSpar) works by altering levels of neurotransmitters and takes a few weeks to achieve optimal anxiety reduction. The drug must be taken consistently for this to occur.

The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent? 1. Provide hot chocolate prior to bedtime. 2. Limit or eliminate television. 3. Engage in a physical activity before bedtime. 4. Play a computer game before bedtime.

Correct Answer: 2 Rationale 1: Chocolate is a stimulant, and could reduce the childs ability to fall asleep. Rationale 2: Preschool children wake up frequently at night, and they might be afraid of the dark or experience night terrors or nightmares. Often, limiting or eliminating TV will reduce the number of nightmares. Rationale 3: Physical activity is a stimulant, and could reduce the childs ability to fall asleep. Rationale 4: Playing a computer game is a stimulant, and could reduce the childs ability to fall asleep or cause an increase in nightmares.

The nurse is preparing to provide a client with mouth care. What should the nurse do to ensure safe handling of the clients dentures? 1. Clean biting surfaces. 2. Place a washcloth in the bowl of the sink. 3. Replace the upper dentures first. 4. Rinse dentures thoroughly with hot water.

Correct Answer: 2 Rationale 1: Cleansing biting surfaces prevents bacteria, odor, and stain formation. Rationale 2: Placing a washcloth in the bowl of the sink serves as a cushion for the dentures if accidentally dropped. Rationale 3: Replacing the upper dentures first promotes comfort. Rationale 4: Dentures should be rinsed thoroughly with tepid water, not hot water, because extreme temperatures will harm dentures.

The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation

Correct Answer: 2 Rationale 1: Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient. Rationale 2: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Rationale 3: Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity. Rationale 4: Risk for Suffocation is inadequate air available for inhalation.

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques.

Correct Answer: 2 Rationale 1: Explaining procedures would not be appropriate with this client. Rationale 2: Alzheimers disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed. Rationale 3: Orienting to surroundings would not be appropriate with this client. Rationale 4: Using relaxation techniques would not be appropriate with this client.

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

Correct Answer: 2 Rationale 1: Flatness is the normal percussion sound over the liver. Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort. Rationale 3: The nurse should not medicate the client until assessment is complete. Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain.

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this clients problem? 1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours.

Correct Answer: 2 Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals. Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas. Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated. Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.

A connection on a clients intravenous solution was dislodged and solution saturated the clients gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early morning care 4. Morning care

Correct Answer: 2 Rationale 1: Hour-of-sleep care includes providing for elimination needs, washing the face and hands, oral care, and a back massage. Rationale 2: As-needed care is provided as required by the client. Because the intravenous solution has saturated the gown and bed linens, this is the type of care the client needs at this time. Rationale 3: Early morning care is provided to clients as they awaken in the morning and consists of aiding to void, washing the face and hands, and providing oral care. Rationale 4: Morning care is usually after breakfast and includes providing for elimination needs, a bath or shower, perineal care, back massage, and oral, nail, and hair care.

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client? 1. Apply ice to the knee over the cast. 2. Rub the knee of the non-casted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity.

Correct Answer: 2 Rationale 1: Ice will not penetrate the cast. Rationale 2: The nurse can use contralateral stimulation, which is accomplished by stimulating the skin in an area opposite to the painful area, such as stimulating the left knee if the pain is in the right knee. The nurse should explain the rationale to the client in that nerves are crossed in the spinal cord, and that is why this technique works contralaterally. Rationale 3: Heat will not penetrate the cast. Rationale 4: Rubbing the foot might not be effective to reduce pain in the knee.

A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client? 1. Ask the physician to change the prescribed pain medication. 2. Reassess the pain and consider another pain relief measure. 3. Limit interaction with the client. 4. Stop using alternative pain relief measures, if not effective.

Correct Answer: 2 Rationale 1: If a pain relief measure is ineffective, encourage the client to try it again before abandoning it. Medications might need repeated doses to saturate plasma proteins before sufficient free drug is available to work on the intended target. Rationale 2: Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. In these circumstances, reassess the pain and consider other relief measures. Rationale 3: The nurse should not ignore the client. Rationale 4: Many nonpharmacologic measures require practice before they are effective.

The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which intervention should the nurse include in this plan of care? 1. Encourage the client to take an over-the-counter medication to improve nighttime sleep. 2. Be certain the client has the prescription for modafinil (Provigil) filled. 3. Have the client purchase sodium oxybate (Xyrem) over the counter to prevent daytime drowsiness. 4. Be certain the client obtains antihistamines to control nasal stuffiness.

Correct Answer: 2 Rationale 1: In narcolepsy, nighttime sleep is not affected. Rationale 2: The medication modafinil (Provigil) is prescribed to control the daytime drowsiness associated with narcolepsy. Rationale 3: Sodium oxybate (Xyrem) is a prescription medication that has very limited availability. Rationale 4: The client should avoid antihistamines, as they can cause daytime drowsiness to increase.

While evaluating how care is delivered at various hospitals, the nurse identifies a facility where caring in the emergency department is perceived differently than caring in the rehabilitation unit. Whose theory of caring is the nurse observing in action? 1. Leininger 2. Ray 3. Roach 4. Boykin and Schoenhofer

Correct Answer: 2 Rationale 1: Leiningers theory is focused on cultural congruency. Rationale 2: Rays theory of bureaucratic caring suggests that caring in nursing is contextual and is influenced by the organizational structure. Each unit had its own specific meaning of caring and how it was influenced. Rationale 3: Roach focuses on the philosophical concept of caring and proposes that caring is the human mode of being. Rationale 4: Boykin and Schoenhofers theory suggests that caring is a lifelong process, lived moment to moment by the nurse and constantly unfolding.

A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain? 1. Phantom pain 2. Referred pain 3. Visceral pain 4. Chronic pain

Correct Answer: 2 Rationale 1: Phantom pain is that which is experienced in a limb after an amputation. Rationale 2: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain. Rationale 3: Visceral pain originates in an organ. Rationale 4: Chronic pain is that which is felt for months after the pain experience should have ended.

While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible.

Correct Answer: 2 Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. Rationale 4: If possible, the client should be turned to the lateral position, not supine, to allow for any secretions to drain out of the mouth.

The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others.

Correct Answer: 2 Rationale 1: Restraints cannot be used for the convenience of the care staff. Rationale 2: In this situation, the clients actions could hinder his or her health status and a restraint would be indicated. Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the clients needs. Rationale 4: This client would not be a candidate for restraints.

A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens easily. What should the nurse suggest to help this client with sleep? 1. Smoke no cigarettes 1 hour before sleep. 2. Smoke no cigarettes after the evening meal. 3. Limit the number of cigarettes smoked during the day. 4. Adjust to the lack of sleep, because those who smoke do not get sufficient sleep.

Correct Answer: 2 Rationale 1: Smoking up to 1 hour before sleep will be too much stimulation before sleep. Rationale 2: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than nonsmokers do. Smokers are usually easily aroused, and often describe themselves as light sleepers. When refraining from smoking after the evening meal, the person usually sleeps better. Rationale 3: Limiting the number of cigarettes smoked during the day will not impact the clients ability to sleep at night. Rationale 4: The client can be instructed not to smoke after the evening meal, and should not be told to adjust to the lack of sleep, because those who smoke do not get sufficient sleep.

Which of the following treatments has the highest potential to provide total pain relief? 1. Chiropractic manipulation 2. Neuronal injection of alcohol 3. Acupuncture 4. Transcutaneous electrical nerve stimulation (TENS)

Correct Answer: 2 Rationale 1: TENS, chiropractic manipulation, and acupuncture are less likely to provide total pain relief. Nerve blocks irreversibly stop impulse transmission along the treated nerves.

Which statement regarding the use of zolpidem (Ambien) for insomnia is accurate? 1. Patients using Ambien should avoid foods that contain tyramine. 2. Ambien will take longer to produce an effect when taken with food. 3. Ambien is contraindicated during pregnancy, but can be taken by breastfeeding mothers. 4. Ambien is classified as a benzodiazepine.

Correct Answer: 2 Rationale 1: The absorption of Ambien is slowed when taken with food. It is classified as a nonbenzodiazepine CNS depressant. It is classified as pregnancy category B, and should be avoided by breastfeeding mothers. Patients using MAOIs (not Ambien) should avoid foods high in tyramine.

A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control? 1. Provide pain medication before every ambulation session. 2. Address the clients fear of pain with walking. 3. Tell the client that the pain is now gone. 4. Explain that the client is confusing postoperative pain with the pain before the surgery.

Correct Answer: 2 Rationale 1: The client may not be prescribed pain medication before every ambulation session. Rationale 2: Nurses can use the gate control theory to stop nociceptor firing by applying topical therapies and addressing the clients mood to reduce fear and anxiety. Rationale 3: The nurse needs to do more than tell the client that the pain is gone. Rationale 4: The client does not appear to be confused between the postoperative pain and the pain before the surgery.

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired.

Correct Answer: 2 Rationale 1: The client may resent limitations and act out in such a way as to cause injury. Rationale 2: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. Rationale 3: Making uninformed choices about ones health would be unsafe instead of safe for the client. Rationale 4: A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity.

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

Correct Answer: 2 Rationale 1: The high Fowlers position should not be used with more than one pillow or with overly large pillows. Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion. Rationale 3: The prone position places the client on the abdomen and makes chest expansion difficult. Rationale 4: The Sims position is a side-lying position and does not support full chest expansion as much as the orthopneic position.

A client questions why a medication that is used to treat Parkinsons disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do? 1. Contact the physician. 2. Assure the client that medications used to treat Parkinsons disease are also used to treat PLMD. 3. Tell the client not to take the medication because there is most likely an error. 4. Check with the pharmacy to make sure the correct medication has been provided to the client

Correct Answer: 2 Rationale 1: The nurse does not need to contact the physician. The nurse can discuss the prescribed medication with the client. Rationale 2: Medications that are commonly prescribed for the treatment of Parkinsons disease are also prescribed for the treatment of PLMD. Rationale 3: This is not an error. Medications used to treat Parkinsons disease are also prescribed for PLMD. Rationale 4: This action is not necessary. Medications used to treat Parkinsons disease are also prescribed to treat PLMD.

The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? 1. The condition of the skin and nails 2. Nothing unless a problem is noted 3. The amount of time taken on foot care 4. The clients comments about the foot care

Correct Answer: 2 Rationale 1: The nurse does not need to document the condition of the skin and nails unless a problem is noted. Rationale 2: Foot care is not generally recorded unless problems are noted. Rationale 3: The nurse does not need to document the amount of time taken on foot care. Rationale 4: The nurse does not need to document the clients comments about the foot care.

