Solution Manual For Foundations and Adult Health Nursing 9th Edition by Kim Cooper Chapter 1-58

Foundations of Adult health Nursing Solutions Answer Key

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Answer Key CHAPTER 1—THE EVOLUTION OF NURSING Matching 1. b 2. d 3. e 4. a 5. f 6. h 7. c 8. g 9. j 10. i Short Answer 11. The National League for Nursing (NLN) established educational standards and criteria and is involved in the voluntary accreditation of nursing programs.

12. The purposes of NAPNES and NFLPN are to: Set standards for practical/vocational nursing programs.

Promote and protect practical/vocational nursing.

Educate and inform the general public about practical/vocational nursing.

13. LPN/LVNs function to provide specific services to patients under the direct supervision of a licensed physician, dentist, or registered nurse; assists individuals, sick or well, in the performance of those activities contributing to health, to their recovery, and to gain independence as rapidly as possible or to have a peaceful death. The LPN/LVN is educated to be a responsible member of a health care team, performing basic therapeutic, rehabilitative, and preventive care to assigned patients. LPN/ LVNs are continuing to provide care in all types of settings, with the majority employed in long-term care settings.

Fill-in-the-Blank Sentences 14. state board of nursing 15. National Council of State Boards of Nursing 16. Patient’s Bill of Rights

Multiple Choice 17. Answer 2: One of the primary problems of the early nineteenth century hospitals was poor hygienic practices. Hospitals were dirty and overcrowded and care was mostly given by untrained persons.

18. Answer 4: The population is aging rapidly and there is an increased need for nursing services for this growing segment of the population.

19. Answer 3: “Nightingale Nurses” improved patient care and advanced the practice of nursing through good hygiene, sanitation, patient observation, accurate recordkeeping, nutritional improvement, and the introduction and use of new equipment.

20. Answer 1: The four major concepts are nurse, patient, health, and environment.

21. Answer 4: Poverty, homelessness, and unemployment are factors in increased risk for health problems.

22. Answer 2: Physiologic needs, such as eating and oxygenation, are the first priority according to Maslow.

23. Answer 4: Adolescence is time when love and belonging to a peer group are very important.

Being part of a team is the best way to help him meet this need.

24. Answer 1, 3, 5: Patient can participate in smoking cessation; stress, weight, and alcohol intake reduction; and control over own body and health. Giving information about technology, new medications, and costs may be of interest to the patient, but these topics are less useful in helping the patient take an active role in her own health.

25. Answer 4: While the UAP or unit secretary can direct visitors, extreme caution should be used in giving out patient information.

(Note to student: Even acknowledging that a patient has been admitted to the hospital can be viewed as a violation of confidentiality.)

Taking vital signs is acceptable; however, the pharmacist generally restocks medications.

Validating and interpreting are nursing responsibilities.

26. Answer 2: Economic use of time and materials is the best way to contain costs for individual

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patients. Malpractice insurance does not help to contain costs. While it is appropriate to question the health care provider about safety issues, it is not appropriate to question use of diagnostic testing. Diagnosis is an extremely complicated process, which requires an extensive depth of knowledge about pathology. Referring patients to another clinic just shifts the financial burden to another part of the health care system.

Answer 1: Orem’s theory is based on helping the patient to attain self-care. Nightingale’s theory uses manipulation of the environment (i.e., patient’s pillows). Benner and Wrubel demonstrate caring by assisting the patient to cope. Parse’s theory encourages the patient to participate in the health experience.

Answer 1, 2, 3, 4, 6: Under the terms of this document, patients are assured that they can expect high-quality hospital care, a clean and safe environment, involvement in their care and the decision-making process, protection of privacy, help when leaving the hospital, and help with billing concerns. Patients cannot always expect to get a private room with all amenities.

Answer 3: Health care workers are entitled to respect from patients and also expect patients to be responsible for their own behavior.

Answer 3: LPN/LVNs never function independently without the supervision of an RN or health care provider.

Critical Thinking Activities 31.

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Wellness Highest level of optimal health

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Illness Diminished or impaired state of health

This patient has some health problems and some changes in her life, but she has a relatively high level of wellness. Her blood pressure is under control and she has adapted to a major change (retirement), by taking on a new challenge of volunteering. Her positive outlook on life allows her to find joy in the prospect of sharing time with a new generation. a. Originally, the white pleated cap and the apron signified respectability, cleanliness, and servitude. Caps gradually became symbolic of office and achievement and were celebrated with capping ceremonies.

Uniforms became more informal and nurses complained that caps interfered

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with care, caused hair loss, took too much time for washing and starching, and were a source of bacteria. Health care facilities and nursing schools typically have dress codes for style of uniform and/or color. Staff are generally required to wear nametags and identification badges. Many nurses do not approve of mandatory dress codes. They argue that other health care professionals do not depend on uniforms for their authority. b. It is likely that as a nursing student and a soon-to-be nurse that looking professional is important to you. You may feel anxious to be rid of your current student uniform for a variety of reasons. Freedom of choice, unattractive style, and not being marked as a student are frequent reasons cited by students. From patients’ point of view, they feel more comfortable and confident when they are easily able to distinguish nurses from other staff members. Recent studies also suggest that patients believe that nurses who wear white are better nurses than those who do not wear white. a. This patient has complex physical problems and he has some lifestyle, social, and financial issues that need extra attention.

Registered nurse (RN)—provides direct patient care in the hospital and an RN from a home health agency could also be involved in the care of this patient.

LPN/LVN—works under the supervision of the RN in providing patient care.

Physician—provides diagnosis and prescription of treatment and medications.

Social worker—provides counseling and referral to community resources.

Physical therapist—offers exercises and will assist this patient in learning techniques for safe ambulation, bending, and lifting.

Dietitian—provides nutritional counseling.

Respiratory therapist—supervises oxygen administration and performs pulmonary assessments.

Technologist—will obtain and analyze specimens and perform other diagnostic procedures.

Pharmacist—prepares the medication in the hospital. The community pharmacist can help this patient monitor his home medications.

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Answer Key 3

(Note to student: Some hospitals will also have a financial counselor to assist the patient in understanding the hospital bill and to make arrangements in paying outof-pocket costs.) b. For primary prevention, the nurse would encourage wellness activities and preemptive screening programs such colonoscopy or glucose screening. For secondary prevention, to reduce the impact of the chronic respiratory disease, the nurse would encourage smoking cessation and weight loss. For tertiary prevention, the nurse would get a referral for home health assistance, including physical therapy, which will improve quality of life and reduce further loss of function.

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CHAPTER 2—LEGAL AND ETHICAL ASPECTS OF NURSING Matching 1. e 2. d 3. b 4. h 5. f 6. a 7. c 8. j 9. g 10. i

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True or False 11. True 12. True 13. False. Duty refers to the established relationship between the patient and the nurse.

14. False. Assault is an intentional threat to cause bodily harm to another; does not have to include actual bodily contact. The nurse would be charged with battery, which is the unlawful touching of another person without consent.

15. True Multiple Choice 16. Answer 4: The student has initiated the nursepatient relationship and therefore has the duty to act. All students are CPR-certified so the student has to perform the duty in a reasonable and prudent manner as would other nursing students. All of the other options are also likely to be necessary. (Note to student:

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Discuss this situation with your clinical instructor for advice about visiting patients during the preclinical preparation time.)

Answer 4: A poor nurse-patient relationship increases the likelihood that the patient will seek legal action and harm has to occur in order for liability to be established. The family of the elderly patient could seek damages, but that is less likely if they understand that the nurse and facility will try their best to prevent falls, but are unable to physically restrain patients for the purpose of preventing falls. The angry patient may report the nurse to the supervisor, but if no harm is sustained then any legal action against the nurse will not be successful. The family who complained at 3:00 am may also be very angry. The nurse’s decision to wait must be based on comprehensive assessment of the patient to ascertain that there is nothing to warrant calling at 3:00 am. Careful documentation is necessary. Making an incident report in all of these situations would be a good idea.

Answer 1, 2, 3, 4, 6: The UAP’s personal health records are confidential and unrelated to the patient’s case.

Answer 2: Early discharge and high levels of patient acuity require excellent discharge teaching so patients can perform self-care and self-monitoring and are therefore less likely to suffer harm. Being able to take a limited number of high-acuity patients would be ideal, but high acuity is the current trend. Having malpractice coverage is good if litigation occurs; however, insurance payouts may actually be contributing to the problem. Ensuring accountability of others is not possible.

Answer 1: Assess knowledge and readiness to perform. Barriers may include knowledge deficit or feelings of anxiety or self-doubt. Going with her and observing performance and pulling her file would be appropriate after assessment. Forcing someone to do a task that is beyond their ability and understanding is inappropriate supervision and the nurse would be liable for the UAP’s errors.

Answer 2: Locate the RN in charge so that the blood can be started. Health care providers can supervise nurses and they know the potential adverse reactions of blood products; however, they are generally less familiar with the policies and procedures related to the actual administration.

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Answer 1, 2, 3, 4: Do not include any information that identifies the patient. Information such as the room number or the health care provider’s name may seem harmless, but including those details could lead to speculation about patient’s identity. A clinical report must include information such as vital signs and medical condition. If in doubt, the clinical instructor should be consulted.

Answer 1: Patients must be at least 18 years old to give consent. If under 18, the exceptions are marriage; court-approved emancipation; self-supporting and living apart from parents; military service; or for STIs, alcohol or drug abuse, sexual assault, or family planning.

Answer 3: Policies about giving patient information over the phone will vary. For example, some facilities may not allow acknowledging that the patient is or is not there. Other facilities require that the patient have a list of people who are allowed to call for information.

Another variation is that selected callers are given a phone code to reach the patient. The nurse should be familiar with hospital policy, because the policies are designed to specifically comply with HIPAA. Answer 3: Alert the health care provider so the child can be examined for occult injury.

The other options may also be used to investigate the possibility of child abuse.

Answer 3: Call for help first, because the health care team is not prepared to face armed assailants. Trying to reassure patients in the immediate area would be the second step.

Stifle the impulse to run out and help. If the emergency staff is killed or injured, this makes the situation worse. Locking doors in an emergency department is likely to be impractical and create additional safety problems.

Answer 1: Being competent and compassionate are the best defenses. Knowing the legal definition may be helpful, but definitions are abstractions and the nurse’s day is full of real-world events. Obtaining malpractice insurance is likely to make the nurse feel better, but it does not decrease the chances of getting sued. Validating nursing actions with another is always beneficial, but this is not a realistic option for minute-to-minute care.

Answer 2: The nurse is assessing the wound during the dressing change and documentation should reflect the nurse’s attention to the standard of care. Documenting the type of

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dressing may be necessary for continuity of care and also for reimbursement. The other options are incorrect.

Answer 4: Disciplinary defense insurance includes attorney; wage loss reimbursement; travel, food, and lodging expenses; and legal fees when the nurse has to go before the board of nursing for disciplinary action. The other types of insurance are for malpractice protection.

Answer a. 4, b. 3, c. 2, d. 5, e. 1: The nurse hopes for dismissal of charges. The letter of reprimand may be formal or informal. Probation with stipulations means that the nurse can continue to work, but under conditions as determined by the board (e.g., monitored).

Suspension with stipulations means that the nurse cannot continue to work, but there are conditions that must be fulfilled. Revocation of license is loss of licensure.

Answer 1: First, assess the patient’s feelings by encouraging expression. The patient may not understand the advance directives or may have issues that were triggered by the discussion. The other options are also necessary.

Answer 2: The patient’s living will is the best protection, because it reflects the patient’s wishes. Policies and procedures and the Joint Commission may contain general guidance about giving excellent care to patients, but will not offer any specific help in this situation. The Patient Self-Determination Act supports the use of living wills to define the individual’s choices about care and treatment.

Answer 4: The nurse, the 13-year old girl, and the mother all have very strong feelings about this emotional situation. First, the nurse must control her own responses. The other options are likely to be necessary, but this will be a difficult process and other health care team members, such as a social worker, family counselor, spiritual advisor, legal counsel, or obstetrician are likely to be involved.

Answer 1, 2, 3, 5: If the nurse observes another nurse being rude toward a patient, the ethical thing to do would be to follow up so that patients are respected. Texting should not be used as an additional method of passing gossip among staff. The other options demonstrate ethical professional behavior.

Answer 3: The supervisor should be presented with the facts. Theft is unethical and elderly residents are in an especially vulnerable position; thus the Nurse B is not giving good

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Answer Key 5

care. Talking to the residents or families will be part of the investigation that is conducted by the supervisor. The supervisor could recommend that both nurses seek assistance for values clarification.

Critical Thinking Activities 36. a. In regard to informed consent for a surgical or diagnostic procedure, the nurse may be responsible for witnessing that the patient is signing the consent and is aware of the treatment, risks, alternatives, and consequences of accepting or rejecting care. The nurse should be careful not to discuss with the patient the elements of disclosure that the health care provider is required to make, such as the risks or benefits involved with the treatment or procedure. b. The nurse should go back to the charge nurse and clarify how nurses are getting informed consent signed. It is possible that health care providers are explaining the procedures and the nurses are later assessing the patients’ understanding and then contacting the provider if the patient has additional questions or needs clarification; however, this is not the best situation. Ideally, the nurse should accompany the provider during the explanation and the form should be signed at that time.

The nurse could ask the charge nurse to obtain the informed consent and then further discuss this process with a supervisor, because the nurses in this facility are at great risk for practicing outside scope of practice and could be liable if the patient suffers harm from the procedure.

37. a. Further assessment is needed to determine the underlying motivation for the action of these two nurses. It appears that Nurse A is reluctant to care for “those kinds of people” and the code specifies that the nurse should provide care without discrimination. Assessment of Nurse A’s behavior may reveal that she lacks the confidence or skills to care for AIDS patients; thus additional training is needed.

Possibly the death of a close friend from AIDS may have created an emotional barrier and thus she may need grief counseling. Nurse B is attempting to help Nurse A, which is a laudable action; however, in order to maintain a high degree of person-

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al and professional behavior, which is also part of the code of ethics, Nurse B should talk to Nurse A about the comment, rather than ignoring it. b. Nurse B should initiate the process of values clarification, either by herself or with assistance from a counselor or supervisor.

This process includes thinking about a belief or behavior, deciding its value and incorporating the value into a response.

Nurse B could talk directly to Nurse A to see if Nurse A is actually discriminating against a certain type of patient or if there is some other problem, such as knowledge/skills deficit. Nurse B may also decide to report Nurse A’s unethical behavior by following the appropriate chain of command, explaining the facts clearly, and documenting the incident objectively and accurately. a. First, the nurse needs to involve other members of the health care team, such as the health care provider and the psychiatric social worker. Physical causes for depression or changes in cognition should be investigated, as well as psychological causes of depression. A psychiatrist or psychiatric clinical nurse specialist should assess the patient for signs of suicide. If the patient is deemed of sound mind, than he has the right to refuse care. b. When a patient refuses care, the nurse may experience a personal feeling of rejection. The nurse has to recognize that refusal of treatment is not a refusal of interaction and human warmth. It may be difficult, but the nurse should continue to check on the patient as before and to spend as much time as before, but the focus may shift from task orientation to therapeutic communication. And of course the patient always has the option of changing his mind and accepting selected elements of care. c. For nurses, the refusal of heroic measures is often easier to accept, because many nurses themselves do not want to be kept “alive by machines.” However, it seems cruel and inhuman if basic needs like food or hygiene are not provided. Nurses have worked for centuries trying to prevent pressure ulcers and to improve patient outcomes. Nurses may also believe that immunization is partially for the pro-

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Answer Key 6

tection of the individual, but also for the purpose of “herd immunity.” Nurses are trained to be problem-solvers and doers.

Doing nothing for the patient may seem difficult, but remember that supporting the patient emotionally and psychologically is also a nursing function.

39. The nurse has gone up the chain of command and reported her concerns to the supervisor.

However, the nurse could still be involved in a legal action if there is an occurrence where a patient is harmed. The nurse could report the conditions to the state board of nursing, but change is likely to come slowly, if at all. The nurse may opt to make personal notes or incidents reports related to working conditions or to discussions with supervisors.

The ethical implications are that the nurse is employed in a situation that is constantly putting the patients at risk; however, in some ways, if the nurse opts to quit and seek another job, then the patients have lost an advocate and a caregiver. In addition, this scenario is not uncommon and the nurse could find that he/she has jumped from the frying pan into the fire.

If the nurse opts to stay, then teamwork is especially important under these conditions and watching out for each other and all of the patients becomes more important when everyone is tired and stressed.

CHAPTER 3—DOCUMENTATION Matching 1. d 2. k 3. f 4. l 5. j 6. h 7. b 8. c 9. a 10. e 11. g 12. i

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teaching, and source for research and data collection.

Focus charting uses the nursing process and the focus is sometimes a current patient concern or behavior, and sometimes a significant change in patient status or behavior or a significant event in the patient’s therapy. In CBE, complete physical assessments, observations, vital signs, intravenous (IV) site and rate, and other pertinent data are charted at the beginning of each shift. During the shift, the only notes the nurse will make will be for additional treatments done or planned treatments withheld, changes in patient condition, and new concerns. Narrative charting is an abbreviated story form of patient care. It is used for both computerized and noncomputerized nurse’s notes and includes subjective and/or objective data, consultations, care and treatments, and response to therapy.

Home health care and long-term care documentation are directly related to reimbursement, because patients’ eligibility and services provided by the nurses must be documented to justify payment by Medicare, Medicaid, or private insurance companies. The charting is not usually done on the same time schedule or with the same frequency as that of the acute care facility. An interdisciplinary approach must be documented in the notes along with evidence of compliance with state and federal regulations. For home health care, nurses carry written records with them or use a laptop computer to maintain patient documentation.

Table Activity 16. See Table 3-1, Essential Elements of Documentation, page 39.

Short Answer 13. The five basic purposes of patient records are communication, permanent record of accountability, legal record of care, information for

Multiple Choice 17. Answer 4: Narrative notes should include a complete description of the patient’s response to any therapies. As a student, you write evaluation statements on a care plan, but in the hospital it is unlikely that you will see the actual care plan format that you use in school.

The Kardex is tool that outlines therapies, orders, and activities, but there is no space for documentation of outcomes. Medication administration times are recorded on the MAR, but usually there is no space for additional notation.

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Answer 3: Documentation can always be improved; however, it is particularly important to document patient condition on discharge and any follow-up instructions. If the patient goes home and immediately dies, the nurse, who is the last professional to see the patient, has made no note to indicate that the patient was stable on leaving the hospital.

Answer 2: In a large hospital, there could be many employees who would have a legitimate reason to look at the patient’s chart; however, for document security and patient confidentiality the nurse is obligated to question any unfamiliar person. If the person identifies self and the nurse is still not sure if access is appropriate, the charge nurse or security could be contacted for advice.

Answer 4: Computer access and time for documentation can always be a problem, so making notes for personal use is an alternative.

The student can always ask the instructor for advice, but there is nothing the instructor can do about lack of functional computers. Hardcopy charting is usually reserved for total system shutdown for prolonged periods of time.

Waiting until the end of the shift is never the best option.

Answer 3: The nurse would meet the patient’s immediate need for the medication. Since the vital sign data are missing, the nurse applies nursing process and assesses the blood pressure and pulse before administering the medication. Then the nurse documents the BP and pulse and the administration of the medication. Next the nurse would find the UAP and ask about the vital signs (Ask about other patients too; the UAP should have finished and recorded all am vitals by 10:00 am.) Giving the medication without knowing the BP is an incorrect action. If the UAP recorded the vitals in the narrative notes, he/she may need additional training, because this is not the best place to document routine vital signs.