A hospitalized client is being woken up every hour during the night for care and procedures. The nurse realizes that the lack of NREM sleep can have which physiological effect? 1. Decrease urine output 2. Increase thirst 3. Increase susceptibility to infection 4. Decrease heart rate

Correct Answer: 3 Rationale 1: The loss of NREM sleep does not impact urine output. Rationale 2: The loss of NREM sleep does not impact thirst. Rationale 3: The loss of NREM sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to infection. Rationale 4: In NREM sleep, the heart rate decreases. With the loss of NREM sleep, this decrease would not occur.

The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot.

Correct Answer: 2 Rationale 1: The restraints should be assessed according to agency policy but no less frequently than every 2 hours. Rationale 2: Padding bony prominences will prevent possible skin breakdown. Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head. Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 45 The mother of a newborn tells the nurse, I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesnt breathe regularly, and she sometimes twitches. What advice should the nurse give this mother? 1. Please bring your baby in immediately for a checkup. 2. These are common behaviors in newborns and are normal. 3. You should ask the physician about these symptoms at your next checkup. 4. If your baby does this again, take her to the emergency department.

Correct Answer: 2 Rationale 1: There is no need for the mother to bring the baby in for an immediate checkup. Rationale 2: These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal. Rationale 3: Having the mother wait until the next checkup unnecessarily delays reassurance that this is normal sleep behavior for a newborn. Rationale 4: This is normal sleep behavior for a newborn. The baby does not need to be seen in the emergency department.

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10

Correct Answer: 2 Rationale 1: This is a normal pulse rate. Rationale 2: A respiratory rate below 8 should be reported immediately. Rationale 3: This is a blood pressure that is within normal limits. Rationale 4: The nurse does not need to report the clients pain rating to the physician.

A client tells the nurse that because of work and life responsibilities, sleep has become optional. What is the best response the nurse should make to this client? 1. Be sure to get extra sleep when you can. 2. A lack of sleep can affect hormone levels and bodily functions. 3. Everyone has different needs for sleep to in order to function. 4. You must be very productive.

Correct Answer: 2 Rationale 1: This statement implies that the client is not getting sufficient sleep. It would be more appropriate for the nurse to suggest that the client obtain more sleep on a routine basis and not just when able. Rationale 2: Different biological functions occur during sleep that become altered with the lack of sleep. The nurse should explain what is affected by a lack of sleep. Rationale 3: Although this might be true, everyone needs sleep. The clients statement of sleep becoming optional indicates that the client is not getting sufficient sleep. Rationale 4: There are studies indicating that errors occur and changes in response times are altered with a lack of sleep. The client might not be productive with a lack of sleep.

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly. 3. Wash feet with water at a temperature of 90F to 98.6F. 4. Inspect feet thoroughly once a week.

Correct Answer: 2 Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients toenails. Only a podiatrist should handle this task. Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration. Rationale 3: The water to wash the feet should be 100F to 110F. Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems.

A client has been taking medication for back pain for several months, and has seen several different health care providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting 1. tolerance. 2. addiction. 3. physical dependence. 4. pseudoaddiction.

Correct Answer: 2 Rationale 1: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time. Rationale 2: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving. Rationale 3: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced. Rationale 4: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might clock watch, and might seem to display other inappropriate drug-seeking behaviors.

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the clients bed 3. Installing oxygen 4. Checking the oral suction apparatus

Correct Answer: 2 Rationale 1: Tongue blades are not used as part of seizure precautions, and should not be placed at the head of the bed. Rationale 2: The nurse can safely delegate the padding of the bed to UAP. Rationale 3: The nurse should install the oxygen. Rationale 4: The nurse should check the oral suction apparatus.

The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed.

Correct Answer: 2 Rationale 1: Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough. Rationale 2: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Rationale 3: Older clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls. Rationale 4: The client should be able to turn the light on before getting out of bed, as inadequate lighting is another cause for falls.

The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

Correct Answer: 2 ( 4 hours ) Rationale 1: The duration of action for most opiates is 4 hours.

The nurse is working on a hospital committee tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful? Standard Text: Select all that apply. 1. Turn off all overhead lights on the unit and use night-lights and flashlights. 2. Establish a time at which radios and televisions should be turned off or down. 3. Discontinue use of the paging system after 2100. 4. Conduct nursing reports in the hallway. 5. Open curtains between beds in semiprivate rooms.

Correct Answer: 2, 3 Rationale 1: It is not possible to turn off all overhead lights and use only night-lights and flashlights, but those lights that can be eliminated should be. Rationale 2: Establishing a time at which radios and televisions should be turned off or down will reduce the amount of disturbance to clients. Rationale 3: Discontinuing use of the paging system at 2100 will also reduce noise. Rationale 4: Nursing reports should be conducted in an area away from the client beds. Rationale 5: Closing the curtains, not opening the curtains, between beds in semiprivate rooms will decrease disturbance.

The nurse is planning to provide care according to Leiningers theory of culturally congruent care. What should the nurse include when providing care to the client? 1. Care should be influenced by the organizational structure. 2. The clients familiar lifeways are preserved. 3. Accommodations should be satisfying to clients. 4. Nursing care must be repatterned to help the client move toward wellness. 5. Care should be structured to fit the nurses needs

Correct Answer: 2, 3, 4 Rationale 1: Care influenced by organizational structure is in line with Rays theory of bureaucratic caring. Rationale 2: Culturally congruent care involves three action-decision care approaches, one of which is preservation of the clients familiar lifeways. Rationale 3: Culturally congruent care involves three action-decision care approaches, one of which is ensuring accommodations that help clients adapt to or negotiate for satisfying care. Rationale 4: Culturally congruent care involves three action-decision care approaches, one of which is repatterning nursing care to help the client move toward wellness. Rationale 5: Structuring care to meet the nurses needs is not an aspect of culturally congruent care.

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation? Standard Text: Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

Correct Answer: 2, 3, 4 Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed. Rationale 2: Documentation should include where the client was when the seizure occurred. Rationale 3: Documentation should include the duration of the seizure. Rationale 4: Documentation should include the status of the clients airway and use of oxygen. Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure.

A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? Standard Text: Select all that apply. 1. Clients ability to maintain a conversation during the procedure 2. Clients tolerance of the procedure 3. Condition and integrity of the skin 4. Client strength 5. Percentage of bath done without assistance

Correct Answer: 2, 3, 4, 5 Rationale 1: It is not necessary for the nurse to document if the client was maintaining a conversation during the bath. Rationale 2: When evaluating the clients bath, the nurse should include the clients tolerance of the procedure. Rationale 3: When evaluating the clients bath, the nurse should include the condition and integrity of the clients skin. Rationale 4: When evaluating the clients bath, the nurse should include the clients strength. Rationale 5: When evaluating the clients bath, the nurse should include the percentage of the bath done without assistance.

An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication? Standard Text: Select all that apply. 1. There are high-dose medications that will eradicate the pain. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 4. The risks of taking pain medication are low in the older population. 5. The lack of pain control will affect mobility and activity tolerance.

Correct Answer: 2, 3, 5 Rationale 1: When planning pharmacologic intervention for an older client, the approach should be to start low and go slow because of the effects on renal and liver function. Rationale 2: If pain is not effectively controlled in the older client, the ability to sleep will be affected. Rationale 3: If pain is not effectively controlled in the older client, irritability can occur. Rationale 4: When planning pharmacologic intervention for an older client, the nurse must assess the client for potential risks because of changes in organ and system functioning. Rationale 5: If pain is not effectively controlled in the older client, mobility and activity tolerance will be affected.

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

Correct Answer: 2, 4, 5 Rationale 1: The can should be held on the stronger side of the body to provide maximum support and appropriate body alignment while walking. Rationale 2: The cane should be moved forward while the body weight is borne by both legs. Rationale 3: The length should permit the elbow to be slightly flexed. Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg. Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg.

While providing a complete bed bath to a client, the nurse discovers abrasions along the clients back and upper buttock area. What should the nurse do to help this client? 1. Apply antiseptic spray to the abrasions. 2. Do not wash the client with soap. 3. Find assistance to help with the remainder of the bath. 4. Apply alcohol-free lotion to the abrasions.

Correct Answer: 3 Rationale 1: Applying antiseptic spray would be applicable for areas of erythema but not for abrasions. Rationale 2: Avoiding soap would be applicable for excessively dry skin. Rationale 3: Because the client has abrasions over the back and upper buttock area, the nurse should lift and not pull or slide the client. The nurse needs to find assistance to help with the remainder of the bath. Rationale 4: Applying alcohol-free lotion would be applicable for excessively dry skin but not for abrasions.

The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client? Standard Text: Select all that apply. 1. Secure all tubing connections with gauze. 2. Apply tape over all injection ports on the tubing. 3. Cleanse the insertion site with alcohol swabs once a day. 4. Label the tubing, infusion bag, and pump with the word epidural. 5. Post a sign above the clients bed indicating that an epidural is being used.

Correct Answer: 2, 4, 5 Rationale 1: Tubing connections should be secured with tape. Rationale 2: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter. Rationale 3: Do not use alcohol in any care of the catheter or insertion site because it can be neurotoxic. Rationale 4: Label the tubing, the infusion bag, and the front of the pump with tape marked epidural to prevent confusion with similar-looking IV lines. Rationale 5: Post a sign above the clients bed indicating that an epidural is in place.

The nurse has completed a back massage for a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Effectiveness of pain medication using a rating scale from 0 to 10 2. Position to perform the massage 3. Content of communication that occurred during the back massage 4. Amount of lotion used during the back massage 5. Client response

Correct Answer: 2, 5 Rationale 1: Effectiveness of pain medication is not a part of the documentation of a back massage. Rationale 2: The nurse should document the position in which the massage was performed on the client. Rationale 3: The content of communication that occurred during the back massage is not necessary to document. Rationale 4: The amount of lotion used during the back massage is not necessary to document. Rationale 5: The nurse should document the clients response to the massage.

The nurse is preparing to massage a clients back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage. Standard Text: Click and drag the options below to move them up or down. Choice 1. Move the hands down the sides of the back. Choice 2. Pour lotion into the palms of the hands to warm the lotion. Choice 3. Massage the areas over the right and left iliac crests. Choice 4. Move the hands up the center of the back. Choice 5. With the palms, massage the sacral area with smooth, circular strokes. Choice 6. Move the hands to the scapulae and massage this region using circular strokes.