Answer 2: If the nurse is clear about the orders, it would be appropriate to carry them out. If there are questions, the nurse should call the health care provider for clarification.

Later, consult a supervisor about provider’s response; SBARR is a relatively new concept and some providers may need some additional instruction about the process. Documenting the incident in the patient’s chart is not appropriate.

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Answer 3: The charge nurse can determine the corrective action, which may include referral to the nurse educator. Coworkers do not have time to teach basic spelling and grammar to other employees. All health care professionals are obligated to watch out for each other and the patients; therefore, doing nothing is incorrect. The nurse can correct (not change) his/ her own documentation, but not the documentation of others.

Answer 3: Documenting the time that the patient is in x-ray explains why the medication was not given on time. Consult the charge nurse, because there are certain medications that should not be held for prolonged time periods. Interventions and therapies should be documented after they are completed, not before. Calling the pharmacy is okay, but the student will have to take additional steps after talking to the pharmacist. An incident report is not needed at this time if steps are taken to resolve the situation.

Answer 1: Clinical (critical) pathways allow staff from all disciplines to develop standardized, integrated care plans for projected length of stay for specific and predictable cases. Day-to-day elements of care such as activity and pain control are laid out. Unusual events with potential for harm or those that cause actual harm are usually documented in an incident report. The pathway is a multidisciplinary care plan that replaces the nursing care plan. The LPN/LVN has a role in monitoring and documenting, but professional roles are not specifically written out in the pathway.

Answer 3: The nurse manager will have knowledge of policies related to medical records and leaving the hospital prior to discharge. The records are hospital property, but this explanation is likely to cause the patient to become more upset. Contacting the health care provider may be appropriate to address the patient’s desire to leave the hospital, but the provider is not the best resource to contact for requesting records. Copying the chart for the patient is incorrect, because policies need to be reviewed and followed.

Answer 4: Contact the nursing instructor for guidance. Immediately shredding the Kardex or checking for patient identifiers at this point does not address the problem. Apologizing and explaining may seem like the best route, but the student should seek out the instructor

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Answer Key 8

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first. This is a serious HIPAA violation that could result in disciplinary action or even a lawsuit for the student and the instructor.

Answer 1: For paper charting, draw a line through it and initial the error. Generally there is no need to report this type of error to the charge nurse, unless there is some unusual occurrence. Using correction fluid is incorrect. Discarding the page is a possibility if the nurse is the first and only person to make an entry on that page.

Answer 1, 2, 3, 4: Failure to completely document allergies puts the patient at risk for severe allergic reactions that could result in death. Using patient quotes may be appropriate for describing symptoms or conditions, but complaints about care or caregivers would be documented in an incident report.

Documenting medication that is not given is falsification. Failure to document assessment of the IV site indicates low quality of care (even if there was no actual problem with the IV site). Clustering information is a common and acceptable method of documentation.

It would be better if the generic and brand names are written in orders; however, if the meaning is clear, legible, and accurate, the order is acceptable.

Answer 2: If the computer monitor is left open, anyone who walks by can look at the information. In addition, an active login allows anyone to go into the system under the nurse’s password. The other actions are acceptable ways to pass information to other health care team members.

Critical Thinking Activities 31. Sample #1: Day of month and time of entry are missing. “Good night” and “status unchanged” are empty, general phrases. There is one spelling error: escendially should be corrected to essentially. Rather than charting diamond ring and gold watch, use descriptive adjectives, such as clear, white, or yellow.

Also, documenting that expensive items are being stored in the bedside table creates liability for theft or loss. Patient’s condition, the time, and the method of transportation to the cafeteria are missing.

Sample #2: Generally charting for another nurse is not done. (Note to student: Charting the actions of another team member could potentially be done in an emergency situation where many tasks are simultaneously being

performed and one nurse is the designated recorder.) “SSE” and “CC” are not approved abbreviations. There are two spelling errors: adominal distencion should be corrected to abdominal distention.

Sample #3: Time of entry is missing. Full assessment of pain is missing. Statement indicating blame, “physician made error,” should not be used. Inppropriate follow-up action is recorded (i.e., the appropriate follow-up is to call the provider for clarification). Patient’s complaint about care and quoted remark should not appear in nurses’ notes. Time of pain medication is missing and there is no note about response to medication. Signature of nurse is missing.

32. Both EHR and hardcopy systems provide a permanent legal record of past and current medical and nursing problems, plans for care, care given, and the patient’s responses to various treatments. Both are used for cost reimbursement and quality assurance and improvement.

EHR eliminates repetitive entries and it is easier to locate and retrieve the data. Generally, EHR increases efficiency, consistency, accuracy, and legibility and decreases cost. EHR has created new issues related to safeguarding patient confidentiality and additional training is needed for new employees and whenever the software is upgraded. Access to functional computers can also be an issue.

Hardcopy charting is less common, especially in large hospital settings; however, hardcopy can be easier to read than a computer screen. The hardcopy system can also be easier to navigate when documenting the atypical situation (i.e., patient’s situation or the event does not seem to fit into the computer’s checkbox style of organization).

CHAPTER 4—COMMUNICATION Fill-in-the-Blank Sentences 1. caring; sincerity; empathy; trustworthiness 2. trust 3. anger; impatience; withdrawal 4.

Impaired verbal communication 5. inability to speak Multiple Choice 6.

Answer 2: The best method is to give report behind a closed door. Eliminating all passers-

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Answer Key 9

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by is almost impossible in busy care settings.

Negative language should be eliminated from reports, but even positive reports should not be broadcast to anyone not directly involved in the patient’s care. Written notes do not guarantee confidentiality unless they are closely safeguarded and shredded appropriately.

Answer 4: Open-ended questions and twoway communication are the best ways to elicit feelings. Asking the patient if he is afraid is a closed question, this could also suggest to the patient that he should be afraid. Giving information or showing pictures creates a one-way information flow from nurse to patient and this doesn’t encourage the patient to speak out.

Answer 1: The nurse acknowledges the patient’s desire to go home, while providing an opportunity to assess (patient must also assess) ability to independently walk and function. The other options indicate that the nurse is agreeing with the patient’s verbal desire to go home and is ignoring the nonverbal grimace.

Answer 4: A notebook and a pen are typically associated with recording new material for later use. However, an optimistic nurse will remember that adolescents may demonstrate behaviors to get peer approval; thus all of these students may be interested in the topic, and the cell phone or the bored expression may be less about the teacher or topic and more about the peer group. Use of the Internet is questionable. The adolescent may be searching for some information that will contribute to the discussion; however, use of the Internet can be a distraction to others in the group.

Answer 4: The nurse checks to understand the patient’s concern. Option 1 is a closed question. Option 2 is giving information. Option 3 is a validating response.

Answer 3: An open-ended question allows the patient to take the lead and provides an opportunity for the nurse to assess the patient’s worries. A closed question that directs the patient’s worries back toward the health care provider does not elicit explanation. The second-best response: the nurse makes a good guess about the patient’s worries, but this is also a closed question. Offering to make the patient feel better is not realistic in this instance.

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Answer 4: Use of closed questions is the best strategy for this type of patient interview. The other techniques will only prolong the discussion of irrelevant information. Focusing could also be used.

Answer 2: In expressive aphasia, the patient understands, but can’t verbally respond; therefore, eye blinks are an alternative. Encouraging the patient to speak is inappropriate at this time. Referring to family members is appropriate if they have knowledge of details that the patient cannot describe; however, do not leave the patient out of the communication loop. Hearing and understanding speech are not the issues.

Answer 1, 2, 3, 6: Method of addressing people, interpretation of time, touch, and eye contact are culturally based. Facial expressions and gestures such as hand-shaking and tone of voice also have a cultural context, so the nurse should investigate cultural norms before assuming that these are acceptable approaches.

Answer 2: Older adults may need additional time to process information or formulate a response. Speaking loudly and slowly is not necessary unless there is some hearing loss.

Well-lit environments are preferred. Discouraging anecdotes or tangential communication may be necessary if there is an urgent need or if the nurse needs specific information.

Answer 3: The nurse paraphrases the patient’s statement. This indicates that nurse heard and interpreted the meaning. For the other behaviors/responses, the nurse is using passive listening and the patient is not sure if the nurse understands what he/she is trying to say.

Answer 2: The nurse is reflecting patient’s feelings and then invites the patient to elaborate. Restating what the patient has said should be used sparingly; overuse sounds like parroting. Offering to review the instructions suggests that grasp of the knowledge will alleviate all problems. Suggesting that someone stay with the patient is offering unsolicited advice.

Answer 1: Intimate space is from the face to 18 inches away; therefore, in assisting the patient to transfer, the nurse would have to touch the patient and should obtain permission first.

Sitting in a chair would be within the personal space of 18 inches to 4 feet. Speaking to the family or handling the patient’s belongings could also have cultural implications; how-

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Answer Key 10

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21.

22.

23.

ever, these are less directly related to intimate space.

Answer 1: Asking about type of surgeries invites the patient to give an exact answer.

“What kinds of problems?” and “How do you feel?” are very broad questions. The patient may be unsure what the nurse is asking about. “Are you having any pain?” is a closed question, which is okay, but requires several other follow-up questions to elicit relevant details.

Answer 2: The nurse should assess the underlying meaning of the patient’s comment (i.e., UAP’s jokes might be hurtful, offensive, or inappropriate to the patient. Or the patient might like the UAP’s communication style.)

Automatic superficial responses, making assumptions, or changing the subject are not therapeutic.

Answer 3: When talking to health care providers, the nurse uses assertive communication that conveys respect, but also communicates what is needed to safely care for the patient.

The other responses are not in the best interests of the patient. Being aggressive towards the health care provider may cause him/her to hang up. Being nonassertive puts the nurse in the position of having no orders to address the change in condition.

Answer 4: The nurse is acting like a physical bridge between the boy at the window and the two at the bedside. Using silence and being physically present are good interventions when a patient has died. Talking to the boy about feelings or directing him to come to the bedside may be premature. He may need a little time to process the death of his father. At the same time, do not leave him isolated by grouping with the two at the bedside.

Answer 2: The nurse must do a quick assessment of her own feelings and decide whether she can be therapeutic with the patient. The patient’s nonchalance could mean many things and the young patient needs to feel that health care personnel are available to help. The nurse must care for a patient if there is no one else available, but asking another nurse would be appropriate if the situation is not urgent and the nurse continues to feel hostile towards the patient. Expressing concern is a possibility, but the nurse and the patient must have a well-established trusting relationship, and when expressed, the concern should be patient-centered.

24.

25.

Answer 4: The nurse is newly graduated and wants to have good relationships with coworkers and to see that the patients get good care. Honest praise is a good way to establish trust in coworker relationships. Once trust is established, the nurse could be more confrontational with the UAP. Role modeling is one way to gently redirect behavior. Gaining more experience is good, but don’t mimic questionable behavior. Speaking to the RN is a possibility, but true disrespect may not be the issue, so assessment of behavior should precede going to the RN. Everyone may seem happy, but residents in long-term care facilities frequently feel that they have to get along, because there is no other option.

Answer 2: First assess the patient to determine if there is an issue with social isolation.

Also remember that hearing-impaired patients may have problems if there is excessive background noise, so he may actually hear better in his own room. Based on the assessment, the other options could be considered.

Critical Thinking Activities 26. a. Problems—slurred words and unclear speech b. Goal—Patient will communicate needs effectively with verbal and/or nonverbal communication. c. Nursing actions—Refer to Box 4-6 on p.

74. Determine the language spoken by the patient, use simple communication, spend time with the patient, and try alternative methods of communication. Allow time for responses; ask questions that can be answered “yes” or “no.” Anticipate patient’s needs. Maintain eye contact. Watch for frustration or fatigue. d. Evaluation statement—Patient is able to convey needs to the nurse by nodding head and using unaffected hand for signaling. e. Reassess the patient and the situation for confounding factors or changes in the patient’s condition that may be interfering with goal achievement. For example, the patient may have pain that is distracting him. Possibly the patient may have a change in mental status that signals a new problem with cerebral perfusion. The patient could be too tired or frustrated to attempt communication. Based on the

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Answer Key 11

new assessment data, the care plan may have to be modified.

27. Environment—the nurse is experiencing an overload of distraction from a variety of sources. The nurse’s posture and position (crossing the arms over the chest) and the space and territory (standing too far away and by the door) convey impatience. The message to the patient is “I do not want to communicate with you.” Any trust between the nurse and patient is destroyed. “Dear” is used less by younger people and possibly the nurse may view “dear” as condescending.

The patient may be experiencing unresolved grief over the loss of husband (recall that she is a widow) or stress related to hospitalization. The patient could also be having a physiologic problem such as fever or an electrolyte imbalance which has triggered confusion or hallucinations. Cultural differences and use of language could also be factors. For example, the patient may not be able to directly express fears and concerns, so repeatedly uses the call bell to get attention.

28. See Table 4-4, p. 73.

We all use responses that block communication, so do not judge yourself to be a poor communicator if you have numerous examples.

On the other hand, if you cannot think of any examples where you used responses that blocked communication, you may need to increase awareness of what you are saying and how others are responding to you. Conscious use of communication responses and the effect that responses have on others allow us to intentionally improve our therapeutic communication.

CHAPTER 5—NURSING PROCESS AND CRITICAL THINKING Crossword Puzzle 1.

See Table 5-3, p. 82.

1

2

3

F A P 5 A U D Y S F U N C T I O N A L B E N N I R 6 7 T C I D L C 8 9 10 I N T E R R U P T E D N E F F E C T I V E C I I A F T I I O S B E Y V 11 P N S I T U A T I O N A L E A A B L S D 12 13 T L O W L I I M P A I R E D O I T V 14 15 R D E L A Y E D N Y E X C E S S I V E Y G 16 I N E F F E C T I V E 4

True or False 2.

True 3.

False. Identification of problems occurs during the diagnosis phase.

4.

False. A nursing intervention is created to provide specific written instructions for all caregivers.

5.

False. Advising patients about medications for a health condition is the responsibility of the health care provider.

6.

False. Perceived constipation is defined as “self-diagnosis of constipation and abuse of laxatives, enemas, and/or suppositories to ensure a daily bowel movement.”

Short Answer [Note to the student: For questions 7, 8, 9, and 10, the answer key shows examples of nursing diagnoses, goals, interventions, or evaluation statements.

Your answers may differ, so check your answers for these questions against the following criteria. The nursing diagnosis should include: (1) the nursing diagnosis label from the NANDA-I list; (2) the contributing, etiologic, or related factor; and (3) the specific cues, signs, and symptoms from the patient’s assessment. A patient outcome statement provides a description of the specific, measurable behavior (outcome criteria) that the patient will be able to exhibit in a given time frame following the interventions. Nursing actions should be directly related to helping the patient achieve the goal and evaluation statements should reflect achievement, partial achievement, or failure to achieve the patient-centered outcome.]

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Answer Key 12

7.

8.

9.

10.

11.

12.

Fluid volume deficit related to severe vomiting and diarrhea manifested by poor skin turgor, weight loss, and decreased blood pressure Patient will demonstrate fluid balance (intake approximates output) within 24 hours.

Impaired physical mobility related to right hemiparesis manifested by an inability to ambulate independently or perform selected activities of daily living. Patient will perform transfer techniques (e.g., moving from lying to sitting position) prior to discharge from rehabilitation facility.

Examples of possible nursing interventions include: assess skin integrity every shift, ensure skin is clean and dry at all times, range of motion to right side, turn every 2 hours if unable to ambulate. a. At 8:00 am, patient passed moderate amount of formed brown stool without straining. b. At 8:00 am, patient reports passing very small amount of stool, but “feels better than I did yesterday.” c. At 8:00 am, patient straining for bowel movement; attempts x 2 for 30 minutes, but unable to pass stool. Is requesting an enema for relief.

Examples of how critical thinking is used by the nurse are (1) deciding when to do vital signs, (2) deciding what temperature site should be used, (3) deciding when to sit and talk with a patient, and (4) determining the presence of hypoglycemia or hyperglycemia in the unconscious diabetic patient. a. Acute pain: Physiologic b. Decreased cardiac output: Physiologic c. Situational low self-esteem: Esteem d. Risk for injury: Safety and security e. Ineffective relationship: Love and belongingness f. Hopelessness: Self-actualization

Multiple Choice 13. Answer 4, 3, 1, 2, 5, 6: The six steps are assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

14. Answer 1: Observing the patient’s abilities is an assessment that will guide the type of interventions that the nurse selects. Modifying a standardized plan is part of the planning phase. Taking the blood pressure after medication is evaluating the efficacy of the intervention. Assisting the patient to make a list of

15.

16.

17.

18.

questions would be done during the intervention phase.

Answer 3: There are a number of things that could cause the patient to be pale, diaphoretic, and tachypneic. Based on the objective cues, the nurse would use critical thinking and conclude that respiratory (e.g., pulmonary emboli) and cardiac (e.g., myocardial infarction) causes would have priority over metabolic (e.g., hypoglycemia or infection) or renal (e.g., kidney stone) causes. Then the nurse will use a series of closed questions to try to determine the cause. In other words, chest pain suggests cardiac or respiratory problems. Fever and chills are related to infection. Difficulty sitting could be related to neurologic dysfunction, systemic weakness, or musculoskeletal problems. Asking about time of onset of symptoms helps to further clarify problem (e.g., onset after exertion).

Answer 3: Prioritize the problems/nursing diagnoses, so that the patient’s health and safety are maintained; immediately intervene if necessary. The other actions are also part of a complete and comprehensive nursing care plan.

Answer 4: The decision to use a PRN medication is based on nursing assessment; therefore, the nurse would obtain a baseline assessment at the beginning of the shift and reassess periodically at least every 4 hours or more often if needed. The nurse could ask the charge nurse if the order could be revised; for example, “use inhaler for respiratory rate > 30/ min with subjective feelings of air hunger.

However, the charge nurse might also point out that all nurses should be familiar with asthma symptoms. Asking the patient about what triggers the asthma gives a clue as to when the inhaler might be needed. Leaving the inhaler at the bedside could be a strategy if the patient is very familiar with the onset of asthma and how to use the inhaler, but this option leaves the decision-making up to the patient.

Answer 1, 2, 4, 5, 6: All subjective, objective, historical (note to student: opioid medication can cause constipation), and functional data related to bowel function are relevant for a diagnosis of Constipation. Flat, brown lesion near umbilicus is noted during physical assessment, but does not apply to bowel function.

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Answer Key 13

19.

20.

21.

22.

23.

24.

Answer 2, 3, 5, 6: A focused assessment is advisable when the patient is critically ill, disoriented, or unable to respond. A focused assessment is also used to gather information about a specific health problem or a patient’s report of a sign or a symptom. A complete assessment involves a review and physical examination of all body systems and cognitive, psychosocial, emotional, cultural, and spiritual components and is appropriate for a patient who is stable and not in acute distress.

Answer 3: Biographic data assists the health care team to identify potential risk factors. For example, the average 85-year-old man has different health issues than the average 3-yearold child. The other options are also true.

Answer 2: The nurse must gather and analyze data to make clinical judgments and determine appropriate nursing diagnoses. In the past, nurses were not encouraged to make judgments, but rather were expected to follow the physician’s orders without question.

Health care providers identify disease and illness. Standardized care plans did evolve from the use of nursing diagnoses; however, standardized plans must be carefully evaluated to make sure that they are appropriate to the individual patient. Nursing diagnoses are not intended to limit, but rather to reflect, the types of problems that the nurse can treat.

Answer 4: Being underweight and having difficulty with independent position changes puts the patient at risk for developing problems with the skin. In the other options, a problem with the skin already exists; therefore, Impaired skin integrity would be a better choice.

Answer 1: Edema would be a collaborative problem, because the health care provider would identify the medical diagnosis that is causing or contributing to the edema and then prescribe medication or other therapies.

The nurse would identify a nursing diagnosis such as Excess fluid volume, and design interventions such as position change, review dietary aspects, and reinforce medication compliance. Assisting the patient with anxiety and coping would be nursing responsibilities.

Making the diagnosis of cancer would be the responsibility of the health care provider.

Answer 3: At discharge, patients should be given a copy of the medication reconciliation form. If the patient does not have the form, the nurse should obtain a copy from the dis-

25.

26.

27.

28.

29.

charging hospital for the patient. Because of confidentiality, the family should not have this form, unless the patient gives permission. Health care providers and pharmacists will also rely on the medication reconciliation form.

Answer 2: Palpating the abdomen to locate any rigidity or rebound tenderness would be part of the focused physical assessment related to the patient’s report of abdominal pain.

The other assessments are appropriate for the head-to-toe assessment that would be done at the beginning of each shift.

Answer 2, 3, 4, 5: Patients with Alzheimer’s disease will have multiple nursing diagnoses.

Acute confusion should not apply, unless the patient has delirium or a new injury/insult to the neurologic system. Chronic confusion would be selected.

Answer 3: All phases of the nursing process are linked together. However, for this patient the problem is straightforward and the solution seems simple, but careful planning is essential, because assisting this patient to the bathroom will be very time-consuming. Elderly people may move slowly, require help to stand, ambulate, sit, undo clothing, clean perineal area, and wash hands. It is likely that the nurse will make a short-term plan that includes assigning a UAP to assist the patient and an order should be obtained for a bedside commode. Also some time must be allocated to teach the patient to call for help.

This patient will also need more frequent skin assessments. Long-term, the plan may include bowel/bladder training, or possibly a physical therapy consult to help the patient gain more independent movement.

Answer 4: If the goals are not being met, then the nurse should evaluate the situation to determine why they are not being met. After that, the nurse may opt to revise the goal or change interventions. Documentation of interventions, results, and any revisions to the plan are always essential.

Answer 2: Evidence-based practice is a scholarly and systematic problem-solving paradigm that draws from research, practicegenerated data, clinical expertise, and health care consumer values and preferences. The committee will draw on many sources to create an evidence-based practice policy and procedure manual, because it guides the employees of an institution in the delivery of

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Answer Key 14

30.

31.

high-quality care. Directly applying research results to the clinical setting is rarely done.

While this is a criticism of research, results generally have to be replicated many times with large numbers of subjects. The Internet is a tool, but sources and information must be validated. Asking for advice from clinical experts is one of many sources used to build evidence-based practice.

Answer 4: The nurse applied critical thinking skills and used assessment findings, knowledge of pathophysiology, and knowledge of equipment used for monitoring to identify the irregular pattern of heart rhythm. Possibly the nurse might visually identify patient risk factors, such as being overweight, smoking, or shortness of breath. In this case, the nurse would use questions to gather more data (e.g., “Do you ever have chest pain?” and “Do you have a personal or family history for heart problems?”). A head-to-toe assessment and a complete evaluation can always give beneficial information; however, because of time constraints, these assessments are not always practical.

Answer 1, 2, 3, 4: Mentally rehearsing is a way to think about a problem before it happens.

Formulating questions is a way of actively engaging the mind while receiving information. Knowing how others are making decisions can guide the learner to understand the linkage of events. Advocating for more clinical time is a reasonable suggestion, but most nursing programs are already providing the maximum number of clinical hours and are constrained by clinical space and faculty.

Scanning nursing information is useful to gather more information, but critical thinking requires active application and practice.

Critical Thinking Activities 32. An example of a potential plan for this patient is: Nursing diagnosis—pain related to abdominal surgery Goal—reduction or relief of pain when treated Assessment—check vital signs and do a complete assessment of the patient’s pain, observe for signs or symptoms of potential complications (e.g., hemorrhage or infection); observe for contributing factors (e.g., noxious stimuli) Nursing interventions—Provide analgesic as ordered, position the patient for comfort, provide distraction if desired (e.g., music)

33.

Evaluation—After intervention, reassess the patient’s subjective reports of pain a. The LPN/LVN assists the registered nurse by performing ongoing complete and focused assessments of patients, depending on the facility and scope of practice in a state. See Box 5-2, p. 90 for additional information. b. The RN is responsible for identifying and prioritizing nursing diagnoses; however, patient care is a collaborative effort and the goal is to provide quality care for the patient. If the LPN/LVN feels that an error has been made, he/she has a responsibility to point out the error to protect the patient. When there is a disagreement, use a diplomatic approach. Organize information, opinions, and rationales in a clear and concise manner. Focus on the patient and avoid making comments that are personal or defensive. If two people cannot resolve their differences, it would be appropriate to discuss the situation with a supervisor. This is very important when patient safety and well-being are involved.

CHAPTER 6—CULTURAL AND ETHNIC CONSIDERATIONS Crossword Puzzle 1.

1

2

3

S T E R E O T Y P E 4 R T E 5 R A C E H L N N A 6 7 S O C I E T Y O S C U C T U L E I 8 M L T N C O T U T I R U R R T 9 A R E T H N I C I T Y L A S 10 S U B C U L T U R E M

Fill-in-the-Blank Sentences 2.

Cultural competence 3. ethnic stereotype 4.

Hispanic 5. biomedical health belief system 6. health care; care; discipline the children

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Answer Key 15

Multiple Choice 7.

Answer 2: People who speak a little English are more likely to understand simple language; brevity is also important because communicating in a second language is very tiring. Speaking loudly may be interpreted as aggression and cause withdrawal or irritation.

Use of an interpreter is necessary when obtaining an initial history or getting informed consent; however, getting an interpreter for every interaction is not possible. Providing detailed directions is not usually a good strategy even for patients who speak English, because details are frequently forgotten or become overwhelming.

8.

Answer 2, 3, 5: While it is important to approach all patients as individuals, older adults are generally less tolerant of other cultures, more likely to be rigid in practices, and use home remedies and traditional religious practices. Those with cognitive impairments may make thoughtless or hurtful comments. Older age is not directly related to educational background.

9.

Answer 2: Discuss the alternatives to blood transfusion with the health care provider and then perhaps the provider can make a plan that will incorporate an acceptable alternative.

Supporting the patient and documenting are also appropriate after alternatives have been fully explored. The risk manager can advise about problems that might occur if the patient feels coerced, but trying to change the patient’s mind about a blood transfusion is not appropriate.

10. Answer 1: There are special procedures for washing and shrouding the body, so contact the family first. Staying with the body and waiting 8-30 minutes before postmortem care would be in keeping with the Jewish religion.

Organ donation may be a personal decision, but many religions forbid it.

11. Answer 1, 3, 6: Self-assessment and understanding of self along with keeping an open mind will help the nurse. Trying to match beliefs is not reasonable, because the nurse is also influenced by his/her own culture. If trying to act the same or ignoring the differences, the nurse is not giving care based on individual needs.

12. Answer 2: Respect and protection of the soul were indicated by all study participants.

Prayers at the bedside may be appropriate for some, but not all; assess before making

13.

14.

15.

16.

suggestions. Religious beliefs can assist with coping, but those who have no religious preferences may have alternative coping methods.

Rituals and ceremonies should be allowed as long as there is no harm to patient or others.

Answer 3: First the nurse controls own behavior; this helps the family to decrease excitement and anxiety. Identifying the leader is important, because the leader can control the family and the information flow. If the leader does not speak the best English, then the nurse can ask him/her to identify the member to speak. Taking the patient to a private room may be counterproductive if the patient relies on family for support or translation. Physically assessing the patient would be appropriate if the patient arrives unresponsive or is in apparent distress.

Answer 3: Talk with the UAP first to assess the circumstances and the UAP’s behavior.

After assessing, the nurse can go back to the patient and apologize or explain as appropriate. There is a chance that the patient did something that made the UAP feel very uncomfortable, in which case the nurse can support the UAP to be professional and to problem-solve in difficult situations. Also, the UAP may be exhibiting behavior that would be considered normal or even respectful, but giving feedback about how patients are interpreting her behavior can help her to work in cross-cultural situations.

Answer 2: If a nurse has very strong beliefs or has certain behaviors that are very natural, finding a work environment that matches personal strengths can be a better solution than trying to modify behavior for every patient situation. For example, pediatrics may be a good match for this nurse, whereas a clinic that serves older multicultural patients may not be a good match. Assessing and understanding behavior is always a good start, but understanding origin of behavior does not ensure change. Learning about other cultures broadens perspective, but patients still need to be assessed and treated as individuals. Requesting certain types of patients is not ethical or fair to staff or patients.

Answer 3: In group settings, people will normally gravitate to preferred areas with preferred company; thereafter the same seat/ area is chosen over and over again. (Watch how a group of students enters and sits in a classroom.) Assigning seats is demeaning for

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Answer Key 16

17.

18.

19.

20.

21.

adults and may inhibit natural development of relationships. Asking every resident for seating preference at every meal is impractical for time management. (Some residents may be confused or very hard of hearing and others may answer, but decide and move very slowly.) Encouraging conversation with a variety of people is not a bad idea, but this might be a better strategy during other social activities.

Answer 1: To prevent delay for all the patients, leave this patient to the end. If there is a medication that cannot be delayed, giving a 15-minute warning might work. Assessing the preoccupation may be useful; however, the patient may just have a number of rituals/ behaviors that always fill the morning hours.

Starting at 8:00 am is impractical, there are many things at the beginning of the shift that the nurse must attend to.

Answer 1: Present orientation is action that is guided by patient’s “feeling okay” in the moment. “What should I do if…?” indicates future thinking and readiness to make contingency plans. “Can we share the pills?” is possibly present-oriented, but also there is no understanding of even basic safety concepts.

“Would you take…?” suggests that the patient is ready to align himself with the future thinking of the nursing student.

Answer 3: Use of herbal tea should be investigated. Many herbs can interact with prescribed medications or will be contraindicated in certain disease conditions. The health care provider should be informed and the pharmacist can be consulted. The other practices should be allowed, because they may be effective or ineffective, but are not harmful.

Answer 4: First gather more information about what the wife is feeding the husband, then this information can be shared with the nutritionist. Revising the goal is necessary.

The dietary plan can be changed, but the change should incorporate compromises that support the patient’s health and meet the cultural preferences.

Answer 2, 3, 4, 5: These questions are designed to elicit what the patient thinks or believes about what is happening to the body.

Asking about onset or duration of sensations are the standard assessment questions used to identify the problem.

Critical Thinking Activities 22. a. The nurse can explain that she understands and speaks a little Spanish, but an interpreter is needed to ensure an accurate history. When speaking to a patient through an interpreter, look at the patient (the way you normally would), rather than looking at the interpreter while speaking. In caring for the patient, the nurse can use her limited Spanish and should keep directions short and simple, and use appropriate gestures or written cues. b. The advantages of having a family member translate include not having to locate and wait for a translator. The family becomes more involved in the patient’s care and the nurse can build rapport with the family and observe the family interactions. The patient may also feel more comfortable or reassured if the family is present during care or procedures.

The disadvantages are that family members may or may not be able to accurately convey the nurse’s meaning to the patient or may intentionally or unintentionally withhold information from the nurse or the patient. Potentially there is a violation of confidentiality; the patient has less opportunity to decide whether the information is something that the family should know. There could also be legal problems; for example, the services of a professional translator should always be used for consent forms. c. i. Language—“What language is used in the home?” ii. Health—”How would you describe your health?” iii. Family structure—“Who will make the decisions about your care?” iv. Dietary practices—“What types of food do you normally eat?” v. Use of folk medicine—“Are there any special remedies that you use? If so, what are they?”

23. The nurses have tried to go up the chain of command and this has not been successful so far. Approaching the nurse manager again would be appropriate, because one person’s behavior is affecting other staff members and potentially patient care is being delayed across the board. Talking to the nurse is an-

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Answer Key 17

24.

other good attempt, but the day-shift nurse’s comment suggests that her time orientation is not the same as the other nurses on the staff.

There are many factors that may contribute to the nurse’s being late. Culture is one factor, but family responsibilities, transportation problems, or health problems may also contribute. The nurse who is late also needs to hear feedback from coworkers about how her behavior affects them. Respect has to be extended both ways. The nurse manager should be involved to help all of the nurses make a personal and unit-wide action plan for the safe and efficient function of the unit. a. Answers will vary widely, because the US is a large country and Americans are frequently influenced by worldwide ancestral backgrounds; however, American nursing students frequently share a belief in equal access to health care and education. As a nursing student, you are likely to place a high value on education, achievement, and scientific principles.

Nurses are also known as having high standards of moral and ethical behavior and being champions of human rights.

It is also likely that you aspire to be a responsible citizen who is willing to be happy on a modest income. You may also identify strongly with one or several other American subcultures. b. As a nursing student who is originally from another country, you are likely to share many of the values that American nursing students hold. If you are not originally from the United States, the impact of being in the American culture may be (or perhaps used to be) very stressful for you. Even if you are relatively comfortable in your job/school, have friends, and speak English very well, it is likely that there are many things about your country that you miss very much. Sometimes you may feel isolated, angry, or just exhausted because of the challenges of being in a country that seems so different. In addition to adapting to American culture, it is also likely that as a nursing student, you will meet many patients from other countries.

CHAPTER 7—ASEPSIS AND INFECTION CONTROL True or False 1.

False. Hand hygiene is considered the most important method.

2.

True 3.

True 4.

False. Coccidioidomycosis (valley fever) and histoplasmosis (a systemic fungal respiratory disease) are examples of systemic fungal infections. Protozoa are responsible for malaria, amebic dysentery, and African sleeping sickness.

5.

False. Accidental needlestick is an example of portal of entry.

6.

False. Microorganisms are present in all people, but infection will not develop unless the host is susceptible to the microorganism’s strength and number.

7.

True 8.

False. Hepatitis B, or serum hepatitis, is the most commonly transmitted infection by contaminated needles.

9.

False. The acute stage is usually when the danger of contagion is the highest.

10. False. Intact multilayered skin surface is the first line of defense.

Short Answer 11. Refer to Table 7-1 on p. 120. The four major categories of pathogens are bacteria, viruses, fungi, and protozoa.

12. Disinfection is used to destroy microorganisms; however, it does not destroy spores.

Disinfectant solutions are too strong to use on human skin, but are appropriate to use on inanimate objects. If a disinfectant solution comes in contact with human tissue, the tissue may feel “slippery.” This is the first step of tissue breakdown. Use clean gloves to protect the skin.

13. Refer to Box 7-5 on p. 127. Standard precautions include techniques for hand hygiene, disposal of equipment/sharps; handling of specimens, supplies, and equipment; and use of private rooms for patients.

14. Everyone (including health care providers) is responsible for disposing of sharps immediately after using them. Sharps should be disposed of in a puncture-proof container in the patient area. Drop sharps into box; never push items into the box or overfill it. Avoid leaving sharps on procedure trays or among bed linens.

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Answer Key 18

15.

16.

17.

Refer to Skill 7-3 on p. 133.

Medical asepsis includes techniques that inhibit the growth and spread of pathogens.

Surgical asepsis destroys all microorganisms.

Sterile technique is required to prevent introduction of organisms. a. MA b. MA c. SA (Interior of syringe, tip and interior of needless adapter, and interior of specimen container are sterile.) d. SA (Tip of cotton swab and interior of specimen container are sterile.) e. SA (Requires sterile gloves, field, and equipment.) f. MA g. MA h. SA (Interior of syringe, entire needle, and interior of medication vial are sterile.) i. MA j. SA (Requires sterile gloves, field, and equipment.) k. SA (Requires sterile gloves, field, and equipment.) l. MA 1. Perform hand hygiene.

2. Place the wrapped sterile package in the center of the work surface.

3. Remove the tape or seal indicating the sterilization date.

4. Grasp the outer surface of the tip of the outermost flap; open the outer flap away from your body.

5. Grasp the outside surface of the first side flap; open the side flap, allow it to lie flat on the table surface.

6. Grasp the outside surface of the second side flap and allow it to lie flat on the table surface.

7. Grasp the outer surface of the last and innermost flap; pull the flap back, allowing it to fall flat.

Multiple Choice 18. Answer 4: A soiled dressing is an environment that is suitable for growth of microorganisms. Wearing gloves and masks and isolating personal items interrupts mode of transmission. Having the patient cover mouth and nose interrupts the portal of exit.

19. Answer 3: Herpes simplex virus is transmitted by contact; thus gloves and gowns are needed, but masks and negative airflow are not necessary.

20.

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24.

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Answer 4: Rubella requires droplet precautions; thus mask and cough etiquette are appropriate. Washing hands before the procedure would be more useful to prevent spread of rubella to others. Calling x-ray is okay, but advise that patient should continuously wear mask; mask should be changed if it becomes wet. An isolation gown is not necessary in this case.

Answer 2: Shaking linens stirs up air currents that encourage transfer of microorganisms.

The other actions are all useful to control infection.

Answer 4: It is mandatory that health care workers wear an N-95 or higher particulate respirator mask when caring for patients with active tuberculosis.

Answer 1: If the closest flap is opened first, the nurse will have to cross the sterile field to open the rest of the kit. The other options are correct.

Answer 2: Antacids can alter the acidity of gastric secretions which offers some defense against microorganisms that are ingested.

Cipro and Vibramycin are antibiotics that fight infectious organisms. Hibiclens is an antiseptic solution for cleaning the skin.

Answer 3: If the white blood cell count continues to be elevated after antibiotic therapy, then the health care provider may have to change antibiotics or do additional diagnostic testing. Positive sensitivity results indicate that the antibiotic should be effective killing the organism. A positive blood titer for antibodies indicates possible previous exposure to disease or vaccination. Negative growth on blood cultures either means that insufficient time has passed for bacterial growth to occur or there are no pathogens in the sample.

Answer 3: An unusual cluster of infection noted in the emergency department must be investigated because of the epidemiologic implications for the community (e.g., bioterrorism or epidemic). The laboratory should be contacted for results of cultures. The nurse should follow protocols for disposal of contaminated waste and putting patients into isolation.

Answer 2: All patients do not have infectious disease; however, use of Standard Precautions is based on the assumption that any of us could have an infectious disease and not necessarily be aware of it. “Universal blood and body fluid precautions” is a term that was

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Answer Key 19

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used in the past. Studies do show higher infection rates if there are no precautions used.

Hand hygiene is always appropriate, but use of gloves, masks, etc., should be based on assessment, protocols, and nursing judgment.

Answer 4: First talk to the patient about why he feels the need to sneak out and smoke.

Smoking and/or getting out appear to have a very high value for him. Educating the patient is often a one-way information flow from nurse to patient; thus education does not always take the patient’s feelings or needs into account. The other options might be used, based on assessment findings.