Correct Answer: 2, 5, 4, 6,1, 3 Rationale 1: To perform a back massage, the nurse should: (1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; (2) with the palms, begin in the sacral area using smooth, circular strokes; (3) move the hands up the center of the back; (4) move the hands to the scapulae and massage this region using circular strokes; (5) move the hands down the sides of the back; and (6) massage the areas over the right and left iliac crests.

The nurse has just taken a job in a hospital that cares for an ethnically diverse population and is concerned about being culturally sensitive. How should the nurse plan to manage caring for patients in pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Treat all patients alike. 2. Listen carefully as the patients comments about pain are translated. 3. Show respect for the patients preferences even if they are very different from the nurses. 4. Ask questions about the patients beliefs and customs regarding pain management. 5. Watch how other nurses provide care to their patients.

Correct Answer: 2,3,4 Rationale 1: Not all patients respond identically to interventions. Rationale 2: Even if the nurse has to use the services of a translator, careful listening is an important step in providing culturally sensitive care. Rationale 3: Showing respect is important in providing culturally sensitive care in all areas, including pain management. Rationale 4: The nurse cannot practice what the nurse does not know. Asking questions is the method used to gain information to facilitate sensitive care. Rationale 5: Other nurses may not be providing the care needed for this nurses patients.

The patient has advanced cancer and is experiencing malignant pain. How should the nurse plan to manage this pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Use the intravenous route for pain medication administration. 2. Set up a dosing schedule that provides for around-the-clock doses. 3. Encourage the patient to wait 10 minutes after pain medication is required to ask for a dose. 4. Augment the patients regimen with other pharmaceutical and nonpharmaceutical pain relief measures for breakthrough pain. 5. Counsel the patient that it is not possible to eliminate all the pain of cancer and that some must be tolerated.

Correct Answer: 2,4 Rationale 1: Approximately 90% of cancer pain can be controlled by use of oral medications if they are dosed appropriately. Rationale 2: Often the problem in controlling pain of any type is that the patient gets behind the pain rather than medicating for it before it gets severe. Around-the-clock dosing helps to prevent playing catch-up to the pain. Rationale 3: This plan would allow the pain to worsen before medication is given and would result in the patient getting behind the pain. Rationale 4: Breakthrough pain is expected and may require additional pharmaceutical or nonpharmaceutical measures. Rationale 5: While it is true that some cancer patients develop intractable pain, many are able to control pain to a level that is very tolerable.

The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath.

Correct Answer: 3 Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath. Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority. Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslows hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall. Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctors order.

The most productive way of managing stress would be to 1. use a combined approach (drug use and nonpharmacological strategies). 2. use anxiolytics. 3. practice meditation. 4. determine the cause and address it accordingly.

Correct Answer: 4 Rationale 1: Stress is generally a symptom of an underlying disorder. It is more productive to uncover and address the cause than to treat the symptoms.

A patient has been in the intensive care unit for a week receiving various procedures throughout the day and night. Currently the patient, though physiologically stable, is irritable and paranoid and complains of vivid dreams when dozing off to sleep. What are the best actions for the nurse to take at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Check the patients oxygen status. 2. Request an order for sleep medication. 3. Assess the patients vital signs. 4. Turn down the lights at night and reduce noise to a minimum. 5. Schedule all tests and procedures before 9 p.m. or after 7 a.m.

Correct Answer: 2,4,5 Rationale 1: The patient is physiologically stable. Rationale 2: Since it is important for the patient to get rest, an order for sleep medication would be appropriate. Rationale 3: It is not necessary to assess the patients vital signs, since the patient is physiologically stable. Rationale 4: When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is speculated that to make up for their lack of dreaming, these persons experience far more daydreaming and fantasizing throughout the day. It is important to institute measures that promote restful sleep. Rationale 5: When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is important to institute measures that promote restful sleep, which would include scheduling tests and procedures so as to not disturb the patients sleep.

What is an important instruction for the nurse to give to the patient who is taking acetaminophen (Tylenol)? 1. Check your gums for bleeding when taking acetaminophen (Tylenol). 2. Do not take any narcotics with acetaminophen (Tylenol). 3. Do not drink alcohol with acetaminophen (Tylenol). 4. Do not take acetaminophen (Tylenol) on an empty stomach.

Correct Answer: 3 Rationale 1: Acetaminophen (Tylenol) is toxic to the liver, and should not be taken by patients who will be consuming alcohol. Acetaminophen (Tylenol) can be taken with or without food. There is no contraindication between acetaminophen (Tylenol) and narcotics; they are often combined for more effective pain relief. Bleeding in the gums is an effect of aspirin, not acetaminophen (Tylenol).

A client repeatedly asks the nurse How much longer until I can get more pain medication? Once the medication is provided, the client stops asking for it. The nurse identifies the clients behavior as being 1. addiction. 2. tolerance. 3. pseudoaddiction. 4. physical dependence.

Correct Answer: 3 Rationale 1: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving. Rationale 2: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time. Rationale 3: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might clock watch, and might display other inappropriate drug-seeking behaviors. To differentiate between pseudoaddiction and addiction, if the clients negative behavior resolves when the pain is treated effectively, the client is exhibiting pseudoaddiction. Rationale 4: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced.

A patient on a morphine patient-controlled analgesic (PCA) IV pump has a respiratory rate of 8, and is difficult to arouse. Which of the following would be the priority intervention? 1. Administering activated charcoal 2. Lowering the dose of morphine 3. Administering a medication that blocks mu and kappa receptors 4. Intubation and mechanical ventilation

Correct Answer: 3 Rationale 1: Administering the opioid antagonist naloxone (Narcan) is indicated in the given situation. Lowering the dose is not aggressive enough, and intubation is too aggressive. Activated charcoal is not indicated for an overdose that has occurred via the IV route.

The 70-year-old client tells the nurse, I can go to sleep without a problem, but then I wake up in a couple of hours and cant go back to sleep. What nursing action would help promote rest and sleep in this client? 1. Have the client develop a bedtime ritual of quiet music and a glass of wine. 2. Encourage the client to avoid taking pain medication prior to sleep. 3. Evaluate if the client perceives sleeplessness to be a serious problem. 4. Have the client perform moderate exercises before bedtime.

Correct Answer: 3 Rationale 1: Alcohol can interfere with sleep. Rationale 2: If the client has pain, the nurse should not encourage avoidance of medication. Rationale 3: The first intervention is to determine what the pattern of sleeplessness means to the client. Many older clients will nap off and on through the day and night and spend wakeful times engaged in activity, even if the active times are not during traditional active hours. Rationale 4: Exercise can interfere with sleep.

Which of the following is an adverse effect associated with morphine, and would be the priority if present? 1. Restlessness 2. Constipation 3. Respiratory depression 4. Psychological dependence

Correct Answer: 3 Rationale 1: All are adverse effects, but respiratory depression is the top priority.

The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier.

Correct Answer: 3 Rationale 1: Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization, not to improve communication. Rationale 2: Using a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification. Rationale 3: Reporting critical results of tests and diagnostic procedures on a timely basis is one way the National Patient Safety Goals improve the communication among caregivers. Rationale 4: Using the clients room number as an identifier is a passive technique that would improve the accuracy of client identification.

The client reports difficulty sleeping. Which environmental intervention should the nurse recommend? 1. Play soft music throughout the night. 2. Keep a television on in the bedroom. 3. Provide white noise with a fan. 4. Play a talk radio station.

Correct Answer: 3 Rationale 1: Music can promote wakefulness. Rationale 2: Television can promote wakefulness. Rationale 3: Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine. Rationale 4: Talk radio can promote wakefulness.

A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? 1. Assign UAP the task of giving the client a bath. 2. Skip the clients bath and document refused in the medical record. 3. Ask the client the usual way bathing occurs at home. 4. Tell the client that a bath is needed and ignore the clients comment.

Correct Answer: 3 Rationale 1: Assigning a UAP the task of giving the client a bath is following the task-centered approach. Rationale 2: Skipping the clients bath and documenting refused is not following a client-centered approach. Rationale 3: To provide a person-centered approach to bathing, the nurse should ask the client to describe the usual way bathing occurs at home. Rationale 4: Telling the client that a bath is needed and ignoring the clients comment is not following a client-centered approach.

The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Rinse the razor after each stroke. 4. Use long strokes.

Correct Answer: 3 Rationale 1: Assist the client to a sitting positionnot a prone positionbecause this is a more natural position. Rationale 2: The skin should be pulled taut with the nondominant handnot the dominant handbecause this provides uniform shaving. Rationale 3: Rinsing the razor after each stroke keeps the cutting edge clean. Rationale 4: Short strokes should be usednot long strokesbecause this provides for a closer shave without irritation.

After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client? 1. Administer another dose of a nonopioid medication. 2. Administer an opioid for severe pain. 3. Administer an opioid for moderate pain. 4. Administer two doses of an opioid for moderate pain.

Correct Answer: 3 Rationale 1: Because the clients pain is persisting, the next step of the WHO ladder for pain control must be applied. Rationale 2: The next step of the WHO ladder for pain indicates that an opioid for moderate pain be provided, not an opioid for severe pain. Rationale 3: If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate, then a step 2 regimen is appropriate. At the second step, an opioid for moderate pain or a combination of opioid and nonopioid medicine is provided with or without coanalgesic medications. Rationale 4: The client should not receive two doses of an opioid for moderate pain at one time.

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem? 1. Have the child walk around in the room when night terrors occur. 2. The next morning, ask the child to describe the event. 3. Have the child empty the bladder prior to going to bed. 4. Use an additional pillow behind the childs head at night.

Correct Answer: 3 Rationale 1: Because this is a partial awakening, walking the child around the room will not help and the child will probably not awaken. Rationale 2: The child will have no memory of the event the next morning. Rationale 3: Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having the child empty the bladder before going to bed might be helpful. Rationale 4: There is no reason to add an additional pillow behind the childs head.

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

Correct Answer: 3 Rationale 1: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Rationale 2: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Rationale 3: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the clients response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse. Rationale 4: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Once the client has successfully ambulated, any nursing staff member can assist.

The nurse is making a clients bed. What safety measure should the nurse implement at this time? 1. Begin at the head and move toward the foot, loosening bottom linens. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client.

Correct Answer: 3 Rationale 1: Beginning at the head and moving toward the foot, loosening the bottom linens, provides maximum work space. Rationale 2: Mitering the corners at the head of the bed prevents linens from becoming easily loosened. Rationale 3: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client. Rationale 4: Preparing the client readies the client for the procedure.

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush her teeth. 4. The nurse will stress the importance of adequate fluid intake.