Answer 1: Contact isolation is needed for infectious diseases that are passed by direct contact with an infected person or item. Draining wounds fall into this category. Leukopenic patients require isolation to protect them from exposure to pathogens. Neisseria meningitides meningitis and tuberculosis require droplet precautions.

Answer 3, 4, 6: Exposure to oral secretions would be reason to wear gloves. Taking a history and reviewing medications should not require gloves (if bottles appear soiled, the nurse may opt to wear gloves). Taking blood pressure should not expose the nurse to any body fluids. (Note to student: Some nursing programs will require students to use gloves for a full set of vital signs. Following program and facility procedures is always recommended.)

Answer 2: Remove the gloves and flush the area freely with water to remove the allergens.

After removing the immediate source, the other options would also apply.

Answer 3: If coworkers are in the middle of a task, help them finish unless there is an immediate patient safety issue and then try to problem-solve to prevent future occurrences.

The nurse could allow the UAP to continue to drag the bag, but the UAP is at risk for injury.

The UAP may or may not be responsible for overfilling the bag; therefore, reporting or reminding are not fair until responsibility is established.

Answer 4: Isolation of patients is increasingly more common, so learning to organize and cluster care is the best strategy. If all patients are stable, then caring for nonisolation patients first is a good idea; however, prioritize according to patients’ needs, not nurse’s convenience. If similar cases can be housed in the

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same room, this might help, but remember that all PPE still has to be changed and hand hygiene performed when moving from one patient to the next. If a nurse is repeatedly given all of the isolation cases day after day, talking to the charge nurse would be an option. Caring for isolation patients is more time-consuming.

Answer 2: All of these patients are going to take extra time and careful planning before starting the procedure; however, the patient who is confused and obese presents two challenges. Inserting a urinary catheter into an obese female presents a challenge to visualize the meatus. If she is confused and moves at the wrong time, sterility will be broken. A 4-month-old is small enough that an experienced nurse can give the injection without assistance; for those who need help, a parent or helper can stabilize the leg during the injection. The patient who is coughing can be medicated with a cough suppressant or given a cough lozenge. Also applying a mask to the patient is necessary. For the patient who is eager to help, give him a task that allows participation, but one that does not interfere with sterility. For example, he could hold the roll of tape and apply a piece of tape to the tubing after the IV is inserted.

Answer 2: Even though the tray was sterilized, if moisture is present it should not be used. The other options are incorrect.

Answer 4: There is no point in putting on sterile gloves to open the bottle, because the gloves are immediately contaminated by the outer surface of the bottle. In addition, the cap would never be placed on the sterile field because the cap is contaminated; thus the entire field would be considered contaminated. The other actions are correct.

Answer 2: All of these strategies are likely to help the patient gain control over fears and concerns associated with being HIV positive; however, the mode of transmission for HIV is well-documented and reviewing this information will help the patient recognize that family members are unlikely to contract HIV during casual contact. The patient and sexual partners can be referred for additional counseling about how to manage intimate contact.

Answer 1: The health care provider demonstrates a bad habit that is placing all of her patients at risk. Consulting the infection-control nurse is a good strategy for a new nurse who

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Answer Key 20

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may be unsure how to approach the provider.

(Remember, if you are unsure about how to do something, seek advice, especially when you are new on the job.) Doing nothing is incorrect. Health care providers are not directly accountable to nurses; however, nurses are directly responsible to safeguard the health of patients. Checking on the patient is okay, but the patient’s status is unrelated to the provider’s failure to correctly perform hand hygiene.

Writing up an incident report could be an alternative if there is no other mechanism available to deal with the problem at the systemic level. Offering a paper towel and assessing knowledge is a possibility, but the nurse must be prepared for the provider’s response.

Answer 3: Advanced age, disease, chemotherapy, and radiation all affect the immune system; thus the 73-year-old man has the most factors. The child needs to have immunizations prior to entering school. Traveling to Japan presents less risk than traveling to other countries where water, sanitation, food handling, and exposure to tropical diseases would create greater risk. Stress and overweight increase likelihood for conditions such as diabetes or heart disease.

Answer 1: If the student has been taking antibiotics for at least 24 hours, it would be okay for him/her to care for patients in the clinical area. The other options create opportunities to spread the infection.

Critical Thinking Activities 41. a. Any patient can develop a health care– associated infection (HAI) if Standard Precautions are not consistently used.

However, the patient with the hip fracture and the patient with dehydration and diarrhea are at a greater risk because of age, debilitation, poor nutritional status, and decreased mobility. The patient who underwent the routine colonoscopy should be further assessed for underlying chronic health problems that may contribute to risk for infection. b. HAIs are mostly transmitted by contact between health care personnel and patients; thus hand hygiene is essential.

Strict adherence to sterile technique is required for invasive procedures. Provide patients with items for personal care that are not shared with other patients (e.g., urinal or water pitcher). Place contami-

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nated articles such as linen in designated receptacles. Teach patients and visitors about hand hygiene and isolation procedures. Staff education, review of infection procedures and policies, review of patient records, and consultation with infectioncontrol nurse contribute to decreased incidence of HAIs. Analyzing data and consultation with public health departments helps alert staff about epidemiologic trends. c. The patient with watery diarrhea should be placed on contact isolation. Clostridium difficile (C. diff.) infection may be the cause. C. diff. infection is more common among elderly institutionalized people.

The health care provider should be notified and an order for stool cultures should be obtained. a. “What is your typical breakfast, lunch, and dinner?” (To determine nutritional status and eating preferences) “Do you have any health problems? Does your immediate family have any health problems?” (Disease or hereditary factors) “Are you currently taking any kinds of prescribed, over-the-counter, or illicit drugs?” (Some medications alter immune response.)

“Have you recently had chemotherapy or radiation therapy?” (Chemotherapy and radiation lower immune response.)

“Do you smoke or use alcohol? If so, how much and how frequently?” (Excessive use of tobacco and/or alcohol contributes to chronic illness. Both can alter immune response and healing.)

“Do you practice healthy habits, such as exercise?” (Better baseline health contributes to the immune response.)

“What do you do for work?” (Occupational exposure to toxins, stress, or pathogens affects immune status.)

“Are you currently experiencing stress at work, home, or otherwise?” (Stress adversely affects immune response.) b. The inflammatory process begins in response to injury or infection, with the cellular response and protective vascular reaction. Fluid, blood products, and nutrients are delivered to the interstitial tissues at the site of the injury. Pathogens are neutralized, allowing cell and tissue repair.

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Answer Key 21

c.

Localized—edema, pain, erythema, heat, pain/tenderness, purulent drainage d. Systemic—fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement (possibly change in mental status, although more likely to occur in elderly patients) CHAPTER 8—BODY MECHANICS AND PATIENT MOBILITY Word Scramble 1.

Flexion: (b) movement of certain joints that decreases angle between two adjoining bones 2.

Extension: (e) movement of certain joints that increases angle between two adjoining bones 3.

Hyperextension: (h) extreme or abnormal extension 4.

Abduction: (a) movement of limb away from body 5.

Adduction: (f) movement of limb toward axis of body 6.

Supination: (g) kind of rotation that allows palm of hand to turn upward 7.

Pronation: (c) kind of rotation that allows palm of hand to turn downward 8.

Dorsiflexion: (d) to bend or flex backward 9.

Circumduction: (i) movement in a circular pattern Multiple Choice 10. Answer 4: Raising the head of the bed and assisting patients to sit upright or even to lean slightly forward over an overbed table help facilitate respiratory efforts. Laying supine is appropriate for patients who are in shock.

Trendelenburg or head downwards with body and legs elevated was also historically used for shock, but is used less frequently now.

Lateral position with knee and leg drawn up can be used for procedures, such as giving an enema.

11. Answer 1: The Sims’ position is a lateral sidelying position with knee and leg drawn up towards the chest. Most patients can easily assume this position. For the lithotomy position, the patient lies supine with knees bent and hips and thighs are abducted. In order to easily access the rectum in the lithotomy position, the patient’s feet have to be in stirrups on a gynecology table or the hips have to be placed on the flat side of a bedpan if the patient is in bed. Trendelenburg or head downwards with

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body and legs elevated was also historically used for shock, but is used less frequently now. In the orthopneic position, the patient is seated and chest is bent slightly forward over a bedside table.

Answer 3: Medications that are used to reduce blood pressure may cause orthostatic hypotension because of vasodilation or a reduction of fluid volume (diuretics).

Answer 1: Keeping the knees slightly bent helps the nurse maintain balance and maximizes the use of leg muscles, which are stronger than the back or arms if the patient needs support. Feet should be positioned apart, approximately at shoulder-width. Contracting the stomach muscles protects the back. Keeping the patient close prevents stretching or reaching.

Answer 2: Immediately assisting the patient to the floor will prevent an uncontrolled fall that could cause injury. Leaning the patient against the wall might be helpful in some circumstances, but there is still a risk of an uncontrolled fall. Supporting the patient and moving quickly back to the room would be ill-advised. This choice would require a relatively strong patient who could move rapidly.

An assistant can be instructed to obtain a wheelchair or a stretcher as needed, but the nurse should not attempt to keep the patient upright while waiting for a wheelchair to arrive.

Answer 4: Deep-breathing and coughing help mobilize secretions and keep the alveoli open and functional. Suctioning the airways is performed if the patient has an endotracheal or tracheostomy tube, but the need for suctioning is based on assessment. Position should be changed a minimum of every 2 hours. Oxygen is only used if the oxygen saturation level is low or has potential to be too low. Nebulizers are used to open narrowed airways in pathologic conditions, such as asthma.

Answer 3: The nurse must assess what the patient normally does at home in order to design interventions that mimic or compensate for routine activities. Limiting visitors may help some patients, but socially active patients may not benefit from restrictions. Independence is always the goal; therefore, offering to do everything for the patient is incorrect. A private room may be appropriate, but this arrangement should be offered after assessing the patient’s needs.

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Answer Key 22

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Answer 1: Plantar flexion or foot drop can be prevented if the feet are positioned so soles of the feet are resting against the footboard in dorsiflexion. A bedboard provides additional support to the mattress and improves vertebral alignment. A trapeze bar enables the patient to raise trunk by grasping the bar. A trochanter roll prevents external rotation of legs when patient is in a supine position.

Answer 2: Pulses should be strong and easily palpated; this suggests good perfusion. Capillary refill is usually 3 seconds (5 seconds for older adults). Loss of sensation is not normal and may suggest pressure on surrounding nerves that could cause damage. Mild localized discomfort could occur with injury, surgery, or pathology, but if the patient does not have any reasons for this to occur, it should be investigated.

Answer 1, 3, 4: Flexion, lateral flexion, or rotation are appropriate for ROM of the neck.

Hyperextending the neck is possible, but not advised, especially in older patients. Supination is rotation of the forearm so that the palm of the hand turns upwards.

Answer 2: A contracture is a fixed joint with shortening (flexion) of muscles, ligaments, and tendons as a result of disuse. The other options are also abnormal conditions that may result from injury, disease, or improper body mechanics.

Answer 4: Shearing results when tissue layers become torn and separated. This occurs as the skin surface is pulled one way and the underlying tissues do not move in the same direction or at the same speed. Pulling patients across linens creates shearing force, as does slipping downwards in bed when the head of the bed is elevated. Dislocation, increased stress, or hyperextension of joints can also occur when moving patients if the joints are not properly supported when assisting the patient to move.

Answer 1: Patients who are at risk for osteoporosis should be encouraged to exercise. This strengthens bones and reduces the risk for fractures. The other complications are more related to immobility.

Answer 3: Standing directly in front of the patient and placing hands on the patient’s waist prevents reaching, which could cause injury to the nurse. Pulling on the patient’s joints could cause injury to the patient. Standing to the side of patient could be an option if there

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were an additional person to assist on the other side of the patient.

Answer 2: According to NIOSH, health care staff should not attempt to lift more than 35 pounds of the patient’s body weight.

Answer 2: Sitting with legs crossed increases the risk for thrombophlebitis, so the patient should be reminded to uncross legs. Forgetting slippers increases the risk for falls and injury to the feet. Rising too quickly can cause orthostatic hypotension, which causes dizziness. Sitting in a slouched position will cause muscle fatigue and bad posture increases back strain.

Answer 1: Tissue damage can occur within 4 hours, so the minimum assessment should be every 4 hours. Assessment at the beginning of the shift is appropriate to establish baseline information, but once per shift is not adequate. Pain is a later sign; thus early detection is essential. Assessment immediately after cast application is to assess comfort and tolerance of procedure. (Note to student: Compartment syndrome can occur without a cast; for example, crush injuries can cause swelling within the fascial compartments.)

Answer 2: Changes related to aging create an increased risk for skin damage. CPM also increases the risk for skin impairment, so skin must be frequently assessed. Fire hazard is unlikely. CPM is not easy to use. CPM is frequently used in conjunction with physical therapy. Degree of flexion and speed must be set correctly.

Critical Thinking Activities 28. a. Before moving the patient, the nurse assesses for the patient’s ability to assist in the move and the necessary safety measures that should be taken (e.g., gait belt, additional people to assist). b. Position the chair on the patient’s stronger side. Stand in front of the patient and place hands at patient’s waist level or below, and allow the patient to use his or her arms and shoulder muscles to push down on the mattress to facilitate the move.

Assist the patient to stand and swing around with back toward the seat of chair.

Keep the strong side toward the chair.

Help the patient sit down as the nurse bends his or her knees to assist the process.

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Answer Key 23

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29.

If the patient starts to fall during transfer, the goal is to ease the patient gently to the floor. The nurse stands with feet a apart, pulls the patient close to own body with patient’s buttocks on nurse’s hip. The patient slides down the nurse’s leg. The nurse bends knees and hips to lower the patient to the floor. d. First demonstrate passive range-ofmotion exercises with use of left arm and leg. Encourage and support any small attempts at movement. Family members can be very helpful with encouraging and assisting with ROM exercises if the nurse teaches them how to do the exercises and the underlying principles. a. Complications of immobility include muscle atrophy, contractures, pressure ulcers, reduced peristalsis, and postural hypotension. Refer to Box 8-2 on p. 166 for additional information. b. Nurses can prevent complications by turning patients every 1-2 hours, providing range-of-motion exercises, obtaining an order for laboratory studies to assess nutritional status (i.e., albumin), obtaining nutritional consult as needed, and obtaining an order for a specialized mattress or a sheepskin covering. c. For a reddened area on the sacrum, provide skin care and turning and supportive devices. Appearance of area and care must be carefully documented. Consult a wound care specialist as needed.

CHAPTER 9—HYGIENE AND CARE OF THE PATIENT’S ENVIRONMENT True or False 1.

True 2.

False. Incontinence is not an expected change that is associated with aging.

3.

False. As of October 2008, Medicare and Medicaid stopped covering the costs of treating pressure ulcers that developed during the patient’s hospitalization.

4.

False. When the external pressure against the skin is greater than the pressure in the capillary bed, blood flow decreases to the adjacent tissues.

5.

False. A male patient’s beard, mustache, or sideburns are never removed without consent of the patient, except for emergency purposes.

Fill-in-the-Blank Sentences 6. physical assessment 7.

68° to 74° F (20° to 23° C) 8.

2 9. tympanic membrane (eardrum); cerumen (wax) 10. skin integrity Multiple Choice 11. Answer 2: Patients with diabetes should be taught to visually inspect the feet because diabetes can cause changes in peripheral sensation. In addition, even small injuries are a risk because of poor wound healing. The other options are incorrect.

12. Answer 3: Dentures are cleaned with a soft toothbrush and stored in a container with a solution of the patient’s choice.

13. Answer 4: Before-breakfast care includes assisting to ambulate to the bathroom, washing face and hands, and oral hygiene if the patient desires it. The other tasks are typically performed after breakfast, unless the patient has procedures, treatments, or diagnostic testing.

14. Answer 2: Patients who are paralyzed from the waist down (paraplegic) should be taught to use arms to shift weight frequently. Changing wet linens is always appropriate, but this intervention is more important for incontinent patients. Paraplegic patients should be assisted to master bowel and bladder training, so that incontinence is less of an issue. Donut cushions are not recommended because they can impair circulation. The skin should be clean and dry.

15. Answer 4: The nurse would continue to assess the patient for additional areas of redness.

Other potential areas include scapulae, ears, elbows, heels, inner and outer malleoli, inner and outer knees, back of head, ischial tuberosities, trochanteric areas of the hips, and heels.

16. Answer 1: This patient will require frequent gentle mouth care several times a day for a period of days to remove the crusting. Scrubbing is likely to cause bleeding. Hydrogen peroxide can impair wound healing and would also create significant bubbling and frothing for a patient who has no control over the gag reflex. Flushing with a bulb syringe creates a potential for aspiration.

17. Answer 1: Dried secretions can be gently wiped with a moist gauze or cotton ball. If soap gets in the eye, it will cause pain and irritation. Eyes should be cleaned from inner

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Answer Key 24

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canthus to outer. Paper towels can scratch plastic lenses.

Answer 3: The hearing aid should not be placed in the sun, by a heating element, or near the stove. The other actions are correct.

Answer 3: Most people prefer to do their own pericare, so the nurse would first assess ability and willingness. Next the nurse could assess secretions, wound site, and other symptoms.

Then the patient can perform the hygiene or the nurse can perform it if the patient prefers.

Answer 1, 3, 4, 6: The patient has functional incontinence, so the staff must help the patient compensate for the difficulty in getting to the toilet. Currently an indwelling catheter and restricting fluids are not appropriate interventions for this patient.

Answer 1: The student would report the abnormal clay color of the stool, which should be a brown color. Clay-colored stool suggests that the patient is having some problem in the digestive tract.

Answer 3: Obese patients represent a challenge because it is difficult for one (sometimes two) person(s) to accomplish tasks that require moving the patient. It is faster and safer for everyone if the nurse and UAP work together. The nurse can simultaneously assess and perform hygienic care. After the initial assessment of skin and self-care, the nurse could adapt the strategies; for example, ask a second UAP to help or instruct patient to do select aspects of hygienic care.

Answer 1: Patients with chronic pulmonary disease will often request a cooler temperature or even a fan, because they have to work harder to obtain adequate oxygen. The patient with chills and fever could request that the temperature be lowered, but may also request warm blankets for chilling. Patients with peripheral vascular disease often report coldness of extremities. Critically ill patients are more likely to need warmer room temperatures.

Answer 2: Getting the residents out of bed is the most important intervention because immobility and pressure on tissues will cause skin breakdown. Daily assessment would be ideal, but it is unlikely to occur in an assistedliving facility. A toileting schedule can help those with incontinence problems, but incontinence is only one of many risk factors that elderly people will have. High-quality protein is important, but protein is only one nutrient

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among many that are required for skin integrity.

Answer 4: The nurse would assess the patient’s discomfort and solicit opinions about how to make the situation more tolerable. A noisy staff could be the only problem, but the family member’s comment could also be the “tip of the iceberg,” and thus the nurse would try to seek out other sources of irritation.

Based on the assessment of the patient, the nurse may decide to use the other options.

Answer 4: Putting up all four side rails is considered a form of restraint, which requires an order.

Answer 3: If the patient is brushing his own teeth, this is a signal of actual independence in accomplishing tasks. The patient may or may not call for help when needed; the nurse would have to assess the patient’s understanding and use of the call light. The position of the commode chair is typical; the nurse should assess the patient’s ability to independently and safely get to the chair. The UAP can tell the nurse that the patient is independent, but the nurse should verify this information with the patient. (Note to student: Observe that the nurse should have given better instructions. An inexperienced UAP may not know how to encourage independence.)