Correct Answer: 3 Rationale 1: Cognitive impairment limits the clients ability to understand and comprehend; therefore, naming the staff is not within the clients realm of understanding. Rationale 2: Cognitive impairment limits the clients ability to understand and comprehend; therefore, eliminating safety hazards is not within the clients realm of understanding. Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush her teeth without prompting from the staff. Rationale 4: Cognitive impairment limits the clients ability to understand and comprehend; therefore, stressing adequate fluid intake is not within the clients realm of understanding.

The client is taking meperidine (Demerol) and experiencing pruritus. Which medication should the nurse expect the physician to order? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

Correct Answer: 3 Rationale 1: Naloxone hydrochloride (Narcan) will not help with pruritus. Rationale 2: Acetaminophen (Tylenol) will not help with pruritus. Rationale 3: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered. Rationale 4: Normal saline will not help with pruritus.

As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions.

Correct Answer: 3 Rationale 1: Displaying the phone number to the nurses station is a way to call for help. Rationale 2: Electrical cords should only be used if necessary, and the maintenance department can help if any of them present a hazard. Rationale 3: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Rationale 4: Reading label directions will prevent the wrong use of substances given to the client, but would not directly prevent falls.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

Correct Answer: 3 Rationale 1: Frequent position changes will not reverse contractures. Rationale 2: The contracture occurs because the flexor muscles are stronger than the extensor muscles. This imbalance in strength pulls the inactive joint into a flexed position, and a permanent shortening of the muscle occurs. Rationale 3: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises. Rationale 4: Weight-bearing activities will not reverse contractures.

A new nurse has just started work on an oncology unit. One of the clients has decided to discontinue treatment, even though he understands that his life will be shortened extensively if he does. The nurse is having difficulty with this situation and decides to approach a seasoned nurse for insight and a way to help support this particular client. The nurse is exemplifying which aspect of caring? 1. Hope 2. Humility 3. Honesty 4. Patience

Correct Answer: 3 Rationale 1: Hope is belief in the possibilities of the others growth. Rationale 2: Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 3: Honesty includes awareness of and openness to ones own feelings and genuineness in caring for the other. In this situation, the nurse has her own feelings about what the client should do, but truly wants to provide good care, so she seeks out assistance from someone who may be able to enlighten her. Rationale 4: Patience enables the other to grow in his or her own way and time.

The hospitalized client requests a bedtime snack. Which food should the nurse offer this client? 1. Hot chocolate 2. Tea and crackers 3. Cereal with milk 4. Chips and salsa

Correct Answer: 3 Rationale 1: Hot chocolate contains caffeine, which can cause wakefulness and nocturia. Rationale 2: Tea contains caffeine, which can cause wakefulness and nocturia. Rationale 3: The nurse should offer the client a light carbohydrate (cereal) and milk. Rationale 4: Chips and salsa is a spicy snack, and may cause gastrointestinal upsets that disturb sleep.

The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? 1. Clothes 2. Family 3. Hair 4. Nutritional

Correct Answer: 3 Rationale 1: Hygienic care does not include care of the clients clothes. Rationale 2: Hygienic care does not include care to the clients family. Rationale 3: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum. Rationale 4: Hygienic care does not include the clients nutritional status.

Which drug category can be used for treating anxiety? 1. Antitussives 2. Anticoagulants 3. Seizure drugs 4. Antibiotics

Correct Answer: 3 Rationale 1: In addition to antidepressants, several other drug classes are used to treat anxiety, including seizure drugs. Antibiotics are used primarily for bacterial infections. Antitussives are used as cough suppressants. Anticoagulants are used to prevent blood clots from forming.

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control? 1. Body 2. Mind 3. Social interactions 4. Spirit

Correct Answer: 3 Rationale 1: Interventions that target the body for pain control include massage, heat, and exercise. Rationale 2: Interventions that target the mind for pain control include relaxation and imagery. Rationale 3: Social interactions that are used as nonpharmacologic pain control methods include pet therapy. Rationale 4: Interventions that target the spirit for pain control include prayer, meditation, and energy work.

A nursing student was involved in a very difficult situation with a client, the clients family, and a physician. The student felt like she was caught in the middle and wasnt sure how to respond to some of the questions that were being asked about care, treatment, and scheduling. Instead of getting her instructor, the student fielded these questions as best she could. In order to help the student work through this situation, the nursing instructor might advise the student to try which action? 1. Meditation 2. Guided imagery 3. Reflection 4. Music therapy

Correct Answer: 3 Rationale 1: Meditation is quieting the mind and focusing it on the present. It helps the individual release fears, worries, and doubts. Rationale 2: Guided imagery is a mindbody intervention that uses the power of imagination as a therapeutic tool. Rationale 3: Reflection is thinking from a critical point of view, analyzing why one acted in a certain way and assessing the results of ones actions. Reflection must be personal and meaningful. In this example, it will help the student understand how the situation could have been handled better. Rationale 4: Music therapy includes listening, singing, rhythm, and body movement. It is often used to induce relaxation.

A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this clients pain intensity? 1. Mild pain 2. Moderate pain 3. Severe pain 4. Physiological pain

Correct Answer: 3 Rationale 1: Mild pain is rated as being from 1 to 3 on a 0-to-10 rating scale. Rationale 2: Moderate pain is rated as being from 4 to 6 on a 0-to-10 rating scale. Rationale 3: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10. Rationale 4: Physiological pain does not describe the intensity of the clients pain.

The nurse has adopted a healthy lifestyle. What action demonstrates that the nurse is being successful in this endeavor? 1. Exercising every day, at least for an hour and a half 2. Buying only fat-free foods and allowing absolutely no deviation from this 3. Balancing good nutrition and exercise in moderation 4. Exercising more on days when feeling guilty about a snack

Correct Answer: 3 Rationale 1: Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Exercising every day for at least an hour an half does not demonstrate balance. Rationale 2: Completely avoiding a certain nutrient or keeping the nutritional aspects of ones life so strict that there can be no variance is difficult and indicates more of a compulsive nature than a healthy one. Rationale 3: Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Rationale 4: Exercising more on days when feeling guilty about a snack is not permitting variation or balance.

Identify the correct statement regarding opioid receptors. 1. The sigma and kappa receptors are of greatest concern from a pharmacologic standpoint. 2. Drugs that block opioid receptors inhibit the pain impulse. 3. Opioid agonists will activate mu and kappa receptors, producing analgesia. 4. Opioids exert their actions by interacting with a total of four receptors.

Correct Answer: 3 Rationale 1: Opioid agonists stimulate mu and kappa receptors, resulting in a variety of effects, including analgesia. There are at least six types of receptors. The mu and kappa receptors are of greatest concern from a pharmacologic standpoint. Drugs that block opioid receptors are called opioid antagonists, and do not inhibit the pain impulse.

The patient receives morphine for pain. He asks the nurse how it works to relieve pain. What is the best response by the nurse? 1. It inhibits the primary pain neurotransmitters in your brain. 2. It stimulates the receptors that secrete endorphins in your brain. 3. It stimulates a receptor in your brain that induces pleasure. 4. It promotes the primary pleasure neurotransmitters in your brain.

Correct Answer: 3 Rationale 1: Opioids exert their actions by interacting with the mu and kappa receptors in the brain. Drugs that stimulate these receptors are opioid agonists. Opioids do not promote release of the pleasurable neurotransmitters. Opioids do not promote secretion of endorphins. Opioids do not inhibit neurotransmitters responsible for pain.

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

Correct Answer: 3 Rationale 1: Palpating the area is contraindicated because injury to the vein may induce a thrombus. Rationale 2: Percussing the area is contraindicated because injury to the vein may induce a thrombus. Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis. Rationale 4: Medicating the client and reassessing in 30 minutes might allow a worsening of the clients condition.

During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain.

Correct Answer: 3 Rationale 1: Pregnant clients should be encouraged to exercise, regardless if exercise was a part of life prior to being pregnant. Rationale 2: Exercise should be done 30 minutes on most days. Rationale 3: The current recommendation of the American College of Obstetricians and Gynecologists is for healthy pregnant women to get as much exercise as the general population (30 minutes on most if not all days). This is a change from the previous recommendation that pregnant women can exercise. Rationale 4: There is no indication that the pregnant woman needs more exercise than the general population.

The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy.

Correct Answer: 3 Rationale 1: Providing oral fluid to a newly extubated client should be done first by the nurse, so the client can be assessed for ability to safely swallow. Rationale 2: Irrigating an indwelling urinary catheter is beyond the scope for UAP. Rationale 3: Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained in their use. Rationale 4: Administering medication is beyond the scope for UAP.

The client who has obstructive sleep apnea is being treated with a nasal continuous positive airway pressure (CPAP) device, but has just been prescribed modafinil (Provigil). What client statement indicates that teaching about these therapies has been effective? 1. I am so glad that I wont have to sleep in this machine anymore. 2. Once I get regulated on the Provigil, I will wean myself off the CPAP. 3. I will continue using my CPAP machine at night. 4. I can turn down the pressure on my CPAP machine in about 1 week.

Correct Answer: 3 Rationale 1: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

A nurse educator is teaching students about the philosophy of caring in nursing and states that nurses can only be truly caring if they are true to themselves first. This action then emphasizes the importance of nurses knowing themselves, which brings about a process that allows the nurse to be with another person. Whose theory is the educator using to teach the concept of caring? 1. Roach 2. Ray 3. Boykin and Schoenhofer 4. Watson

Correct Answer: 3 Rationale 1: Roachs theory focuses on caring as a philosophical concept and proposes that caring is the human mode of being, or the most common, authentic criterion of humanness. Rationale 2: Rays theory of caring focuses on caring in organizations and is influenced by the organizational structure. Rationale 3: Boykin and Schoenhofer emphasize the importance of the nurse knowing oneself as caring. Through knowing oneself as a caring person, the nurse can be authentic to self, freeing oneself to truly be with others. Rationale 4: Watson views caring as the essence and the moral ideal of nursing.

The patient is scheduled to have an EEG to confirm the presence of a sleep disorder. The patient asks the nurse to describe Stage IV NREM sleep. What is the best response by the nurse? 1. This is the lightest stage of sleep, and is profoundly affected by anxiety. 2. Dreaming occurs here; without dreams you will be irritable and paranoid. 3. This is the deepest stage of sleep; without it you will be tired and depressed. 4. This stage comprises the greatest amount of sleep time, and is important.

Correct Answer: 3 Rationale 1: Stage IV NREM sleep is the deepest stage of sleep. Patients who are deprived of it experience depression and a feeling of apathy and fatigue. Dreaming occurs in REM sleep, not NREM sleep. Stage IV NREM sleep is the deepest stage of sleep, not the lightest stage of sleep. Stage II NREM sleep, not Stage IV NREM sleep, comprises the greatest amount of total sleep time.

A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client? 1. I understand. 2. There are ways to treat addictions to pain medications. 3. If the medication is taken to treat pain, you will not become addicted to it. 4. All pain medication causes addiction. There is nothing that can be done to prevent it.

Correct Answer: 3 Rationale 1: Stating that the nurse understands the clients concern is not sufficient. The nurse needs to explain how the pain medication will not likely lead to addiction. Rationale 2: This response supports the clients fears of becoming addicted to pain medication. Rationale 3: Clients are unlikely to become addicted to an analgesic provided to treat pain. Rationale 4: Not all pain medication causes addiction. Clients are unlikely to become addicted to an analgesic that is provided to treat pain.

The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

Correct Answer: 3 Rationale 1: Stopping the treatment is not justified until an assessment occurs. Rationale 2: Stopping the exercises is not justified until an assessment occurs. Rationale 3: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued. Rationale 4: Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain.

The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4.

Correct Answer: 3 Rationale 1: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 1 indicates normal activity with slightly more shortness of breath. Rationale 2: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 2 indicates ability to walk about one level city block without difficulty or to climb one flight of stairs without stopping. Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 3 (this clients level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping. Rationale 4: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 4 indicates dyspnea and fatigue at rest.

The nurse is working with a client to develop an expected outcome for the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this clients situation? 1. The client will sleep at least 8 hours each night. 2. The client will list three positive coping mechanisms for anxiety relief. 3. The client will report getting sufficient sleep to provide energy for daily activities. 4. The client will manifest less anxiety after taking prescribed medications.

Correct Answer: 3 Rationale 1: The client may require more than 8 hours of sleep to feel rested and have sufficient energy. Rationale 2: Simply listing coping mechanisms for anxiety relief is not as helpful as actually getting sleep. Rationale 3: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities. Rationale 4: Antianxiety medications are probably not the most important factor for this client.

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the clients room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise.

Correct Answer: 3 Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall. Rationale 2: Wearing terry-cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles. Rationale 3: Providing adequate lighting will help prevent the client from falling. Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client.

The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding client safety once the beds are completed? 1. Folding of the top sheet 2. Direction of the pillow 3. Call light being readily available 4. Presence of mitered corners

Correct Answer: 3 Rationale 1: The folding of the top sheet is not important for client safety. Rationale 2: The direction of the pillow is not important for client safety. Rationale 3: The nurse should assess for the call light being readily available while the client is out of the bed. Rationale 4: The presence of mitered corners is not important for client safety.

The nurse is shampooing a clients hair. Which assessment finding should the nurse consider as expected? 1. Dry, dark, thin 2. Smooth, taut, shiny 3. Smooth texture and not oily or dry 4. Tender, warm scalp

Correct Answer: 3 Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool. Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair. Rationale 3: The hair should be smooth in texture and neither oily nor dry. Rationale 4: A tender, warm scalp could indicate a problem, so this would not be normal.

The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. What action should the nurse take? 1. Encourage the client to accept the back rub, saying how much it will relax the back muscles. 2. Document that the client is noncompliant with the nursing plan of care. 3. Accept the declination but tell the client to call if he changes his mind. 4. Instruct the UAP to rub the clients back while assisting him to change into a clean gown.

Correct Answer: 3 Rationale 1: The nurse should not force the client to have a back rub if one is not desired. Rationale 2: The client is not noncompliant; he is simply stating his preference. Rationale 3: Some clients are eager to have a back rub, but others are not comfortable with the close physical contact this intervention requires. Respect the clients decision, but keep the offer open if he changes his mind. Rationale 4: The UAP should not attempt to rub the clients back without permission.

The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should the nurse use to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous

Correct Answer: 3 Rationale 1: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client. Rationale 2: This medication is not available as a vaginal suppository. Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client. Rationale 4: There is not an intravenous form of this medication.

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

Correct Answer: 3 Rationale 1: There is no physiological reason why a client with pneumonia would need to be logrolled. Rationale 2: There is no physiological reason why a client recovering from abdominal surgery would need to be logrolled. Rationale 3: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house. Rationale 4: There is no physiological reason why the client with a headache would need to be logrolled.

While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion.

Correct Answer: 3 Rationale 1: This activity does not utilize all of the major joints in the hands and arms. Rationale 2: The wash basin should be close to the client to prevent overreaching and possible falls. Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. Rationale 4: Passive range of motion is a second best choice after normal use of the joints.

Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin

Correct Answer: 3 Rationale 1: This is an example of subjective data. Rationale 2: This is an example of subjective data. Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client.

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

Correct Answer: 3 Rationale 1: This is not the most important action of the nurse. Rationale 2: This is not the most important action of the nurse. Rationale 3: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall. Rationale 4: This is not the most important action.

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

Correct Answer: 3 Rationale 1: This position could cause the nurses trunk to twist. Rationale 2: This position could cause the nurses trunk to twist. Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur. Rationale 4: This position could cause the nurses trunk to twist.

During an assessment, the nurse learns a client has soft contact lenses that have not been removed or cleaned for weeks. What should the nurse do? 1. Nothing, because these types of lenses can be worn for months. 2. Remove the clients lenses, wrap in tissue, and place in the bedside table. 3. Assist the client to remove and clean the contacts. 4. Ask the physician for ophthalmology consult because the client will need help removing the lenses.

Correct Answer: 3 Rationale 1: This type of lens should not be worn for more than 30 days. Rationale 2: The lenses should not be wrapped in tissue because this will cause the lenses to dry out and not be able to be worn or used. Rationale 3: Most eye specialists recommend that soft contact lenses be removed and cleaned every week. The nurse should assist the client to remove and clean the contacts. Rationale 4: The client does not need ophthalmology consult. The nurse can help the client remove the lenses.

The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurses first action? 1. Administer IV pain medication as ordered. 2. Start an IV line of lactated Ringers. 3. Assess pain using a scale of 1 to 10. 4. Place a Foley catheter to bedside drainage.

Correct Answer: 3 Rationale 1: This would occur after the client was assessed. Rationale 2: This would occur after the client was assessed. Rationale 3: Assessment should always occur before implementation. Rationale 4: This may or may not be appropriate for the client.

A client is complaining of having the same type of pain that he experienced prior to being diagnosed with cancer. The nurse realizes that which process will influence this clients perception of pain? 1. Transmission 2. Modulation 3. Perception 4. Transduction

Correct Answer: 3 Rationale 1: Transmission is a process by which the pain signals are transmitted to the brain. Rationale 2: Modulation is the process where signals are sent back down the spinal tracts in response to the pain. Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows. Rationale 4: Transduction is a process whereby chemicals are released in response to noxious stimuli.

A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain? 1. Mild pain 2. Severe pain 3. Somatic pain 4. Visceral pain

Correct Answer: 3 Rationale 1: Mild is not a type of pain. Rationale 2: Severe is not a type of pain. Rationale 3: Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain. Rationale 4: Visceral pain is that which originates within an organ.

Which sleep stage accounts for about one-half of total sleep? 1. NREM sleep stage 1 2. NREM sleep stage 3 3. NREM sleep stage 2 4. NREM sleep stage 4

Correct Answer: 3 (Stage 2) Rationale 1: NREM sleep stage 2 accounts for 4555% of total sleep. The other stages are considerably less than half

The nurse is assisting a client in removing soft contact lenses. Place in order the steps the nurse should take to help this client. Standard Text: Click and drag the options below to move them up or down. Choice 1. Using the pad of the index finger of the other hand, move the lens down to the sclera. Choice 2. Have the client look forward. Choice 3. Apply gloves. Choice 4. Gently pinch the lens between the pads of the thumb and index finger. Choice 5. Retract the lower lid with one hand.

Correct Answer: 3, 2, 5, 1, 4 Rationale 1: The nurse should use the pad of the index finger of the other hand to move the lens down to the sclera. Rationale 2: The nurse should ask the client to look forward. Rationale 3: The first step is for the nurse to apply gloves. Rationale 4: The nurse should gently pinch the lens between the pads of the thumb and index finger to remove the lens. Rationale 5: The nurse should retract the lower lid with one hand.

A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effects on the client? Standard Text: Select all that apply. 1. Encourage the development of tolerance. 2. Encourage the development of addiction. 3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects. 5. Reduce the onset of pseudoaddiction.

Correct Answer: 3, 4 Rationale 1: Blended medications do not encourage the development of tolerance. Rationale 2: Blended medications do not encourage the development of addiction. Rationale 3: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing toxicity. Rationale 4: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing side effects. Rationale 5: Blended medications do not reduce the onset of pseudoaddiction.

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this clients risk for injury? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status

Correct Answer: 3, 4 Rationale 1: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 2: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 3: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 4: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 5: Cognitive awareness, mobility, and health status are factors affecting safety.

The graduate nurse learns of failing the NCLEX-RN examination but realizes that passing the examination is a challenge worth achieving. To improve her outlook, the graduate nurse writes positive affirmations that are reviewed daily before studying for the examination. Which affirmations would be the most beneficial for the graduate nurse to use? Standard Text: Select all that apply. 1. I will focus on a new career. 2. I should have studied harder . 3. I am doing what brings me joy. 4. This is an opportunity to grow. 5. I cannot remember everything.

Correct Answer: 3, 4 Rationale 1: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on a new career is not a positive affirmation. Rationale 2: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on study habits in school is not a positive affirmation. Rationale 3: Positive affirmations can lead to greater self-esteem and control self-doubt. Stating what brings joy is a positive affirmation. Rationale 4: Positive affirmations can lead to greater self-esteem and control self-doubt. Realizing the situation is an opportunity to grow is a positive affirmation. Rationale 5: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on the inability to remember everything is not a positive affirmation.

Mobility Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 44 Question 1 The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

Correct Answer: 3, 4, 5 Rationale 1: A pillow between the legs when logrolling does not stabilize the spine. Rationale 2: A pillow between the legs when logrolling does not prevent hip contractures. Rationale 3: A pillow between the clients legs when logrolling supports the upper leg when the client is turned. Rationale 4: A pillow between the clients legs when logrolling keeps the legs parallel and aligned. Rationale 5: A pillow between the clients legs when logrolling prevents adduction of the upper leg.