Answer 1, 2, 4, 5, 6: An upright position and oral suctioning are used to prevent aspiration.

(Facility policy may vary, but oral suctioning is not an invasive procedure and UAPs, conscious patients, and family members can be taught to use this device.) The UAP can observe for and report conditions if the nurse specifies what to watch for. Brushing someone else’s teeth should mimic the action that you would use to brush your own teeth, unless the patient has special conditions, such hard, dried secretions. Gloves and hand hygiene are always part of oral care. Checking for gag reflex is a nursing responsibility.

Answer 1: Hot baths with water temperature of 113° to 115° F (45° to 46° C) provide relief for sore muscles. A tepid bath of 98.6° F (37° C) can be used to lower elevated body temperatures. Warm baths with temperatures of 109.4° F (43° C), help to relieve tension, although many people prefer to shower. A sitz bath is used primarily to reduce inflammation for patients who have had perineal or anal surgery.

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Answer Key 25

30.

Answer 1, 3, 5, 6: Being relaxed, calm, and reassuring are useful. Using distraction is more useful than negotiating, and making demands is likely to increase agitation. Demonstrating and explaining desired behavior is usually a good strategy, but for safety and efficiency the nurse is more likely to finish the bath without trying to teach the patient with dementia how to accomplish the task. Repeating patterns is a good general strategy, but for hygiene the washing of body parts should be prioritized on a daily basis. Having consistent caregivers is the ideal.

Critical Thinking Activities 31. Bathing may be affected as follows: a. A fatigued patient—Perform only the care that is absolutely necessary for comfort and safety. b. Patient on complete bedrest—Assist as necessary with the bath and other hygienic measures such as oral care while the patient is in bed. c. Right-sided paralysis—Encourage the patient to do as much hygienic care as possible with the left arm, assisting as necessary. d. Inflammation of the perianal tissue—A sitz bath is indicated. e. East Indian Hindu patient—Hygiene is extremely important and a daily bath is part of the patient’s religious duty; bathing after a meal or with water that is too hot may be avoided. f. Older adult who is incontinent—Special care should be given to cleanse and dry the skin carefully; perineal care may be done more frequently and a skin barrier cream can be applied.

32. a. Risk factors for development of pressure ulcers include chronic illness, debilitation, limited mobility, incontinence, and poor nutrition. b. Stage I is intact skin with nonblanchable redness. The wound characteristics vary: areas may be painful, firm, soft, warm, or cool compared to adjacent tissue. c. During suspected deep tissue injury, the wound appears as a localized purple or maroon area of discolored, intact skin or a blood-filled blister. Characteristics of the area range from painful, firm, mushy, boggy, or warm to cool compared to ad-

jacent tissue. The wound sometimes becomes covered with thin eschar. d. Pressure ulcers can be prevented by repositioning the patient frequently in the bed or chair, providing good nutrition, keeping the skin clean and dry, and using pressure-relieving surfaces. e. Refer to Box 9-5 on p. 202.

CHAPTER 10—SAFETY Abbreviations 1.

Rescue patients, sound the Alarm, Confine the fire, and Extinguish or Evacuate 2.

Center for Disease Control and Prevention 3.

Occupational Safety and Health Administration 4.

P—Pull the pin to unlock the handle. A—Aim low at the base of the fire. S—Squeeze the handle. S—Sweep the unit from side to side.

5.

Safety reminder device True or False 6.

True 7.

True 8.

False. Safety reminder devices (SRDs) can be used in any health care setting. Many longterm care facilities are currently adopting a restraint-free environment.

9.

False. There is a 0.03% chance of a health care worker becoming infected with HIV from a sharps injury.

10. True Multiple Choice 11. Answer 1: Everyone should leave the room where the thermometer has been broken.

Close interior doors and open windows to increase ventilation to the outside. The area should not be vacuumed, but should be moped with a mercury-specific cleansing agent.

The home health nurse should refer to agency policy for additional directions that relate to the home environment.

12. Answer 4: By delegating the UAP to move ambulatory patients, the nurse is rescuing the greatest number. Next, the nurse would call 911. Closing the door is appropriate because the door will block the smoke and the fire.

The nurse must then attend to the helpless ventilator patient. Oxygen creates a good environment for a hotter and faster fire, so oxygen is turned off. The nurse now has to

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Answer Key 26

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manually support respiration by delivering breaths with a bag-valve-mask or a pocket mask. Both methods will be delivering room air. The nurse is aware that moving the patient and equipment would take minimum of two people and this action would also partially block the hallways; thus the nurse would use critical thinking to determine when (or if) to move the patient.

Answer 1, 3, 4: No one should smoke around oxygen. Fire alarms and other detectors should be properly installed and function should be routinely checked. Family should have escape routes planned and practiced.

Use of candles should not be encouraged. Using one electrical circuit creates a potential for overload. Covering electrical cords may decrease falls, but the carpet will mask frayed cords and offer a fuel source for fires.

Answer 1: A bed and chair alarm alert the nursing staff that the patient is getting up, so someone knows to go to assist the patient.

Keeping the light and television on would add to confusion and disorientation. Side rails are considered a form of restraint and confused patients often attempt to crawl over the rails. Frequently checking on the patient is always a good idea, but the patient can still wander off between times. Having family come in every night is unpractical and unrealistic in an extended-care situation.

Answer 3: The nurse stands on the weaker side and grasps the gait belt at the back. This position allows the nurse to provide support and ease the patient to the floor if he begins to fall.

Answer 1, 2, 3, 5: The use of SRDs requires an order, explanation to patient and family, and is only used as a last resort after other methods have been tried or considered. The entire nursing staff does not have to be consulted about the type of SRD. Type of SRD depends on provider’s orders, clinical judgment, and ongoing assessment.

Answer 2: The nurse remembers RACE and first removes the patient from the room. As they exit the room, the nurse closes the door to confine the fire to that room and then sounds the alarm. The nurse is not likely to turn off all electrical equipment in this case.

Answer 3: A sentinel event is an occurrence that causes death or serious injury. A broken arm suggests that there may have been improper assessment, application, monitoring,

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or choice of SRD. The other events may be subject to an internal review by risk management, hospital administration, or the nurse manager.

Answer 1, 3, 4, 6: Previous history of falls and unsteadiness increase the risk for falls. If assistance is required to walk from room to room, the nurse must plan to assist the patient to the bathroom and to meals. The nurse ensures that all assistive devices are close to the bed or chair. Asking the patient if he can independently get up after a fall is an assessment of strength and independence, but this also suggests that the patient should independently attempt to get up after a fall. (Patient should be assessed for injury after a fall and encouraged to regain balance and strength before attempting to get up.) Assessing for loss of consciousness is usually performed when trying to determine the etiology of the fall (e.g., head injury, neurologic event, cardiac event).

Answer 3: The nurse gives specific measures to prevent orthostatic hypotension (i.e., sit slowly and dangle legs before standing).

“Whenever she needs help” is a vague direction that requires the patient to ask for help and then the UAP must decide if help is appropriate, but there is no guidance about circumstance or execution. The nurse should assess whether the use of the bedpan is appropriate for the patient. If the patient is able to get up, walking decreases the complications of immobility. The UAP should not be expected to make a decision about “if she seems weak.” This decision should be based on nursing assessment.

Answer 3: The UAP can be instructed to assist the patient to change position every two hours. Assessment of circulation and respiratory effort should be performed by the nurse.

The RN and the health care provider should be consulted to determine the time for removal of SRDs. Answer 4: Anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter. This includes handling items such as linen and trash.

Routine care must continue (e.g., vital signs and hygiene); thus staff will enter the room whenever necessary, but care should be wellorganized so that minimal exposure occurs.

Children under the age of 18 should not visit the patient while there is a danger of radiation exposure. Wearing a mask, eye shield, and

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Answer Key 27

23.

24.

25.

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isolation gown do not offer sufficient protection against radiation exposure.

Answer 2: If the patient is having uncontrollable movements during a grand mal seizure, placing soft material against the side rails offers some protection. Checking the airway and suctioning secretions should be performed by the nurse. Inserting an oral airway is not done during the seizure, but may be done after the seizure is over to keep the tongue from falling backward; also there is always a possibility of a repeat seizure until medication or other therapy is given.

Answer 3: For infants who are just learning to crawl, the mother should look at what’s on the floor and within arm’s reach from a crawling position. This would include electrical sockets and cords. Pot and pan handles should be turned away from the child’s reach.

This becomes relevant when the child begins to stand and walk. Pool safety is more related to toddlers and children. Children can be taught to recognize dangerous products, but this is for preschoolers who have developed language skills.

Answer 2: Any new device or equipment has some risks because of the learning curve; however, new prescription lenses frequently cause some distortion in depth perception and they are less likely to be perceived by the patient or the staff as “new” or directly related to safe ambulation. A wheelchair, safety bar, and walker are designed to increase stability.

In addition, the elderly adult is likely to approach these new items with caution.

Answer 1: Postoperative patients have a risk for blood loss, and anemia can cause dizziness and shortness of breath. An infection would cause an increased white cell count; dizziness and shortness of breath may accompany infection, but these would not be the most typical symptoms. Blood urea nitrogen (BUN) and creatinine reflect kidney function; however, changes in BUN and creatinine can occur and the patient would not necessarily show immediate symptoms.

Answer 2: Antihistamines cause drowsiness and have mild sedative properties, so patients should be cautioned about side effects.

Answer 4: The infant is using his right hand to grab at the dressing on the left arm. If the right elbow is secured in a straight position, he should not be able to reach the dressing.

(Note to student: Sometimes it may be neces-

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sary to pin or secure the SRD to the linen/ mattress if the child is very determined.)

Mummy wrap is more restrictive and usually used as a temporary restraint during procedures. Bilateral wrist SRDs are also more restrictive and the infant is likely to have skin damage because he will continuously pull to get free. The wrap jacket allows free arm movement.

Answer 3: In cases of overdose, it is essential to determine quantity. The mother may need help to remember that the bottle was half full, or only had 2 or 3 pills. In the case of aspirin, number of times of vomiting is less relevant, because aspirin is readily dissolved and absorbed in the stomach. The health care team will contact Poison Control regardless of the mother’s report or the first aid given at home.

In addition, Poison Control is likely to have the mother’s call on file. Asking about previous episodes of poisoning would be relevant after current emergency care is given, if the health care team has reason to suspect child neglect/abuse.

Answer 2: Laryngeal edema puts the patient at risk for an airway obstruction. The other signs and symptoms could occur during a type IV hypersensitivity allergic reaction which is less serious.

Answer 2: Scrubbing and flushing the wound with soap and water is the best first measure to decrease risk of infection. The UAP should contact the infection-control nurse. Sharps boxes should never be overfilled, but are disposed of before they are full and immediately replaced. The nurse and the UAP should both write an incident report which would include the facts.

Answer 3: The nurse would first review the facility’s emergency/fire policies and procedures to determine if contingency plans have been made for the blocked hallway. Based on the review of the policies/procedures, the nurse may decide to use the other options.

Answer 4: Before any action is taken, someone must recognize that an unusual biologic event is occurring. The nurse is one of the first health care professionals who will assess patients for flulike symptoms or other symptoms that mimic endemic disorders. The nurse would isolate any suspected cases and immediately contact the supervisor, so that emergency/disaster plan can be activated.

The plan should include notification of the lo-

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Answer Key 28

34.

35.

36.

cal public health department and attention to public safety.

Answer 3: Severe respiratory distress is the most prominent symptom of cyanide gas exposure.

Answer 2, 3, 4, 6: For nursing homes or longterm care facilities, the plan must include ways to keep track of residents and notification of families and health care providers.

The goal would be to provide a safe environment, which may include moving residents to another location. Providing emergency treatment for critically injured patients or initiating decontamination would be included in hospital disaster plans.

Answer 2: Botulism can be transmitted by contaminated food. Inhalation is the most likely form for anthrax as a bioterrorist weapon. A bioterrorism-related outbreak of pneumonic plague is likely to be airborne and can spread among people via large aerosol droplets. Smallpox can be transmitted by contact or by the airborne route.

Critical Thinking Activities 37. a. Patient outcome: Patient will be free of injury and practice safety measures.

Nursing interventions: Assess patient’s status and safety needs.

Provide instruction on use of call light.

Place patient near the nurse’s station, orient patient to the surroundings, assist with ambulation, have patient use rubbersoled shoes or slippers, remove clutter from walk spaces, use side rails as necessary, and check equipment such as cane or walker for disrepair. b. Safe ambulation can be promoted by the nurse using a gait belt for patient support, having the patient use hand rails in hallways (if available), walking to the patient’s side with the closest leg behind the patient’s knee, and having the patient walk using a wide base of support. c. The safety of the older adult is influenced by changes in sensory function (vision, hearing, touch), decreased muscle strength, decreased circulation, medications taken, and possible cognitive alterations.

38. a. Refer to Box 10-12, p. 246. The nurse’s role in a disaster is to know the necessary procedures and maintain personal safety and patient safety.

39.

b. Indications of a possible bioterrorist attack include: A rapidly increasing incidence of disease Unusual increase in the number of people seeking care for fevers, respiratory problems, GI complaints An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern Lower attack rates for people who have been indoors Clusters of patients from a single area Large numbers of rapidly fatal cases Presentation of diseases that are relatively uncommon There is no right or wrong answer to this question. Nurses must safeguard their own health in order to care for family and patients.

Some nurses may decide that the risk of exposure is too high and will decide that the health of family will come first. Others will decide that the family is prepared and able to care for themselves and these nurses will continue to care for patients even in high-risk situations.

Having information about the disaster plan and how to safeguard self, family, and patients is one strategy. Having discussions with coworkers and supervisors is another strategy to help prepare for such an event.

CHAPTER 11—VITAL SIGNS Word Scramble Scrambled Term

Unscrambled Term

Definition or Characteristic

1.

cardiaydarb

bradycardia

b

2.

dysaenp

dyspnea

e

3.

pertherhymia

hyperthermia

g

4.

pneabrady

bradypnea

f

5.

eeafbril

afebrile

c

6.

achypneat

tachypnea

d

7.

yyhhdrstmia

dysrhythmia

a

8.

pohymiather

hypothermia

j

9.

diacartachy

tachycardia

h

10.

sionperthenhy

hypertension

i

Figure Labeling 11. See Figure 11-5, p. 266.

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Answer Key 29

Fill-in-the-Blank Sentences 12. 105.0° F (40.5° C) 13. 97° F to 99.6° F (36.1° C to 37.5° C) 14. 1½ inches 15. thready 16. medulla oblongata 17. alveoli 18. cardiac; arteries

Figure Labeling 19. The reading should be marked as 136/78 on the aneroid gauge; check your ability to read an aneroid gauge with an instructor or a classmate.

Table Activity 20. See Table 11-1, p. 256.

Age Group

Heart Rate (per Minute)

Respiratory Rate (per Minute)

Blood Pressure (mm Hg)

Neonate

120-160

36-60

Systolic: 20-60

Infant

125-135

40-46

Systolic: 70-80

Toddler

90-120

20-30

Systolic: 80-100

School-age (6-10 years)

65-105

22-24

Systolic: 90-100 Diastolic: 60-64

Adolescent (10-18 years)

65-100

16-22

Systolic: 100-120 Diastolic: 70-80

Adult

60-100

12-20

Systolic: 100-120 Diastolic: 70-80

Older adult

60-100

12-18

Systolic: 130-140 Diastolic: 90-95

Multiple Choice 21. Answer 4: First determine if the experienced UAP selected the axillary method for a specific reason; then teach the UAP about selection of measurement sites if needed. Although the patient wants breakfast, the nurse may elect to assess the patient first to determine if there is a fever and identify a potential infection source. Instructing the UAP to repeat the temperature using a more accurate method would be the second step after the nurse determines that the axillary method was inappropriate. If the UAP’s performance of vital signs appears to be a problem, observing technique would be an option.

22. Answer 3: For stable medical-surgical patients, every 4 hours is typical; however, policies can vary. The nurse could take the vital signs more frequently, but this is likely to interfere with accomplishing other tasks. The beginning and end of the shift are good times to take vital signs, but if the nurse works a 12hour shift there could be as much as 10 or 11 hours between vital signs, if these are the only times that vital signs are taken.

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Answer 2: For teaching purposes and for safety, the nurse would take the student back to the patient and teach assessment for other signs and symptoms that indicate dangerous conditions, such as shock or sepsis. After teaching the student that assessment is always the first response, then the nurse could use the other options to teach problem-solving for abnormal vital signs.

Answer 3: Hypothermia results in a decreased heart rate, because lowering body temperature lowers metabolism. Tachycardia is not expected for this patient; irregular tachycardia is a danger sign because hypothermia patients have a risk for cardiac dysrhythmias. Palpating radial or dorsalis pedis pulses may be difficult, but the carotid and femoral pulses should still be palpable, or the nurse could check an apical pulse.

Answer 1: Between 1:00 am and 4:00 am, the body temperature is lower. Thanking the UAP is appropriate because he/she has noted a change in the patient’s baseline. An explanation helps him/her to gain a greater

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Answer Key 30

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27.

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understanding that will contribute to future performance.

Answer: Pulse deficit is 9.

Answer 2: The apical pulse should be counted for a full minute.

Answer 1: The carotid pulses should not be palpated bilaterally, because of the potential to interrupt blood flow to the brain. The other actions are correct.

Answer 2: Patients who are having acute pain often demonstrate an increased respiratory rate. Opioid medications, hypothermia, and brainstem injury are more likely to cause a decreased respiratory rate.

Answer 3: Patients can intentionally or unintentionally alter rate if they know they are being observed. The other options may also be true or partially true.

Answer 1: Using a cuff that is too small is likely to yield a blood pressure that shows a false high reading. The cuff is more likely to pop off than to create discomfort for the patient. A large cuff on a small arm can yield a false low blood pressure. In order for blood pressure to approximate baseline, conditions should be repeated during measurement (e.g., appropriate cuff, same time of day, no exercise prior to measurement).

Answer 4: The respiratory rate of 9 is low and needs immediate attention. (Note to student: in the event of getting such a report, immediately stop report and assess the patient. After attending to the patient, talk to the nurse who gave report or to the charge nurse, because a respiratory rate of 9 should be immediately addressed. The situation might need additional investigation.)

Answer 3: A 4+ pulse is considered a bounding pulse that feels full and springlike even under moderate pressure. This indicates a hyperdynamic state that would be more consistent with high blood pressure; whereas a weak or thready pulse is associated with low blood pressure, decreased peripheral perfusion, or pulse deficit.

Answer 1: First, the nurse would check to see if the pulse oximeter is correctly positioned.

The other options are also a possibility. If the fingers are cold because of environment or poor circulation, the pulse oximeter may not work correctly. Assuming that the nurse is healthy and a nonsmoker, applying the pulse oximeter to own finger is a quick way to test the function.

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38.

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Answer 4: The temporal arterial method is appropriate in virtually all situations. An infant cannot cooperate for an oral temperature. The axillary is the least accurate and the rectal is the most invasive.

Answer 3: The earpieces should be cleaned regularly. Draping the stethoscope around the neck, rubbing the tubing frequently between palms, or using alcohol for cleaning will cause the tubing to dry and crack.