From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time? Standard Text: Select all that apply. 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility

Correct Answer: 3, 4, 5 Rationale 1: The diagnosis of Anxiety would not be applicable, as the client did not express past experiences of poor control of pain or anticipation of future pain events. Rationale 2: The diagnosis of Hopelessness would not be applicable, as the client did not state that the pain is continuous. Rationale 3: The diagnosis of Ineffective Health Maintenance would be applicable, as the client is experiencing chronic arthritic pain and is fatigued. Rationale 4: The diagnosis of Insomnia would be applicable, as the client is experiencing increased pain perception at night, affecting sleep. Rationale 5: The diagnosis of Impaired Physical Mobility would be applicable, as the client is experiencing arthritic pain in the hips and knees.

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? Standard Text: Select all that apply. 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath

Correct Answer: 3, 5 Rationale 1: Getting into and out of a shower might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 2: Getting into and out of a bathtub might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 3: Because the client is prescribed bed rest with bathroom privileges, the self-help bed bath would be appropriate because the client can independently wash with some help from the nurse. Rationale 4: A therapeutic bath is for some physical effect and not used routinely for morning care. Rationale 5: Because the client is prescribed bed rest with bathroom privileges, the partial bath would be appropriate because the client can independently wash with some help from the nurse to wash the back area.

A patient who has recently experienced the loss of a spouse asks the nurse if there are any over-the-counter herbs or nonprescription medications that can be used to improve insomnia. How should the nurse respond to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ginger root is commonly taken to improve sleep. 2. Ginkgo is an herb commonly taken to improve sleep. 3. Diphenhydramine (Benadryl) and doxylamine are over-the-counter meds sometimes taken to produce drowsiness. 4. Valerian and melatonin are herbs commonly taken to improve sleep. 5. Kava is an herb taken to improve sleep.

Correct Answer: 3,4 Rationale 1: Ginger root is not used to improve sleep. Rationale 2: Ginkgo is not used to improve sleep. Rationale 3: Diphenhydramine and doxylamine are two antihistamines frequently used to produce drowsiness. Rationale 4: An herbal product with demonstrated efficacy in promoting relaxation is valerian root. Supplemental melatonin, 0.5?3.0 mg at bedtime, is alleged to decrease the time required to fall asleep and to produce a deep and restful sleep. Rationale 5: High doses of kava can damage the liver and should not be used unless recommended by a health care provider.

A patient who is complaining of anxiety and difficulty sleeping has asked what prescription medications would assist in getting to sleep. What would be appropriate responses? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Diphenhydramine (Benadryl) 2. Valerian root 3. Ramelteon (Rozerem) 4. Flurazepam (Dalmane) 5. Zolpidem (Ambien)

Correct Answer: 3,4,5 Rationale 1: Diphenhydramine (Benadryl) can be obtained over the counter and does not need a prescription to obtain. It does promote getting to sleep. Rationale 2: Valerian is an herbal product that does not need a prescription to obtain. It does promote getting to sleep. Rationale 3: Rozerem is a newer, nonbenzodiazepine hypnotic approved to treat chronic insomnia in people who have problems falling asleep. Rationale 4: Benzodiazepines are drugs of choice for generalized anxiety disorder and the short-term therapy of insomnia. Flurazepam (Dalmane) should be taken at bedtime because it quickly produces significant drowsiness. Rationale 5: Ambien is a sedative-hypnotic approved for short-term treatment of insomnia.

The patient is receiving clonazepam (Klonopin) for the treatment of panic attacks. What is an important medication outcome for this patient as it relates to safety? 1. The patient will verbalize the signs of developing Stevens-Johnson rash. 2. The patient will verbalize the importance of diet restrictions related to this drug. 3. The patient will verbalize the importance of having routine blood work done. 4. The patient will verbalize the consequences of stopping the drug abruptly.

Correct Answer: 4 Rationale 1: Abrupt discontinuation of clonazepam (Klonopin) can result in serious withdrawal symptoms. There arent any diet restrictions with the use of clonazepam (Klonopin). Routine blood work is not required with the use of clonazepam (Klonopin). Stevens-Johnson rash is not a side effect of clonazepam (Klonopin

The nurse provides care for several patients. For which patient would the nurse assess acetaminophen (Tylenol) to be contraindicated? 1. A 2-year-old with a high fever due to the flu 2. A 65-year-old with osteoarthritis 3. A 19-year-old with a bladder infection 4. A 55-year old who socially drinks alcohol

Correct Answer: 4 Rationale 1: Acetaminophen (Tylenol) is hepatotoxic, and may cause problems in patients who consume alcohol. Acetaminophen (Tylenol) would be the drug of choice for a child with the flu. Acetaminophen (Tylenol) would not be contraindicated with osteoarthritis, but aspirin would be more effective. There isnt any association between the use of acetaminophen (Tylenol) and a bladder infection.

The client who has sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client? 1. Disturbed Sleep Pattern related to difficulty staying asleep 2. Risk for Impaired Gas Exchange related to sleep apnea 3. Disturbed Thought Processes related to chronic insomnia 4. Risk for Injury related to somnambulism

Correct Answer: 4 Rationale 1: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 2: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 3: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 4: The priority is Risk for Injury related to somnambulism because it reflects the most dangerous situation for the client.

The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays

Correct Answer: 4 Rationale 1: Banging into objects is what a toddler would be likely to do, not an expectant mother. Rationale 2: Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Rationale 3: Physical activity promotes good health. Rationale 4: Exposure to x-rays in the first trimester could cause harm to the developing fetus.

Which explanation best indicates why barbiturates are rarely used to treat anxiety and insomnia? 1. They have a greater associated cost. 2. They have a high risk of producing an allergic response. 3. They are seldom effective. 4. They produce many serious adverse effects.

Correct Answer: 4 Rationale 1: Barbiturates were the drug of choice for anxiety and insomnia prior to the discovery of safer drug alternatives. They can be effective, and are not necessarily more expensive. Allergic reactions can occur, but are rare, and are not a primary reason they are no longer used for anxiety and/or insomnia.

A nurse practitioner emphasizes the importance of the staff engaging in activities that help restore peace and balance between the mind and body. Which might be an appropriate therapy for this? 1. Bike riding 2. Cake decorating 3. Reading 4. Storytelling

Correct Answer: 4 Rationale 1: Bike riding is an exercise. Rationale 2: Cake decorating would be recreation. Rationale 3: Reading would be recreation. Rationale 4: Mindbody therapies include storytelling, which is a complementary therapy that brings balance to thoughts and emotions.

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox

Correct Answer: 4 Rationale 1: Cancer does not pose a threat to homeland security. Rationale 2: Seasonal flu does not pose a threat to homeland security. Rationale 3: Tuberculosis does not pose a threat to homeland security. Rationale 4: Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism.

Caring Intervention Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 25 Question 1 The student nurse is following a preceptor on the assigned clinical shift. Which behavior of the nurse should the student interpret as caring? 1. Making sure that all medications and treatments are done on time 2. Using aseptic technique when performing a dressing change 3. Advising the physician that the client wants to speak to him or her prior to a procedure 4. Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure

Correct Answer: 4 Rationale 1: Caring is more than just performing skills adequately or even efficiently. Rationale 2: Caring is more than just performing skills adequately or even efficiently. Rationale 3: Caring is more than just performing skills adequately or even efficiently. Rationale 4: Caring practice involves connection, mutual recognition, and involvement. Its a sense that the nurse has made a difference to someone else. Caring means that people, relationships, and things matter. Explaining a procedure, then seeking permission to begin, lets the client know that the nurse respects the client as an individual.

A client is working two jobs, caring for aged parents, and maintaining a household for the family. The nurse realizes that this emotional stress will have what impact on the clients sleep? 1. More REM sleep 2. Less Stage 1 and Stage II NREM sleep 3. More NREM sleep 4. Less deep sleep and more awakenings during the night

Correct Answer: 4 Rationale 1: Chemical changes result in less REM sleep. Rationale 2: Chemical changes result in less NREM sleep in Stages III and IV. Rationale 3: Chemical changes affect deep and REM sleep. Rationale 4: Stress is considered by most sleep experts to be the number one cause of short-term sleeping difficulties. A person preoccupied with personal problems might be unable to relax sufficiently to get to sleep. Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings.

A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing? 1. Chronic pain 2. Phantom pain 3. Visceral pain 4. Acute pain

Correct Answer: 4 Rationale 1: Chronic pain, also known as persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning. Rationale 2: Phantom pain is the feeling that a lost body part is present. It occurs in most people after amputation. Rationale 3: Visceral pain tends to be characterized by cramping, throbbing, pressing, or aching qualities. Often visceral pain is associated with feeling sick. Rationale 4: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

The nurse is working in a busy intensive care unit. A client is admitted with extensive medical problems and requires a ventilator. Because the nurse already has two other clients assigned to his care, he requests that the nurse manager change assignments so that appropriate attention can be given to this new admission. According to Roachs six Cs of caring, which one is the nurse emulating? 1. Compassion 2. Confidence 3. Commitment 4. Conscience

Correct Answer: 4 Rationale 1: Compassion is about being aware of ones relationship to others; sharing joys, sorrows, pain, and accomplishments; and participating in the experience of another. Rationale 2: Confidence is the quality that fosters trust. It means the nurse has comfort with himself, his clients, and his family. Rationale 3: Commitment is a convergence between ones desires and obligations and the deliberate choice to act in accordance with them. Rationale 4: Conscience deals with morals, ethics, and an informed sense of right and wrong as well as an awareness of personal responsibility. This nurse understands the situation of taking on a critically ill client when he is already busy enough and makes an appropriate request for a change in assignment.

The patient is receiving zolpidem (Ambien) for treatment of short-term insomnia. What is the primary safety concern of the nurse when the patient takes this medication? 1. Dizziness and daytime sedation 2. Nausea and diarrhea 3. Nausea and gastrointestinal (GI) distress 4. Sleepwalking

Correct Answer: 4 Rationale 1: During sleepwalking, a patient may leave the home and cause injury to self. Nausea and gastrointestinal (GI) distress are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication. Dizziness and daytime sedation are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication. Nausea and diarrhea are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication.

A nurse has been asked to be a member of a hospitals internal review board and evaluate research studies. Which characteristic does this nurse most likely possess? 1. Sound empirical knowledge 2. Sound personal knowledge 3. Sound aesthetic knowledge 4. Sound ethical knowledge

Correct Answer: 4 Rationale 1: Empirical knowledge is systematically organized into laws and theories for the purpose of describing, explaining, and predicting phenomena. Rationale 2: Personal knowledge promotes wholeness and integrity in the personal encounter. Rationale 3: Aesthetic knowledge is the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of clients. Rationale 4: Ethical knowing focuses on matters of obligation or what ought to be done and goes beyond simply following the ethical codes of the discipline. Internal review boards review research projects and determine whether they meet sound, ethical standards. The more sensitive and knowledgeable the nurse is to these issues, the more ethical the nurse will be.

Unlicensed assistive personnel are caring for a clients ears. What information should be reported to the nurse? 1. Excessive earwax 2. Loud talking 3. Presence of a hearing aid 4. Presence of any drainage

Correct Answer: 4 Rationale 1: Excess earwax is not an immediate problem. Rationale 2: Loud talking could be an indication the client is hard of hearing, which is not an immediate threat. Rationale 3: The presence of a hearing aid should already be noted on the clients admission assessment. Rationale 4: The health care provider should report any drainage from the ears to the nurse.

The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib

Correct Answer: 4 Rationale 1: Exposure to alcohol consumption is a safety hazard to a fetus. Rationale 2: Drowning is a safety hazard in toddlers and preschoolers. Rationale 3: Pedestrian accidents are safety hazards in the older adult. Rationale 4: Suffocation in the crib is a safety hazard for both newborns and infants.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 33 Question 1 The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurseclient relationship 3. Moisturize the skin 4. Stimulate circulation

Correct Answer: 4 Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most important purpose. Rationale 2: Giving a bath to a client will allow the nurse to develop a nurseclient relationship but this is not the most important purpose. Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most important purpose. Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client.

A client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses? 1. Pinch the lenses out of the clients eyes to remove. 2. Remove both of the clients lenses before storing in the appropriate storage cup. 3. Document when the lenses need to be removed and cleaned every 2 weeks. 4. Ask the client how many hours the lenses are worn each day.

Correct Answer: 4 Rationale 1: Hard contact lenses are not removed by pinching. Rationale 2: The nurse should remove one lens at a time and store in the appropriate storage cup. Rationale 3: Hard contact lenses should be removed and cleaned every day, not every 2 weeks. Rationale 4: Hard contact lenses should only be worn for 12 to 14 hours.

The patient has generalized anxiety disorder. He asks the nurse, Will I need medication for this? My neighbor is very nervous and he takes medication. What is the best response by the nurse? 1. Medications are a way of life for patients with anxiety disorders. 2. Medication is necessary initially; later we will try therapy. 3. Probably not, but you shouldnt compare yourself to your neighbor. 4. Medication is necessary when anxiety interferes with your quality of life.

Correct Answer: 4 Rationale 1: It is more productive to identify and treat the cause of anxiety than to use medications. When anxiety becomes severe enough to significantly interfere with the patients quality of life, pharmacotherapy is indicated. Medications are not considered a way of life for patients with anxiety disorders; many patients can manage anxiety without medications. The nurse does not have enough information to tell the patient that medications will probably not be necessary. Medication combined with therapy is considered the best approach for treatment of anxiety disorders.

The nurse is working in the school system with a group of students who are struggling with the death of a classmate. The nurse encourages the students to talk about their friend, bring pictures, and share memories with each other. The nurse also invites the deceaseds family members to come to the school and visit with their childs classmates. This nurse is working in which of Swansons processes? 1. Knowing 2. Being with 3. Doing for 4. Enabling

Correct Answer: 4 Rationale 1: Knowing is striving to understand an event as it has meaning in the life of the other. If this were the case in this situation, the nurse would be asking the students to explain what they are going through, or what it feels like to lose a friend. Rationale 2: Being with is being emotionally present to the other. Rationale 3: Doing for is providing for others as they would do for themselves if it were possible. Rationale 4: Enabling is facilitating the others passage through life transitions and unfamiliar events. Being supportive of the students and encouraging them to share and talk about their friend is allowing them to move through the grief process. Enabling also includes supporting, assisting, guiding, and validating.

A nurse manager has been dealing with staffing problems and high patient acuity on the unit. The director of nursing unit has been sensitive to other issues in the past, so the nurse manager decides to approach her with these new concerns. Which aspect of caring is the nurse manager demonstrating? 1. Knowing 2. Trust 3. Humility 4. Courage

Correct Answer: 4 Rationale 1: Knowing means understanding the others needs and how to respond to these needs. Rationale 2: Trust involves letting go, to allow the other to grow in his or her own way and own time. Rationale 3: Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 4: Courage is the sense of going into the unknown, informed by insight from past experiences. Because the manager had prior experience that was positive from the director of nursing, the manager will use this information to address a problem that has not been introduced before.

Which statement is accurate concerning the management of migraine headaches? 1. Acute treatment and prevention are achieved via the same medications. 2. There are no pharmacologic agents available to prevent migraine headaches. 3. Chronic headache pain is managed via daily NSAID use. 4. Vasoconstriction of cranial arteries helps reduce acute headache pain.

Correct Answer: 4 Rationale 1: Migraine headaches are thought to occur from an initial vasoconstrictive episode that is followed by vasodilation and acute pain. Acute episodes are treated with cranial artery vasoconstrictors and prevention via vasodilators.

The patient has a patient-controlled analgesia (PCA) pump following surgery. The nurse keeps naloxone (Narcan) in the patients room as per protocol. What does the nurse recognize as the rationale for this protocol? 1. Naloxone (Narcan) enhances the effect of the opioid in the patient-controlled analgesia (PCA) pump and increases analgesia. 2. Naloxone (Narcan) is the antidote if an anaphylactic reaction to the opioid in the patient-controlled analgesia (PCA) pump occurs. 3. Naloxone (Narcan) is available to treat any systemic side effects, like constipation, of the opioid in the patient-controlled analgesia (PCA) pump. 4. Naloxone (Narcan) will reverse the effects of the narcotic in the patient-controlled analgesia (PCA) pump if an overdose occurs.

Correct Answer: 4 Rationale 1: Naloxone (Narcan) is an opioid antagonist, and will reverse the effects of the narcotic in the pump if an overdose occurs. Naloxone (Narcan) does not enhance the effects of opioids. Naloxone (Narcan) is not used to treat anaphylactic reactions. Naloxone (Narcan) is not used to treat opioid-related constipation.

The patient has intractable pain, and the physician has proposed a nerve block. The nurse plans to teach the patient about nerve blocks. Which statement would be included in the best plan of the nurse? 1. A nerve block depresses the activity of the sympathetic nervous system. 2. A nerve block enhances the effect of most of the endogenous opioids. 3. A nerve block modifies sensory information being sent to the spinal cord. 4. A nerve block stops pain transmission along the nerve to stop the pain.

Correct Answer: 4 Rationale 1: Nerve blocks are accomplished by injection of alcohol or another neurotoxic substance into neurons. This blocks nerve transmission and has the potential to provide total pain relief. A nerve block does not enhance the effect of endogenous opioids. A nerve block does not modify sensory information sent to the spinal cord. A nerve block does not depress the activity of the sympathetic nervous system.

The nurse is researching the concept of caring as it relates to specific situations in the clinical area. More specifically, the nurse is interested in caring as it relates to cultural differences. Of the following theorists, which would be of the most help to this nurse researcher? 1. Florence Nightingale 2. Jean Watson 3. Dorothea Orem 4. Madeline Leininger

Correct Answer: 4 Rationale 1: Nightingales theory focuses on the environment. Rationale 2: Watsons theory focuses on caring in itself. Rationale 3: Orems theory is about self-care and deficit. Rationale 4: Leiningers theory of culture care diversity and universality is based on the assumption that nurses must understand different cultures in order to function effectively.

The patient comes to the emergency department with a head injury, broken ribs, and internal bleeding. Opioid analgesics are contraindicated. What does the nurse recognize as the primary rationale for this? 1. The use of opioid analgesics will depress the patients blood pressure. 2. The patient may not be able to communicate his level of pain. 3. Opioids will not effectively relieve pain in the patients periphery. 4. Opioids can mask changes in the patients level of consciousness.

Correct Answer: 4 Rationale 1: Opioids are central nervous system (CNS) depressants and can mask the patients level of consciousness; this is dangerous when the patient has a head injury. Depression of blood pressure could occur, but this is not as critical as level of consciousness. The patient may not be able to determine his level of pain, but this is not as critical as level of consciousness. Opioids do not effectively relieve pain in the patients periphery, but this is not as critical as level of consciousness.

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.

Correct Answer: 4 Rationale 1: Placing the feet together makes the body more unstable and more likely to fall. Rationale 2: In order to pick up this box as safely as possible, the nurse should flex the knees to lower the center of gravity. Rationale 3: After picking up the weight, the body should not be rotated, but should be turned to face the table. Rationale 4: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible.

The nursing instructor teaches the nursing students about neural mechanisms of pain. What does the nursing instructor teach about substance P? 1. Substance P modifies sensory information in the spinal cord. 2. Substance P is also known as an endogenous opioid. 3. Substance P stimulates pain receptors in the spinal cord. 4. Substance P controls which pain signals reach the brain.

Correct Answer: 4 Rationale 1: Spinal substance P is critical because it controls whether pain signals will continue to the brain. Endogenous opioids, not substance P, modify sensory information at the level of the spinal cord. Substance P does not stimulate pain receptors in the spinal cord. Substance P is not an endogenous opioid.

During a midterm evaluation, the nurse educator tells the students they need to work on improving their aesthetic knowledge. How should the students plan to accomplish this recommendation? 1. Study harder. 2. Take better notes. 3. Read about the same topic from a variety of sources. 4. Spend time in the clinical area with seasoned nurses.

Correct Answer: 4 Rationale 1: Studying harder improves empirical knowledge. Rationale 2: Taking better notes improves empirical knowledge. Rationale 3: Reading about the same topic from a variety of sources improves empirical knowledge. Rationale 4: Aesthetic knowing is the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of clients. Understanding how other nurses meet the needs of their clients and seeing a variety of methods to provide the same care will help improve this type of knowledge for the students.

For which of the following patients suffering a migraine headache would sumatriptan (Imitrex) be indicated? 1. 73-year-old with angina pectoris 2. 36-year-old female with preeclampsia 3. 45-year-old diabetic male 4. 27-year-old asthmatic male

Correct Answer: 4 Rationale 1: Sumatriptan is contraindicated in patients with hypertension, angina, and diabetes. It also is a Pregnancy Category C drug.

The nurse manager determines that a staff nurse demonstrates compassion when providing client care. What did the manager observe to come to this conclusion? 1. A nurse who has expert technical skills and has the most experience with critical care 2. A nurse who routinely gives back rubs to clients before they go to sleep 3. A nurse who has written procedures and policies in language that is both professional and realistic 4. A nurse who takes time to understand the spiritual needs of clients

Correct Answer: 4 Rationale 1: Technical skills focus on the competency of the nurse. Rationale 2: Giving routine back rubs focuses on comfort. Rationale 3: Writing abilities focus on the competency of the nurse. Rationale 4: Attention to spiritual needs is part of compassionate care, particularly in the face of death and bereavement.