Answer 1, 2, 3, 4, 5: Any of these factors can cause tachycardia. (Note to student: Substance abuse is not an expected event in the hospital; however, patients have been known to go out and smoke cigarettes or to use illicit drugs that are supplied by friends or family members. If substance abuse is suspected, explain to the patient in a matter-of-fact tone that the health care team is merely seeking an explanation for a change in vital signs.) Hypothermia would cause a decrease in pulse rate.

Answer 3: The sudden decompensation and accompanying symptoms suggest that cardiac output has been greatly decreased.

In this case, the blood flow to the periphery will decrease so that the brain and heart are preserved. The carotid is likely to be the strongest. The femoral is often used during cardiac arrest, because getting to the patient’s neck is not always easy (too many staff members at the head of the bed).

Answer 4: The report is a normal and expected condition; thus the nurse plans to do the routine assessment and observe as needed.

Answer 1, 2, 4, 5, 6: If the patient is having alterations in respiration, the nurse would assess for additional symptoms. Pursed-lip breathing is seen among patients with chronic respiratory disease, such as emphysema. Nostril flaring, especially when seen in small infants, is an ominous sign. Retractions indicate that the patient is working very hard to draw air into the lungs. Worsening fatigue will occur as the patient approaches the need for intubation. Subjective shortness of breath is likely, but do not ask the patient for a detailed description; talking interferes with breathing.

Epistaxis is not expected.

Answer: Pulse pressure is 50. The usual pulse pressure is around 40; consistently elevated pulse pressures may be a predictor of heart disease, especially in the elderly.

Answer 4: In patients with hypertension, the sounds usually heard over the brachial artery

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Answer Key 31

disappear as pressure is reduced and then reappear at a lower level. This temporary disappearance of sound is the auscultatory gap.

Math and Conversion 43. a. 98.6° F b. 38.4° C c. 102.6° F d. 36.5° C 44. a. 20 kg b. 94.45 rounded to 94 kg 45. a. 13.2 rounded to 13 lbs b. 35.2 rounded to 35 lbs 46. a. 175.26 rounded to 175 cm b. 68.58 rounded to 69 cm 47. 2000 mL or 2 liters of fluid loss is equal to 2 kg of weight Critical Thinking Activities 48. a. For this patient, menopause may be causing hormonal changes which would cause the temperature to fluctuate. Physical or emotional stress associated with illness and hospitalization may also be factors.

The nurse should also consider the ambient temperature of the room and the excessive layering of blankets or clothes.

Also, assess the ingestion of hot liquids or smoking that may have occurred immediately before the temperature measurement. See Box 11-4 on p. 258 for additional information. b. Signs and symptoms of an elevated temperature include thirst, anorexia, warm skin, headache, elevated pulse and respiratory rates, restlessness, increased perspiration, and disorientation. See Box 11-5 on p. 258 for additional information. c. For the patient with an elevated temperature, the nurse should recheck the temperature, keep the linens dry, limit activity, administer antipyretic medication as ordered, and increase fluid intake.

The health care provider should be kept informed about changes in the patient’s condition. Refer to Box 11-6 on p. 258 for additional information.

49. a. For this patient, the physical stress of chronic respiratory disease is the most

50.

likely factor. While the patient is instinctively attempting to get into a sitting position to facilitate breathing, the motion of changing position is a form of exercise that creates an additional need for oxygen. The nurse should also assess for fever, emotional stress, medication history, smoking, and pain. See Box 11-11 on p.

271 for additional information. b. If the patient’s respirations are rapid and labored, the nurse should position the patient as upright as possible, check the vital signs, provide oxygen, remain with the patient, and contact the health care provider as needed. See Box 11-12 on p.

271 for additional information. c. “Sir, there is no need to apologize. You are no bother. Right now, we need to focus on helping you breathe, so you can explain everything to me later, after you are feeling better. I want to help you sit upright, get you some oxygen and check your vital signs.” (Note to the student: Usually you would respectfully listen to a patient and encourage expression of feelings; however, with this patient the priority is oxygenation. His talking is interfering with his breathing and oxygenation.)

The nurse has to use knowledge of normal daily fluctuations, normal variations, and normal values (baseline) for the individual patient. Many factors, such as age, environment, psychological state, and disease process can affect vital signs. Other factors, such as equipment malfunction, room temperature, and patient cooperation or condition can interfere with the accuracy of vital signs. Medications and treatments such as oxygen, dietary therapies, or radiation treatments can influence outcomes. The nurse must know which diagnostic tests and medical procedures will increase the risk for complications of hemorrhage, infection, or loss of function. Finally the nurse has to have knowledge of normal body response and changes in patient status that signal the need to intervene to maintain the health and safety of the patient.

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Answer Key 32

CHAPTER 12—PHYSICAL ASSESSMENT Table Activity 1.

Term

Description

Anorexia

Lack of appetite resulting in the inability to eat

Constipation

Difficulty passing stools or infrequent passage of hard stools

Cyanosis

Bluish discoloration of the skin and mucous membranes

Diaphoresis

Profuse sweating

Diarrhea

Frequent passage of loose, liquid stools

Dyspnea

Shortness of breath or difficulty breathing

Ecchymosis

Extravasation of blood into the subcutaneous tissues

Edema

Abnormal accumulation of fluid in interstitial spaces

Erythema

Redness or inflammation of the skin or mucous membranes

Fetid

Pertaining to something that has a foul, putrid, or offensive odor

Inflammation

The protective response of the tissues of the body to irritation or injury

Jaundice

Yellow tinge to the skin

Lethargy or lethargic

State or quality of being indifferent, apathetic, or sluggish

Nausea

Sensation often leading to the urge to vomit

Orthopnea

Must sit upright or stand in order to breathe comfortably

Pallor

Unnatural paleness or absence of color in the skin

Pruritus

Itching and an uncomfortable sensation leading to an urge to scratch

Purulent drainage (pus)

Creamy, viscous, pale yellow or yellow-green exudate; liquefied necrosis of tissues

Sallow

Unhealthy yellow color; usually said of a complexion or skin

Scleral icterus

Yellow color of the sclera

Tachycardia

Heart contracts at a rate greater than 100 beats per minute.

Tachypnea

Abnormally rapid rate of breathing

Vomit

Expel the contents of the stomach out of the mouth

Fill-in-the-Blank Sentences 2. birth 3. lack of nutrients 4. inspection 5. introduce yourself 6. half Multiple Choice 7.

Answer 2: Sickle cell anemia is a hereditary disease; thus genetic counseling may be considered.

8.

Answer 2: Diabetes mellitus is a metabolic disease. Ulcerative colitis is an autoimmune disorder. Cystic fibrosis is inherited. Heart failure cannot be linked to any one cause, but lifestyle modification is an important preventive measure.

9.

Answer 4: High levels of cholesterol increase the risk for coronary artery disease.

10. Answer 3: All the options are recommended to patients for overall good health; however, smoking cessation is the single most important intervention for lung disease. Participation in cancer screening is recommended, but currently there is no reliable screening test for lung cancer.

11. Answer 4: Diaphoresis and flushing can be seen in a variety of disorders and circumstances, but are frequently associated with hypermetabolic states, such as fever or exercise.

The other vital signs are lower than expected for the average adult.

12. Answer 2: Cyanosis and dyspnea indicate that oxygenation of tissues is inadequate and that the patient is having trouble breathing, so frequent assessment of respiratory effort is required.

13. Answer 3: In orthopnea, the patient has difficulty breathing in a flat position, so is likely to be more comfortable sitting in a chair or having the head of the bed elevated.

14. Answer 1: If the patient can identify other symptoms, this helps the health care team to locate the source of the infection. For example, back pain or problems with urination suggest a urinary tract infection. A sore throat with difficulty swallowing suggests pharyngitis. Allergies can cause some people to have low-grade temperatures, but fever is not typically associated with allergic reactions. Asking about previous similar episodes could be a follow-up question to try to narrow the search; for example, tuberculosis or AIDS could cause episodes of respiratory infections

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Answer Key 33

15.

16.

17.

18.

19.

20.

21.

that recur. Onset of fever is also a follow-up question that could be used if a pattern of infection is currently noted; for example, a number of people have developed febrile illness after attending the same event.

Answer 4: A patient who is anorexic has a poor appetite with a subsequent poor intake of nutritious foods, so the nurse would assess need for supplemental feedings, which could include high-calorie, high-protein oral supplements, tube feedings, or intravenous nutrition.

Answer 2: The nurse recognizes that the patient is tired. Shortness of breath is visible as the patient’s respiratory rate increases and the focus of attention is on breathing; usually the facial expression conveys anxiety. Licking lips or dry lips would signal need for water. There many ways that pain manifests, but restlessness, shifting weight, or expiratory grunting would be a few of the nonverbal behaviors that the nurse might observe.

Answer 3: Fear activates the sympathetic nervous system, so the blood pressure will rise and the pupils will dilated (fight or flight response). Pain and nausea are subjective symptoms.

Answer 1: Patient is likely to have scratched self to relieve the sensation of itching.

Answer 2: P stands for PrecipitatingProvocative-Palliative. Rating the pain is a query about Severity. Onset is determined by asking when it started. Spread of symptoms to other body parts is used to determine Radiation and location. (See Box 12-6, p. 295 for additional information.)

Answer 1: Crackles (produced by fluid in the bronchioles and the alveoli) are short, discrete, interrupted, crackling, or bubbling sounds that are most commonly heard during inspiration.

Sibilant wheezes have a high-pitched, squeaking, musical quality and are produced by airflow through narrowed airways. Sonorous wheezes have a lower-pitched, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and the large airways. Pleural friction rubs are produced by inflammation of the pleural sac; the nurse will hear a rubbing, grating, or squeaky sound upon auscultation.

Answer 3: A normal white cell count is the best indicator of the success of antibiotic therapy. A decrease in pain and increase in function are good indicators that the medication

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25.

26.

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is working. However, subjective symptoms may improve after several days of antibiotic therapy, but the infection can still be present until antibiotic therapy is completed. Edema, redness, and elevated white count suggests that the antibiotic may need to be changed.

Answer 1: Watching the patient as he/she performs an activity is the best method for assessing abilities to accomplish ADLs. Asking the patient who does the shopping and cooking would be a better question than asking him what he eats. (He may rely on others to obtain and prepare the food.) A full set of vital signs gives some indirect information about the patient’s abilities; for example, a rapid respiratory rate would suggest that activity intolerance would be a factor in performing ADLs. Level of consciousness and orientation are important, but a person can be fully conscious and oriented, yet be unable to get to the bathroom.

Answer 4: The nurse should use terminology that is familiar to the average person.

Answer 2: The Glasgow Coma Scale is used for patients who have potential for neurologic abnormalities related to brain injury. The other patients have potential for brain injury related to poor tissue perfusion secondary to a disease state, but there are many other interventions that the nurse would use to prevent coma from happening to patients with cardiac, infection, or respiratory problems.

Answer 3: The most likely finding would be dependent edema in the lower extremities.

Answer 2: The preceptor would try to determine what process the new nurse is using to assess and to document. There is a possibility that the new nurse knows what to do, but is not able to describe the findings. Thus there is either a knowledge deficit or a communication problem. There is also the possibility that the new nurse copied the assessment from a previous entry. This is falsification of documentation, but probably occurs more often than it should. After assessment, the preceptor could decide to use the other options.

Answer 2: Press against one nostril and have patient breathe. If the nostril is patent, air should flow freely; then switch and occlude the other nostril. Using a penlight only allows visualization of the opening of the nostril.

Having the patient blow the nose first would be appropriate if the patient is having rhinorrhea (runny nose). Having the patient breathe

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Answer Key 34

28.

29.

30.

quietly is an opportunity to observe respiratory effort, but air will enter the unobstructed nostril if the other is obstructed.

Answer 1: The UAP can observe and report on respiratory rate and depth, but the nurse should give the UAP parameters for reporting, especially if the patient is at risk for respiratory problems or if the UAP is inexperienced. The other tasks are nursing responsibilities.

Answer 1: An inward curvature of the lumbosacral area is normal. An exaggerated posterior curvature of the thoracic spine is kyphosis.

An increased lumbar curvature is lordosis. A lateral curvature is scoliosis.

Answer 2: The popliteal pulse is hard to find and the patient may have difficult assuming the prone position which is optimal for this assessment. Prior to calling the health care provider, the nurse would assess pulses and tissues that are distal to the popliteal area; thus if the dorsalis pedis pulse and/or the posterior tibial pulse are palpable, the blood is flowing through the popliteal area to the distal tissues.

Critical Thinking Activities 31. a. Respiratory: “Do you have difficulty breathing?” “Have you ever been exposed to TB?” “Do you smoke?” b. Endocrine: “Has your weight changed recently?” “Do you have a personal or family history of diabetes?” “Have you noticed any change in your tolerance to heat or cold?” c. Gastrointestinal: “Do you have any trouble swallowing?” “Is there any change in your appetite?” “Have you had nausea, vomiting, diarrhea, or constipation?” d. Cardiac: “Have you had any chest pain?”

“Do you have a personal or family history of hypertension?” “Have you experienced any palpitations?” e. Neurologic: “Are you having headaches?”

“Have you ever had a serious head injury in the past?” “Have you experienced any changes in sensation or coordination?” f. Genitourinary: “Do you have any discomfort when you urinate?” “Have you noticed any changes in frequency of urination?” “Do you suspect that you may have been exposed to a sexually transmitted infection?”

32.

33.

34.

a.

O Onset When did the pain start?

P Precipitating-Provocative-Palliative What causes it? What makes it better?

What makes it worse?

Q Quality-Quantity How does it feel, look, or sound, and how much of it is there? How often, when, how long…?

R Region-Radiation

Where is it? Does it spread?

S Severity scale Does it interfere with activities? How does it rate on a severity scale of 0 to 10?

T Treatments What helps? For how long?

U Understanding What do you think is causing it? How does it affect you?

V Values Goals of care; on a scale of 1 to 10, what would you consider a tolerable level of pain? b. In assessing the abdomen, first inspect for shape, contour, lesions, and skin color.

Listen for bowel sounds for 1 minute in all four quadrants. Next use light to moderate palpation and check for texture, temperature, and moisture of the skin.

Also note distention, firmness, tenderness, or guarding.

The nurse must have knowledge of normal body function and pathophysiology in order to determine which questions to ask and investigate underlying physiologic disorders. If the patient has a headache, the logical place to start is to collect subjective data about the pain (e.g., “What does it feel like?” “Where is the pain located?” “Are you having pain at any other location besides your head?”). Ask about associated symptoms that are likely to accompany a severe headache (e.g., “Have you felt nauseated?” “Have you felt dizzy?”

“Are you experiencing any problems with your vision?”). Based on the nurse’s knowledge of pathophysiology, the nurse would obtain objective data; for example, hypertension could cause headaches. Intracranial bleeding could cause a change in pupil size and reaction. Meningitis could cause an elevation of body temperature.

The patient might see the nurse as efficiently using the time, but is more likely to think

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Answer Key 35

that the nurse is very busy and focused on completion of tasks. The nurse’s actions have blocked communication and created psychological distance between herself and the patient. The patient is less likely to give complete information to this nurse, because she doesn’t appear to be interested in hearing what he has to say.

CHAPTER 13—ADMISSION, TRANSFER, AND DISCHARGE Identifying Patients’ Reactions to Hospitalization 1. a. Reaction: Fear of the unknown. Patient is manifesting fear of the unknown, which causes insecurity, and relates to the need for safety according to Maslow. b. Reaction: Separation anxiety. Separation anxiety is a reaction that reflect the needs Maslow identified as belongingness and love. c. Reaction: Loneliness. Patient is showing loneliness, which is a reaction that reflects the needs Maslow identified as belongingness and love. d. Reaction: Loss of identity. The adolescent feels that his clothes are a part of his identity. His behavior reflects a need that Maslow identified as self-esteem.

Fill-in-the-Blank Sentences 2.

The Patient Self-Determination Act 3.

Joint Commission; Medicare; Medicaid 4. accepting facility; signed consent 5.

24 Multiple Choice 6.

Answer 1: The nurse should notify the health care provider, who ideally will come immediately and talk to the patient and have the patient sign the AMA form. The incident should be documented in the nurse’s notes. An incident report may also be completed as needed.

It is inappropriate to detain a rational patient if he/she wants to leave.

7.

Answer 2: A patient with an old head injury can be considered a chronic care case that could be assigned to LPN/LVN; however, it would be appropriate for the LPN/LVN to notify the supervising RN because the patient’s change in status and needs should be assessed by the RN. Explaining the AMA

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form to the patient could be done, but the question is whether the patient can legally assume responsibility for his own actions.

Contacting the family is a possibility, but the hospital/nurse could still be held liable if the patient were to injure himself or others in a confused state. Calling the risk manager is an option, but it is unlikely that the manager will make the decision to detain the patient, because the decision has to be based on whether the patient is rational and able to make safe judgments.

Answer 1, 2, 3, 5, 6: When the admission is conducted through the admissions department, efforts are made to obtain demographic, insurance, and emergency contact information. The ID band is immediately placed, so that all health care team members can correctly identify the patient for appropriate care. HIPAA and Patient’s Bill of Rights can be explained by the admissions representative. Discussions about medication and other health-related matters should be done by the nursing staff.

Answer 3. While all patients benefit from an individualized approach, the farmer from rural China is most likely to be unfamiliar with plumbing conditions in a Western hospital.

The patient with Alzheimer’s disease is not going to remember any new information.

Children who are just starting to toilet train are likely to need diapers during hospitalization, because the stress may cause them to revert to earlier behavior. The woman with stress incontinence needs interventions to help tighten the pelvic musculature.

Answer 2: Explaining that the band is for safety reassures the patient that the band is for his/her benefit and not just a standard method of classification, and that he/she is not viewed as just an assigned number. Joking with patients is often appropriate, but first the nurse should establish rapport with the patient; otherwise he/she may believe that there is real possibility of getting lost or displaced.

Answer 4: First the nurse reflects the patient’s feelings of anxiety and then directly invites the patient to ask questions. Indicating when to call and willingness to help is a good thing to say after the patient appears to be comfortable and settled in his/her new surroundings.

Telling the patient “not to worry” does not address his/her specific concerns. “I know I would” switches the focus to the nurse.

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Answer Key 36

12.

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Answer 4: This elderly patient is refusing information that the nurse believes is necessary; however, the nurse can spend the time making the patient safe and comfortable and then return when the son arrives. At that time the nurse can assess the family dynamics to determine if the patient relies on the son for decision-making or information retention and filtering.

Answer 1, 2, 6: UAP can assist by making the room more comfortable and welcoming.

Needs should be assessed by the nurse and then signs, equipment, or other items can be obtained. Items of value should not be stored in the bedside table.

Answer 4: A transfer requires an order from the provider, and the provider must speak directly to accepting provider at the receiving hospital. The receiving hospital must be contacted and accept the transfer and the nurse must give a report to the nurse who will be caring for the patient.

Answer 2: For any patient who has change of mental status, knowing baseline behavior is important. For a patient with dementia, knowledge of baseline behavior is especially important, because delirium and dementia can have some similarities. The other information is also relevant, but not as critical as meeting the patient’s immediate physical needs.

Answer 1: An older patient with chronic disease and fewer personal resources is likely to have the most complex discharge plan, which may include social services, nursing, physical therapy, and home health aides. He is more likely to need help with issues such as transportation, shopping, preparing food, and assistance with ADLs. He is also likely to be taking more medications and have more ongoing health problems.

Answer 4: The nurse would first attempt to assess the caregiver’s attitude. Based on the assessment findings, the nurse could use the other options.