A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing 1. a placebo. 2. distraction. 3. guided imagery. 4. the gate control theory of pain.

Correct Answer: 4 Rationale 1: The application of ice is not a placebo. Rationale 2: The application of ice is not a distraction. Rationale 3: The application of ice is not a use of guided imagery. Rationale 4: In the gate control theory, signals of noxious stimuli are carried to the dorsal horn, where they are modified according to the balance of the substantia gelatinosa. By using ice, the substantia gelatinosa is calmed, reducing the pain.

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated.

Correct Answer: 4 Rationale 1: The bed safety device was not activated. It was not malfunctioning. Rationale 2: The client did not remove the leg band of the monitoring device. Rationale 3: The nurse needs to report the fall to the primary care physician. Rationale 4: The nurse needs to document what occurred with the client and why.

A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this clients hygienic practice? 1. Religion 2. Personal preference 3. Culture 4. Health and energy

Correct Answer: 4 Rationale 1: The clients inability to lift the legs to get into the shower is not a religious practice. Rationale 2: The clients inability to lift the legs to get into the shower is not a personal preference. Rationale 3: The clients inability to lift the legs to get into the shower is not a cultural preference. Rationale 4: Ill people or those with neuromuscular disorders may not be able to perform hygienic care.

A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the clients medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

Correct Answer: 4 Rationale 1: The nurse is responsible for communicating the clients medications to the long-term care facility, and documents this communication. Rationale 2: The clients medications will not be filled prior to going to the long-term care facility. Rationale 3: It is not the clients responsibility to communicate medications to the nurses at the long-term care facility. Rationale 4: The nurse should communicate the clients medications to the nurses at the long-term care facility and document that this communication occurred.

The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury.

Correct Answer: 4 Rationale 1: The nurse will need to assess the clients mental status to help accomplish this goal. Rationale 2: Keeping the client dependent on the staff for care does not encourage independence. Rationale 3: Making all choices for the client does not encourage independence. Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free.

The postsurgical patient has an order for morphine 2 mg IV push every 2 hours and propoxyphene 100 (Darvon 100) every 3 hours. He received the morphine 2 hours ago, and is complaining of pain again. What will the best plan of the nurse include? 1. Plan to administer the morphine again. 2. Plan to administer the propoxyphene 100 (Darvon 100). 3. Plan to have the patient do some distraction techniques. 4. Plan to assess the patients level of pain.

Correct Answer: 4 Rationale 1: The patients level of pain should be assessed prior to the administration of any analgesic. The patients level of pain should be assessed prior to administration of propoxyphene (Darvon) 100. The patients level of pain should be assessed prior to administration of additional morphine. Distraction techniques are appropriate, but should not take the place of a pain assessment and administration of an analgesic.

A clients pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? 1. Provide NSAID medication as prescribed. 2. Coach the client with guided imagery. 3. Suggest the client read or watch television until the pain subsides. 4. Provide opioid analgesic as prescribed.

Correct Answer: 4 Rationale 1: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If the client reports mild pain, an analgesic such as acetaminophen might be indicated. Rationale 2: Using a technique such as guided imagery is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected. Rationale 3: Using a technique such as watching television is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected. Rationale 4: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If a client reports severe pain, a more potent pain relief measure is indicated.

The patient has been receiving escitalopram (Lexapro) for treatment of obsessive-compulsive disorder. Unknown to the nurse, the patient has also been self-medicating with St. Johns wort. The patient comes to the office with symptoms of hyperthermia and diaphoresis. Which statement best describes the result of the nurses assessment? 1. The patient is experiencing symptoms of St. Johns wort toxicity, as the medication was most likely outdated. 2. The patient has contracted a viral infection. Escitalopram (Lexapro) and St. Johns wort are safe to take together. 3. The patient has not been taking escitalopram (Lexapro) and is experiencing withdrawal. 4. The patient has combined two antidepressant medications and is experiencing serotonin syndrome.

Correct Answer: 4 Rationale 1: Use caution with herbal supplements such as St. Johns wort, which may increase the effects of escitalopram (Lexapro) and cause serotonin syndrome. The patients symptoms are consistent with serotonin syndrome, and there is no evidence that the patient has not been taking the escitalopram (Lexapro). The patients symptoms are consistent with serotonin syndrome, and there is no evidence that the patients St. Johns wort is outdated. The patients symptoms are consistent with serotonin syndrome. It is not considered safe to combine escitalopram (Lexapro) and St. Johns wort.

A dull, aching pain is defined as 1. nerve pain. 2. somatic. 3. neuropathic. 4. visceral.

Correct Answer: 4 Rationale 1: Visceral pain is defined as a dull, throbbing, or aching pain.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.

Correct Answer: 4 Rationale 1: Wearing a back belt does not prevent injury. Rationale 2: Body mechanics training does not prevent injuries. Rationale 3: Physical fitness does not prevent back injury. Rationale 4: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting.

Question 6 The client is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to the client? 1. The client has lost 7 pounds since treatment began. 2. The client sleeps so soundly that he snores. 3. The clients diabetes is now under control. 4. The client reports a decrease in morning headache.

Correct Answer: 4 Rationale 1: Weight loss is not a direct result of CPAP therapy. Rationale 2: Snoring is a sign of apnea, not sound sleeping. Rationale 3: Successful treatment for sleep apnea will not help control diabetes. Rationale 4: The fact that the client experiences a decrease in morning headache indicates the client is sleeping better.

The nurse, seeing a client asleep, turns off the television in the room. The client opens her eyes and says I was watching that. I wasnt sleeping. The nurse realizes that the client was demonstrating which stage of NREM sleep? 1. IV 2. III 3. II 4. I

Correct Answer: 4 ( Stage I ) Rationale 1: Stage IV is not a stage of NREM sleep. Rationale 2: Stage III is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a 30-second period. During deep sleep or delta sleep, the sleepers heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur. Rationale 3: Stage II is the stage of light sleep during which body processes continue to slow down. The eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature falls. An individual in stage II requires more intense stimuli than in stage I to awaken, such as touching or shaking. Rationale 4: Stage I is the stage of very light sleep, and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened, and might deny that she was sleeping.

The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client? Standard Text: Select all that apply. 1. Lower respiratory rate 2. Increased muscle tension 3. Increased lower extremity edema 4. Lower blood pressure 5. Lower heart rate

Correct Answer: 4, 5 Rationale 1: A change in respirations is not associated with sleep. Rationale 2: Skeletal muscles relax during sleep. Rationale 3: Peripheral blood vessels dilate during sleep, which will reduce lower extremity edema. Rationale 4: One physiological change that occurs during sleep is a drop in arterial blood pressure. Rationale 5: One physiological change that occurs during sleep is a decrease in heart rate.

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? Standard Text: Select all that apply. 1. Supine 2. Fowlers 3. Trendelenburg 4. Prone 5. Side-lying

Correct Answer: 4, 5 Rationale 1: The supine position does not expose the clients back. Rationale 2: The Fowlers position does not expose the clients back. Rationale 3: The Trendelenburg position does not expose the clients back. Rationale 4: The prone position is recommended for a back rub. Rationale 5: The side-lying position can be used if a client cannot assume the prone position for a back rub.

The patient, addicted to heroin, is being treated for opioid dependence. He has been prescribed methadone (Dolophine). The patient asks how this will help because methadone (Dolophine) is another opioid. What is the best response by the nurse? 1. Methadone (Dolophine) will make you really sick if you use heroin. 2. Methadone (Dolophine) does not cause euphoria like heroin does. 3. Methadone (Dolophine) cures your addiction to heroin. 4. Methadone (Dolophine) causes you to have an allergy to heroin.

orrect Answer: 2 Rationale 1: Methadone (Dolophine) does not cause the euphoria of heroin, or cure the dependence. It is a substitute drug that allows the patient to be productive. Methadone (Dolophine) does not cure heroin addiction. Methadone (Dolophine) does not cause an allergy to heroin. Methadone (Dolophine) will not cause a person to become sick if they use heroin.

What is a priority assessment question to ask a postsurgical patient prior to administration of an opioid analgesic? 1. Have you ever been addicted to prescription pain medications? 2. Why do you want to receive this pain medication? 3. Would you like me to help you change your position for comfort? 4. Would you please rate your pain on a scale of 1-to-10?

orrect Answer: 4 Rationale 1: The nurse should always assess the patients level of pain prior to the administration of an analgesic. Asking a postsurgical patient why a pain medication is requested does not make a lot of sense. Administration of pain medication postsurgery is a priority; this is not the time to assess if the patient has an addiction. Offering to help a postsurgical patient change positions is appropriate, but should be done after the patient receives the pain medication.

Perception

■ Client becomes conscious of pain ■ Sum of complex activities in the CNS that shape the character and intensity of pain perceived.

Pharmacological Management-Mild pain (1 to 3 on pain scale)

■ NONOPIOD Analgesics/ NSAIDS ■ Mild pain (1 to 3 on pain scale) - Acetaminophen - Acetylsalicylic acid - Choline magnesium trisalicylate - Ibuprofen - Indomethacin sodium trihydrate - Naproxen - Ketorolac - Piroxicam - Meloxicam - Celecoxib

Pharmacological Management-Moderate pain (4 to 6 on pain scale)

■ OPIOID Analgesics for Moderate Pain ■ Moderate pain (4 to 6 on pain scale) - Hydrocodone - Codeine - Tramadol - Pentazocine

Pharmacological Management-Severe Pain (7 to 10 on pain scale)

■ OPIOID Analgesics for Severe Pain ■ Severe Pain (7 to 10 on pain scale) - Fentanyl Citrate - Hydromorphone hydrochloride - Oxycodone - Morphine sulfate - Oxmorphone - Methadone

Opioid Side Effects

■ Respiratory depression ■ Sedation ■ Nausea/Vomiting ■ Urinary retention ■ Blurred vision ■ Sexual dysfunction ■ Constipation

Modulation "descending system"

■ Signals are sent back through dorsal horn of spinal cord & release & inhibit pain: - Endogenous opioids - Serotonin - Norepinephrine ■ Meds: - Tricyclic antidepressants - NMDA antagonists (ketamine, dextromethorphan)

Gate Control Theory

■ pain pioneer(youtube) ■ Using the Gate control theory nurse can use this model to stop nociceptor firing (treat the underlying cause), apply topical therapies (heat, ice, electrical stimulation or massage) and address the client's mood (reduce anxiety and anger).