Critical Thinking Activities 18. a. There are certain responsibilities that must be performed. Checking and verifying ID band to ensure identification must be performed. b. Immediate needs must be assessed and addressed. In this case, the patient’s respirations and breathing are the priority.

19.

The nurse would check respiratory rate, get a pulse oximeter reading, and initiate interventions such as assisting the patient to sit in an upright position, encouraging slow purse-lipped breathing, and discouraging excessive talking. c. Ordinarily, the nurse would explain hospital routines such as visiting hours, mealtime, and medication times; however, based on the assessment of the patient, the nurse may opt to temporarily delay long explanations. The nurse might say, “Sir, when you are feeling more relaxed and breathing easier, I can explain more about the hospital routines and what you can expect.” d. The information that is generally included in the orientation for the patient includes location of the room (proximity to nurses’ station), location of bathroom, how to call for assistance, how to adjust the bed and lights, how to operate the phone and television, and policies that apply to the patient (e.g., smoking, visiting hours).

For this patient, the nurse may decide to explain how to call for assistance and how to adjust the bed, but delay all additional information. The nurse should make a plan, inform the patient, and then follow through. For example, the nurse might say, “Sir, I am going to let you rest for about an hour. Use the call button before then if you need anything, but in an hour I will come back and finish telling you about hospital procedures.” a. Other health care providers involved in the discharge process include: Social worker—counseling, determination of community and financial resources Wound care specialist—advice about cleaning wound and changing dressings Physical therapist—rehabilitation plan of exercise Occupational therapist—ADLs, vocational skills b. Rationale for nursing interventions for patient discharge: i. Verifies health care provider’s decision to discharge patient ii. Prevents waiting when patient is leaving and allows for initial determination of insurance coverage iii. Avoids delays in the process and allows for family members to prepare

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Answer Key 37

iv. Ensures that the patient has all personal items and assists the family v. Conserves the patient’s strength

13.

CHAPTER 14—SURGICAL WOUND CARE Matching See Table 14-3, p. 347.

1. e 2. c 3. a 4. g 5. b 6. d 7. f Short Answer 8. a. Inflammatory phase—24-48 hours, blood elements leak into the tissues, leukocytes appear b. Reconstruction phase—2-3 weeks, fibroblasts are present, collagen formation begins, wound strength begins to increase c. Maturation phase—after 3 weeks, fibroblasts exit, wound becomes stronger 9. a. Primary—surgical wound, clean edges b. Secondary—wound edges not close together, may have purulent drainage c. Tertiary—infected wound left open, delayed suturing 10. a. Gauze—to permit air to reach wound b. Semiocclusive—to permit oxygen to reach wound, but not the impurities in the air c. Occlusive—to prevent air or oxygen from reaching the wound to keep the wound moist and promote healing d. Dry dressing— nondraining wounds, protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing e. Transparent—able to visualize wound, contain exudates, and decrease wound contamination 11. a. Finger or wrist—circular b. Calf or thigh—spiral reverse c. Joints—figure 8 d. Scalp—recurrent Multiple Choice 12. Answer 3: Seafood supplies protein and zinc.

The salad provides vitamin A and the tomato juice provide vitamin C. The other meals also

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provide good nutrition, but do not offer all of the required nutrients.

Answer 4: The goal for the patient (assuming no fluid contraindications) is 2000-2400 mL. He drank a total of 1460 mL, so he if he drinks two or three additional 8-ounce servings, he will be closer to the recommended amount.

16 ounces = 480 mL 10 ounces = 300 mL 6 ounces= 180 mL Half a liter =500 mL Total intake =1460 mL Answer 2: The nurse helps the patient learn to move independently and safely. This is accomplished in steps: rolling, leverage, and pushing. The patient should not be encouraged to just lay in bed. Holding a pillow to the abdomen is appropriate during coughing and deep-breathing. Calling for assistance is okay, but this limits independence.

Answer 1, 2, 3: Initially, the nurse inspects the dressing for intactness and for any signs of hemorrhage. The skin surface around the dressing is also noted for baseline comparison. Exudate will drain downwards, so the nurse must look underneath the patient to ensure that there is no drainage present. The initial dressing is generally removed by the health care provider. Sanguineous drainage is expected at first; serous drainage occurs later as wound healing progresses.

Answer 2: The nurse suspects that an infectious process is occurring and knows that an elevated white blood cell count is likely to validate this suspicion.

Answer 2: The triangular binder (sling) will provide support for the possible fractured forearm.

Answer 1: The nurse would not remove staples or sutures if the wound edges appeared to be separating. Serous drainage is a sign of healing and should be cleaned away.

The patient’s anxiety can be addressed before the procedure. Staple removal should feel like a tug or a pinch, but should not cause great pain. The site can be reinforced with SteriStrips, so this should decrease worries about the incision coming apart. Keloid formation and scarring could be aggravated by leaving the staples in too long.

Answer 4: If the dressing is moistened with saline, this will help loosen the crusty exudate.

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Answer Key 38

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Answer 3: The nurse should first reinforce the dressing, because this may help stop or slow the bleeding. Next, the nurse would assess for signs of shock. The charge nurse and the health care provider should be notified about the saturated/reinforced dressing and the vital signs and pain symptoms. The dressing should not be removed at the 3-hour point by anyone except the health care provider.

Answer 4: The wound should be covered with sterile dressings moistened with saline. The patient should be placed in a low Fowler’s position with the knees slightly flexed. The health care provider should be notified. A patent IV is needed because the patient is likely to need a surgical repair.

Answer 1: For a postoperative patient, the nurse is likely to first suspect hemorrhage, so taking the pulse and blood pressure and checking for pain would be the best actions.

The nurse would check for wound approximation if dehiscence or evisceration were expected. The patient is more likely to report a pop or release sensation if the incision comes apart. Infection is also a possibility. The symptoms in the scenario could accompany septic shock, but the goal is to identify infection signs prior to the onset of septic shock. (Note to the student: The patient’s symptoms could also be related to other disorders such as pulmonary emboli or hypoglycemia.)

Answer 2: An expected output ranges from 250-500 mL. Answer 2: Clean gloves are adequate to remove old dressings. The other options are correct.

Answer 3: The student has performed the correct action. Telling the patient that the student is doing a great job gives the student positive reinforcement, while reassuring the patient that the student’s technique is correct. The other options are incorrect.

Answer 2: The amount of drainage is excessive, so the nurse would take vital signs and assess for other symptoms of hemorrhage or shock and inform the health care provider.

Documenting is always necessary and comfort measures are always welcome once the immediate problem is addressed. The nurse should not apply a pressure dressing, but the supine position would be appropriate if the nurse determines that the patient is hypovolemic.

27.

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Answer 1: The primary concern is that respiratory function could be restricted if the binder is too tight. Vomiting and nausea are not contraindications, but the patient may need assistance in positioning the emesis basin.

Binders can be used for obese patients, but the appropriate size is needed. Older patients do have more fragile skin, so the skin must be assessed frequently, or the nurse may decide that the binder should not be used because of the fragile skin.

Answer 3: The transparent dressing is currently the dressing of choice.

Critical Thinking Activities 29. a. Factors that impair wound healing include age, malnutrition, smoking, drugs, and diabetes mellitus. Patient’s ability to care for himself is also not optimal. b. The nurse would assess his ability to perform self-care, to reach the wound, and to manipulate the wound dressings.

He has trouble with his vision, so the nurse would adapt the teaching (e.g., using color-coding of dressing materials).

The nurse will increase time allowed for the skills and repetition of teaching and give small amounts of information at a time. This patient will have a decrease in sensory receptors and a decrease in pain sensation; therefore, he will need to have someone to help him visually inspect the wound on a routine basis. The nurse should ask the patient about his resources and arrange for home health if necessary.

This patient needs assistance to increase fluid intake and nutrition. Social services could be contacted about having meals delivered to his house.

30. a. Wound irrigation is used to clean the wound and remove debris and eschar. b. Equipment needed: 35-mL syringe, 19-gauge catheter, sterile solution. c. Syringe is held 1 inch above the wound for irrigation. d. Direction of cleansing is from least to most contaminated. e. Report evidence of fresh bleeding, sharp increase in pain, retention of irrigant, or signs of shock.

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Answer Key 39

CHAPTER 15—SPECIMEN COLLECTION AND DIAGNOSTIC TESTING Matching 1. d bronchoscopy 2. c mammogram 3. b arteriography 4. a paracentesis For additional examples of diagnostic tests, see Table 15-1, pp. 369-383.

Fill-in-the-Blank Sentences 5. health care provider; supplies or equipment; patient 6. informed verbal consent 7. human immunodeficiency virus (HIV); hepatitis B 8. recap; puncture-resistant containers 9. interpreters 10. confidentiality 11. abnormal 12. psychological preparation Figure Labeling 13. See Figure 15-7, p. 401.

Short Answer 14. Assess patient’s ability and concerns. Ensure proper preparation. Give explanations that are appropriate to developmental age and cultural background. Wear gloves and perform hand hygiene. Collect and label using correct techniques. Ensure that specimens are transported to the laboratory in a timely manner.

See Box 15-4, p. 385.

15. Refer to Box 15-1, p. 368 and Skill 15-1, p. 367.

General preparation of the patient before diagnostic testing includes checking the medical record for the order, making sure the consent is signed (if necessary), gathering equipment and supplies, teaching and preparing the patient, providing privacy, maintaining asepsis, assisting the health care provider, labeling and sending the specimen to the laboratory, and documenting the procedure.

16. Assess for pain, infection, and the ability to understand the procedure and directions.

Also note any physical problems that may interfere with the procedure; for example, ability to maintain the position (e.g., remaining quiet and still) or using equipment (e.g., opening a sterile wipe). Assess for anxiety, fear, or concerns about the procedure. Assessing for past experiences (negative or positive) is also

17.

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useful in anticipating the patient’s response to the procedure. For many tests, baseline vital signs, mental status, or peripheral perfusion should be obtained. If a contrast medium is to be used, assess for allergies.

For the older adult, there may be physical difficulty in manipulating equipment for specimen collection or achieving necessary positions. Hearing or vision may add to problems in understanding instructions. Alterations in circulation and respiratory function may interfere with obtaining specimens. NPO status may lead to dehydration. Contrast media such as barium can cause constipation, which is a chronic problem for many older adults. Decreased kidney function can be further compromised by contrast media that are excreted by the kidneys. Multiple medications may alter results.

Proper labeling of specimens requires date and time, patient’s full name, ID number and/or room number, age and sex, health care provider’s name, test ordered to be completed on the specimen, and collector’s name and initials.

Figure Labeling 19. See Skill 15-14, figure in Step 9b(1), p. 410.

Delegation 20. The UAP must be trained in the procedure of specimen collection. The nurse must assess the patient before directing the UAP to collect the specimen. If assessment findings indicate that the patient’s condition is unstable or if the patient’s condition hinders specimen collection, it is not appropriate to direct the UAP to do the task. a. Yes b. No c. No (Note to student: drawing blood is frequently done by the phlebotomist. In some cases, the LPN/LVN may draw the blood, but this can be based on facility policy.) d. No e. Yes f. No g. Yes h. No i. No j. No k. Yes l. No

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Answer Key 40

m. No n. Yes o. Yes—If the patient has had the colostomy for a long period of time and is familiar with the care, it is appropriate to direct the UAP to collect the specimen. If the patient is still trying to learn about colostomy care, then the nurse should collect the specimen and take the opportunity to teach the patient more about self-care.

Multiple Choice 21. Answer 4: See Skill 15-11, p. 395. The inner ampule is crushed so that the medium for organism growth coats the swab tip. Closing the lid tightly would apply to any specimen. Liquid culture medium or color change reagents apply to different types of specimens.

22. Answer 4: Flat, supine position or head not elevated more than 30 degrees is for prevention of spinal headaches. Fluid intake would be encouraged. The health care provider would be notified if the pain is unrelenting.

23. Answer 3: See Table 15-1, figure under subheading “Thoracentesis,” p. 382.

24. Answer 2: Sounds will be heard during the test. There are no food or fluid restrictions. No discomfort should occur and the patient must remain motionless.

25. Answer 1: Blood is allowed to drop onto the test strip rather than smearing it, which could alter results. The side of the finger is used because it is less painful than the center. Gently squeezing the finger and holding it downwards will encourage the blood flow.

26. Answer 3: Voiding at least 30 mL is thought to flush organisms that remain on the skin.

The cup must be sterile, only about 10 mL is needed. Betadine was used in the past, but chlorhexidine is now more commonly used to clean the skin.

27. Answer 2: Clamping the tube allows fresh urine to collect. Clean gloves are needed, not sterile gloves. Disconnecting the catheter increases the risk for HAI. Inserting a needle directly into the catheter will cause leakage; specimen should be drawn from the port.

28. Answer 3: The purpose of catheterizing for residual is to determine how much urine remains in the bladder after voiding. The other options are incorrect.

29. Answer 2: All of these values are of concern and would be evaluated in terms of the patient’s condition and reported to the health

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care provider. However, a low platelet count will result in prolonged bleeding at the puncture site, because platelets are involved in the clotting process.

Answer 2: The tourniquet is left in place no more than 1-2 minutes because of discomfort and possible alteration of test results. One end is crossed tightly over the other, then the upper end is tucked under the band to form a half bow. The tourniquet is generally positioned 4 to 6 inches above the selected site.

Tourniquets serve to prevent venous blood flow but not arterial blood flow. Make sure the tourniquet is tight enough that the veins distend; however, pulse should be palpable.

Answer 4: The patient may not be aware that different bacteria can cause UTI; therefore, explaining the rationale helps the patient understand the need for the test. Routine testing or health care provider’s desire to order the test are both true, but these are vague answers that do not help the patient understand why the test is ordered. Possibly, the patient could convince the provider to prescribe antibiotics without doing the test, but most providers are very reluctant to do this and inappropriate prescribing does contribute to resistant strains of bacteria.

Answer 1: Stool is taken from two separate areas to demonstrate that blood is throughout stool and not localized. Specimen should not be taken from toilet bowl. The control should be tested at the same time as the specimen.

Hemolysis and urgent delivery to the laboratory are not relevant for this test.

Answer 2: During bronchoscopy, a flexible tube enters the airway; therefore, impaired respirations, aspiration, laryngospasms, bronchospasms, or effects of anesthesia could be causing hypoxia. The nurse should assess respiratory rate and effort; pulse oximeter is used to check oxygenation. The other assessments may also be relevant in contributing to the overall status of the patient, but airway is the priority.

Answer 3: Elderly patients have a greater risk for dehydration and fluid and electrolyte imbalance. The patient has had the preparation twice and repeating the preparation for a third time increases the risks. After assessment is completed, calling the health care provider and technician and explaining to the patient can be done.

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Answer Key 41

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Answer 2: Extra fluids, especially water, will help thin the mucus and make it easier to expectorate. Mouth care should be performed after expectoration, not before. Avoidance of red meat and caffeine are relevant to other diagnostic tests, not to sputum specimens. Collecting saliva is not the goal.

Answer 4: If the test is totally unfamiliar to the nurse, checking facility manuals that are related to diagnostic testing will guide the nurse in assessing the patient for specific symptoms, and in knowing normal values versus slightly abnormal or critical values.

The laboratory technician may be able to help, but frequently technicians are not familiar with how a test might relate to patient circumstances.

Answer 4: All of these patients represent different challenges in obtaining a voided urine specimen. The patient who is comatose is not going to be able to understand or cooperate.

For women who are menstruating, if flow is finished or nearly finished, then extra cleaning can sometimes overcome the interference of menstrual blood. The overweight patient may need assistance in cleaning and holding labia apart to prevent contamination (a bedpan might be considered). Patients with prostate problems can have various flow problems (i.e., some difficulty starting stream or complete blockage).

Answer 1: Patients who travel to foreign countries and develop GI symptoms are at risk for ova and parasites. The stool must be examined when it is fresh, because these organisms are easier to detect when they are alive. Dark stool suggests blood, normalcolored stool can still be tested for occult blood. Stool is frequently examined if foreign body ingestion is suspected; small, smooth, rounded objects will usually pass. Floating stool is usually associated with fat in the stool and signals problems with digestion of fats.

Answer 4: Recall that vagal stimulation can result in bradycardia and the overall decreased perfusion will cause diaphoresis. This can result even when the correct technique is used. Five to ten seconds for suctioning is considered acceptable. Anxiety can cause diaphoresis, but tachycardia is more likely than bradycardia. The nurse would monitor the patient and notify the health care provider about the incident.

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Answer 1, 2, 3, 4: Symptoms of systemic infection and localized infection should be assessed. Possibly the infection control nurse or the charge nurse could review past records to identify quality of care issues. If the dressings are not being changed, this could contribute to the development of infection, but this investigation should not delay reporting or treating the immediate problem.

Answer 2: It is likely that the phlebotomist will draw the blood cultures and the blood chemistries at the same time; however, from a treatment standpoint the blood cultures should be done immediately so that the antibiotics can be started as soon as possible.

Answer 1: The nurse would remind the student that venipunctures (and other procedures such as taking a blood pressure) should not be performed on the side of mastectomy or a shunt. The other actions are correct.

Answer 1: The patient is having a delayed allergic reaction as evidenced by the signs and symptoms of swelling and itching, dyspnea, and tachycardia. The treatment is to administer prn diphenhydramine (Benadryl) and contact the health care provider for additional orders, such as steroid medication. The nurse would watch for worsening. If the patient is worsening, alerting the rapid response team and preparing emergency equipment would be appropriate. Contacting the health care team member who administered the contrast medium might be done later by risk management or hospital administration to investigate issues of patient safety. Applying a cool compress and suggesting rest are comfort measures that could be offered in addition to the Benadryl.

Answer 1, 2, 3, 5, 6: If the environmental temperature is cool, peripheral blood flow decreases. Likewise if the arm is lowered, it is easier to draw blood and gravity will facilitate the flow once the skin is punctured. Technique includes many factors, the position of the arm, the depth and site of puncture, and the gentle squeezing or milking to encourage the drop to flow. Certain disease conditions (e.g., Raynaud’s disease) can cause problems with peripheral circulation. Calluses or skin injury or disease (e.g., burns) can alter the condition of the skin and make piercing the skin more difficult. Improper calibration of the glucometer can alter the accuracy of the

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Answer Key 42

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results, but this does not affect the difficulty in obtaining the blood sample.

Answer 1: The NG tube is not designed or intended to be pierced with a needle. The other options are correct.

Answer 2: The cough reflex is stimulated by the catheter. The other occurrences are not normal or expected.

Answer 3: Having the patient say “ahhh” facilitates visualization, minimizes the gag reflex, and gives the patient something to focus on. Using a tongue blade can make visualization more difficult if the patient is already prone to gagging. The blade can trigger the reflex and the patient will tense up as the blade is inserted. Also, if the nurse uses the tongue blade, both hands have to be performing; tongue blade requires steady even pressure, but no pushing backwards; whereas the culture swab needs a light quick sweep backwards towards the tonsillar wall. It is impossible for the patient to obtain a good throat culture on himself. The health care provider should be notified if the specimen cannot be obtained. There are mild topical anesthetic preparations that could be used, but these are not typically used for this procedure.

Answer 1, 2, 4: For elderly patients and children, the nurse should select 23- to 25-gauge needles. For most adults 20- to 21-gauge is selected. Butterfly needles are frequently used for children or older adults because they are easier to hold during insertion. If a vacuum tube is used, sterile double-ended needles are desirable. The nurse may be tempted to grab equipment that is familiar, but it is the nurse’s responsibility to become familiar with equipment that best suits the needs of patients.

The collection tube does not affect the nurse’s choice of needle, nor the type of blood chemistry that is ordered.

Answer 4: Nurse A should go up the chain of command to address this problem. Reporting to the nurse manager is an option if the charge nurse is not willing or able to deal with the problem. If Nurse A was a preceptor for Nurse B, then assessing skill in performance would be appropriate. Offering to help is always good for morale and teamwork, but Nurse B needs help with knowledge/skills deficit and stepping in and taking over does not help Nurse B improve.

Answer 2: Continue the procedure, but continuously monitor the patient for worsening,

because chest pain suggests inadequate oxygenation of heart muscle. Time of pain should be indicated on the ECG strip or request slip (it is possible that the pain will correlate to a dysrhythmia on the ECG tracing). Chest pain should be reported to the health care provider and treated, but the target of the medication will be the oxygen deficit that is causing the pain. A crash cart should not be needed, unless the health care team fails to notice and treat the chest pain.

Critical Thinking Activities 51. a. Assess the patient’s baseline vital signs and pain, lung sounds, presence of cough, level of knowledge about and prior experience with the procedure, ability to understand and follow directions, and overall physical and emotional status. b. Lungs should be auscultated before the procedure so that the nurse can compare lung sounds after the procedure. Diminished or absent breath sounds after the procedure are a sign of possible pneumothorax. If the patient has an uncontrollable cough, the nurse should obtain an order for a cough suppressant, because excessive coughing or moving can result in damage to the lung if the needle moves during the procedure. c. Refer to Skill 15-1 on p. 367. Check the medical record for the order and make sure the consent is signed. Teach the patient that a sitting position must be maintained and coughing and moving could potentially cause damage to the lungs.

Explain that a local anesthetic is used and there is a pressure-like pain as the needle passes through the pleura and the fluid is removed. Gather equipment and supplies.

Provide privacy and assist the patient to a sitting position. Maintain asepsis, assist the health care provider, label and send the specimen to the laboratory, and document the procedure. d. Monitor vital signs and observe for cough, hemoptysis, dyspnea, tachypnea, diminished or absent breath sounds, anxiety, restlessness, fever, or subcutaneous emphysema. Turn patient to unaffected side for 1 hour. Obtain a chest x-ray if ordered. Resume normal activity in 1 hour if patient is asymptomatic.

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Answer Key 43

52.

For this patient, there may be physical difficulty manipulating the specimen cup or cleaning the perineal area. Explain the process of a midstream urine collection and do additional assessments on fine motor skills.

Obtain an order for a straight catheterization specimen if she is unable to manipulate the wipes and the specimen cup while holding the labia apart. Older adults are likely to have fragile veins; consider doing the venipuncture without a tourniquet; also consider getting the most experienced person to draw the blood.

NPO status and bowel cleaning procedures may lead to dehydration. This patient reports poor appetite and fluid intake, so she has an increased risk for fluid and electrolyte imbalance. Older adults have decreased renal function and the contrast media can contribute to additional decreased kidney function. The BUN and creatinine results must be checked before the IVP. Fluids should be encouraged after the test and urine output should be monitored, because decreased urine output can be a sign of renal failure.

CHAPTER 16—CARE OF PATIENTS EXPERIENCING URGENT ALTERATIONS IN HEALTH Word Scramble See Box 16-3, p. 423.

1. anaphylactic (b) 2. cardiogenic (e) 3. hypovolemic (a) 4. neurogenic (f) 5. psychogenic (c) 6. septic (d) Short Answer 7.

The caller should identity self and location.

State that structure collapsed and several people were injured. State possibility of ongoing danger related to the unstable structure.

Currently there are ____ adults and ____ children with ____ injuries. First aid measures: ____, ____, and ____ have been provided. One victim has chronic ____. The parking lot is congested with cars and people who are trying to leave. Best access is on the south side of the community center. See Box 16-1, p. 415 for additional information.

8.

Patient’s weight, age, substance ingested, inhaled, or injected, amount of substance taken,

9.

10.

time taken, any medications patient has taken, and current status of patient.

The teaching plan should include keeping emergency first aid supplies and instructions available. Maintaining a list of emergency phone numbers. Accident-proofing the home: Keep poisons locked away from children, use handrails, use nonskid surfaces, have good lighting, and practice electrical safety (e.g. check electrical appliances for frayed cords).

54%

Multiple Choice 11. Answer 1: First, the nurse assesses level of consciousness. Based on the assessment, the nurse may decide to question the person, start CPR, call 911, or check for injuries.

12. Answer 4: Health care professionals, including nurses, should check for a carotid pulse, but spend no longer than 10 seconds.

13. Answer 4: A high-pitched inspiratory noise suggests that there is an object in the airway that is allowing a small amount of air to go around the object. This is an emergency, because the object could become lodged and allow no air movement. If the person can speak, this means that air is passing over the vocal cords and into the airway. Forceful coughing is a good sign because it is the most effective means for the person to independently rid the airway of a foreign body. If the person is coughing, rescuer would not interfere, even if some wheezing is heard.

14. Answer 3: Placing the fist just above the navel is the position to create enough force to expel the foreign body, and to avoid fracturing underlying bone structures.

15. Answer 4: The nurse would visually inspect the mouth for an object, open the airway, and attempt to ventilate. If ventilation is not possible, deliver five abdominal thrusts; then look in the mouth for foreign object and repeat sequence until object is dislodged and breathing resumes, or if no spontaneous breathing, initiate CPR. 16. Answer 1, 2, 4: Immediate measures are to establish an airway and control bleeding.

Body temperature should be maintained, so covering the person helps minimize heat loss.

The head should not be elevated, because this will decrease perfusion to the cerebrum. Also, spinal precautions would be applied if head or neck injuries are suspected. Oral fluids are typically withheld. Intravenous fluids would

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Answer Key 44

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be started if available. No medication should be given at the scene of the accident.

Answer 3: A person with a known allergy to bee stings is supposed to carry an epinephrine pen and the pen should be immediately available in case the person has an anaphylactic reaction or becomes unconscious or unable to speak. If a pen is not available, taking diphenhydramine and immediately seeking medical assistance would be the next best thing. Discussions about past episodes of allergic reaction should not delay treatment or seeking medical assistance. Allergic reactions can be progressively worse with repeated exposures to allergens.

Answer 2: The person should not be moved, but since he is conscious it would be appropriate for the nurse to identify self and ask for permission to help. Resist the impulse to assist the person into a sitting or standing position. (Person may also be attempting to get up.) Initiating spinal precautions is correct; however, failure to ask permission or explain actions could be interpreted as an attack, especially if the person is confused and the nurse is a stranger to him/her. Asking the person about pain, symptoms, and events is appropriate after he is calm, immobile, and help has been summoned.

Answer 2, 4, 5: CPR can be stopped to apply the AED, and for trained personnel to take over. If the person is spontaneously breathing and has a pulse, CPR should be discontinued even if the person remains unconscious. Pulse and breathing should be continuously monitored. The nurses should not trade off with a layperson unless they are exhausted and unable to continue with CPR. Trading causes delay. In addition, the nurses are more likely to have experience, recent training, and better compression technique than a lay rescuer. The nurses should not be distracted by the relative or the crowd. CPR requires intense effort and timing. The nurses could stop if the relative or crowd were threatening their personal safety.

Answer 3: The wife is acknowledging that it is time to say goodbye. It is not uncommon for families to need additional time at the bedside when someone dies. The other statements indicate a belief or hope that he can still recover.

Answer 2: Absence of a carotid pulse is indicative of cardiac arrest. The peripheral pulses are not as strong and blood flow to extremities will decrease to preserve the brain and

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heart. It is possible for respirations to cease while the heart continues to beat (e.g., choking or drowning); however; cardiac arrest will quickly follow respiratory arrest. There are many reasons for decreased responsiveness (e.g., diabetic coma, stroke, drug overdose, electrolyte imbalance) where the heart will continue to beat.

Answer 3: The goal of CPR is to mimic the pumping action of the heart and if compressions are too rapid and the heart is not allowed to fill with blood, there is nothing to pump out. The rescuer will become fatigued even if the proper rate is maintained; altering the speed of compressions is not the solution.

Lacerations or fractures are more associated with proper hand position than speed of compressions. A smooth motion is more related to proper position of arms and hands in relation to the victim’s body. Rescuer fatigue could also contribute to smoothness of movements.

Answer 2: For infants, gastric distention is common because an excessive amount of air is delivered during rescue breathing. To prevent this, the amount of air that is held in the nurse’s cheeks is given during each rescue breath.

Answer 4: For infants, use five back blows, turn him over and deliver five chest thrusts.

For back blows and chest thrusts, head should be lower than the trunk. See Figure 16-9, p.

423. If the object is expelled during blows or thrusts and the head is downward, gravity will help. Using a flashlight and looking in the mouth will delay the intervention of clearing the airway. The child is likely to struggle out of fear and respiratory distress and visualizing the back of the mouth will be very difficult.

Answer 2: Oliguria is urine output less than 500 mL in 24 hours. During shock, blood flow to the kidneys is decreased. This can result in damage to the kidneys. Paralytic ileus is decreased or absent motility of the bowel, which can also occur with shock; however, the appropriate assessment would be bowel sounds, abdominal pain, or failure to pass gas or stool.

Shock can also produce electrolyte imbalance, but assessment of laboratory values would be more appropriate than observing amount of urine output. Heart failure is the least likely complication of shock. Right-sided heart failure is more associated with long-term respiratory or circulation problems.

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Answer Key 45

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Answer 3: The patient has an arterial bleed, so the nurse would not waste time seeking out sterile supplies. Clean gloves and a clean towel are adequate. Elevation above the level of the heart will also help control the bleeding.

Wrapping the area with layers of sterile gauze would be done after initial bleeding is controlled. Pressure to the brachial artery would only be done if direct pressure and elevation were not controlling bleeding.

Answer 4: If direct pressure, elevation, and indirect pressure have failed to control bleeding and the patient’s life is in danger, the nurse would use a tourniquet. Use of a tourniquet should not be considered part of general first aid or the Good Samaritan principles. A health care provider could order the application of a tourniquet over the phone or the victim could request it; however, as with other procedures that are not within the scope of practice, the nurse should decline unless he/ she deems that the patient’s life is in jeopardy.

Answer 1: The nurse should assess for all of these options; however, for elderly patients hypertension is a primary risk factor. If hypertension is the underlying cause, the blood pressure is likely to be very high. Because the bleeding was easily controlled, the nurse suspects that the patient did not know how or could not perform the self-care measures to stop the bleeding, so knowledge and skill must be assessed. Infections can also contribute to nosebleeds, so checking the temperature would also be appropriate.

Answer 2: All of these patients are at risk for internal bleeding; however, Coumadin (warfarin) is an anticoagulant and fractures of hip or femur can result in 500-1500 mL of blood loss. Small children with bumps to the forehead usually do well and are generally discharged to parents with a careful explanation of what to watch for. Blunt trauma to the abdomen can cause rapid or slow internal bleeding. This patient should receive serial abdominal assessments and complaints of increasing pain are immediately reported to the RN or health care provider. Women with postpartum hemorrhage can die if the bleeding is excessive or if there are complications, (e.g., disseminated intravascular coagulation), but generally a dilation and curettage and IV fluid replacement are sufficient treatment.

Answer 1, 2, 3, 5, 6: Respiratory distress, pain, and decreased perfusion are signs/symptoms

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of a pneumothorax or hemothorax. A patient could be unconscious and responsive if excessive blood is lost or decreased oxygenation of tissues has occurred; however, patients with a hemothorax or pneumothorax are frequently conscious and experiencing pain, anxiety, and severe respiratory distress.

Answer 1: The nurse cannot immediately determine if the patient has been overcome by gas or heat, or by something else; however, for the nurse’s safety, he/she steps out of the house and calls 911. If the nurse is overcome by gas and help has not been summoned first, the nurse and the patient could die. If the nurse can remove the patient from the house, this would be the best thing for the patient; however, if the nurse cannot safely move the patient, the nurse should use critical thinking.

(Windows could be broken from the outside.

Two strong neighbors could assist the nurse to drag the patient from the house.) Cooling measures and contacting Poison Control can be done once the victim is out of the hot and toxic environment.

Answer 4: Loss of bowel and bladder function, rapid and weak pulse, labored breathing, seizures, nausea, vomiting, diarrhea, loss of memory, lack of coordination, and depressed muscle reflexes are signs of serious intoxication. The other adolescents are demonstrating signs and symptoms of mild intoxication.

Answer 4: Victims are first moved into a cool environment. Next, the nurse would assist to remove constrictive clothing, offer cool drinks, and give cool compresses. A circulating fan will also help.

Answer 3: No creams, ointments, sprays, or other topical applications should be put on the skin. The skin will have to be assessed and cleaned at the hospital and topical applications can create complications. The other actions are correct.

Critical Thinking Activities 35. a. Good Samaritan laws stipulate legal protection for those who give first aid in emergency situations if they follow a reasonable and prudent course of action.

Once the nurse initiates any action, there is a moral and legal obligation to continue until qualified help arrives. b. Use simple language and remain calm.

Direct a bystander to call 911. Ask the woman for permission to help her and tell

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Answer Key 46

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her to remain in a supine position. Check the airway, breathing, and circulation.

Identify the source of bleeding and apply direct pressure (use the cleanest material available). Once bleeding is controlled continue observations of skin color, temperature, pupil reaction, and neuromuscular status. c. A victim in shock may have a change in the level of consciousness, skin temperature and color changes, decreased blood pressure, increased pulse rate and respirations, diminished urinary output, muscle weakness or tremors, pupil dilation, nausea, and vomiting. d. Appropriate interventions for this victim in shock include: establish airway, control bleeding, maintain supine body position, and avoid hyperextension of the neck to protect against potential neck or spine injuries. Cover the patient. Do not allow anyone to administer food or fluids. Give emotional support. a. The weather is cool and windy. The man’s clothes are wet. He is shivering, confused, and his speech is slurred. The absence of shoes suggests that he has discarded them in his confusion, and that loss of the shoes is contributing to heat loss. b. Hypothermia is demonstrated by uncontrollable shivering; low body temperature; slow, slurred speech; disorientation; and uncoordinated or decreased muscle movement. The skin may appear mottled and edematous, with general numbness. Pulse is weak and irregular, with depressed respiratory rate. The victim becomes more lethargic, with decreasing level of consciousness, until reflexes are also lost. c. Victim should be moved to a warm environment if possible and wet clothes should be removed and the victim should be covered with warm blankets. For a conscious victim, warm nonalcoholic fluids should be provided. The victim needs medical help as soon as possible.

Your selection of event could be related to your family. For example, you have young children and a neighbor has a swimming pool where the children are frequently invited for play dates. In your mental rehearsal, where was the nearest phone to call 911? Who was most likely to be there to assist you? Did you

remember how to do CPR on young children? What were the children doing when the drowning occurred? Could the incident have been prevented?

The event could relate to your job in an assisted-living center. Who discovered the resident? What actions did you take first? Where is the AED located? Do you remember how to use the AED? Does the facility have a bagvalve-mask or is mouth-to-mouth the method that you would use?

CHAPTER 17—COMPLEMENTARY AND ALTERNATIVE THERAPIES Fill-in-the-Blank Sentences 1.

Complementary therapies 2.

Alternative therapies 3. mind-body-spirit 4. allopathic medicine 5.

Integrative medicine True or False 6.

False. Chiropractors do not prescribe medication.

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True 8.

False. Reflexologists are not qualified to diagnose.

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True 10. False. Acute infectious conditions such as appendicitis should be assessed by an allopathic health care provider.

Multiple Choice 11. Answer 1: Many people use CAM therapies, but will not report the usage. Reasons for not reporting include fear of disapproval by health care team, belief that natural products are not harmful, or assumption that supplements are not worth mentioning. Practices may seem so “normal” or routine that the patient would overlook them as health care issues; thus direct questions are needed to elicit information, rather than waiting for the patient to offer the information. Taking a complete history and advocating are expected routine nursing behaviors. Some CAM therapies may be covered by insurance, but usually a health care provider’s order is required for coverage.

12. Answer 3: National Center for Complementary and Alternative Medicine serves as a clearinghouse to distribute information to

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Answer Key 47

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the public, the media, and professionals.

Supporting, coordinating, and conducting research, and research training in the area of alternative medicine are also performed.

Textbooks include much basic and valuable information, but the information will be outdated compared to other sources. Use of the Internet is likely to yield much information, but sources may not be validated. American Cancer Society is the second best option.

Answer 1, 2, 3, 4, 5: Lack of research, accountability, consistency, and standardization contribute to safety and quality problems. An herbal preparation usually includes an unpurified extract of the whole plant. One herb may be used for a variety of purposes, and its action is usually gentler than those of pharmaceuticals.

Answer 4: Herbal preparations should be discontinued at least 2 weeks before a surgical procedure to prevent interactions with drugs and to avoid complications such as hemorrhage. Over-the-counter products can have dangerous side effects, especially if there are interactions. Following the package instructions is correct, but this is just one aspect of using the product correctly.

Answer 2: See Table 17-1, p. 447 for herb-drug interactions.

Answer 4: Studies support the use of T’ai chi in preventing osteoporosis. Acupuncture is used in the treatment of osteoarthritis. Osteoporosis is a contraindication for chiropractic treatments. Reflexology decreases stress, enhances circulation, and normalizes metabolism.

Answer 2: Acupuncture has been used in smoking cessation and to treat other addictions. Exchanging tobacco leaf for another type of plant leaf could be dangerous and is ill-advised. Inhalation of lavender oil does reduce stress; possibly stress could be one reason that a person reaches for a cigarette, but nicotine is highly addictive and the craving would persist. Biofeedback could also be useful for increasing awareness of physiologic changes associated with wanting a cigarette and/or withdrawal from nicotine.

Answer 2: Patients who are at risk for thrombophlebitis should not have the legs massaged. The other patients could all benefit.

Answer 4: It is likely that the student’s initial reaction on seeing the patient was already manifest through nonverbal behavior. Focus-

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ing on the face will help reestablish rapport and the patient’s face is more familiar to the student than the wrinkled landscape of the patient’s body. Safety is the primary concern at the moment, so leaving to step out into the hall or find the instructor is incorrect. Not looking directly at the patient will increase the patient’s feelings of rejection.

Answer 2: “Skin hunger” refers to lack of being touched; therefore, the nurse would assess who is amenable to receiving touch and hugs from staff members.

Answer 1: Inhalation of substances can trigger or worsen asthma symptoms. Aromatherapy may help decrease depression, stress, or pain.

Answer 3: Myasthenia gravis causes muscle weakness and possibly the magnet’s action could cause relaxation of muscles; thus magnet therapy is contraindicated for patients with myasthenia gravis. Magnet therapy is also thought to cause vasodilation and antiinflammatory action. So checking vital signs and being vigilant for occult signs of infection would also be relevant for anyone who is using magnet therapy. Memory and cognition should not be affected.

Answer 1: Guided imagery helps the person gain control over responses to stress or stimuli by modifying perceptions. Deep-breathing, accessing all senses, and using images such as warmth or success are part of the technique.

Answer 1, 2, 6: Research indicates that animals have a calming effect and reduce blood pressure and anxiety. Interaction can stimulate mental activity. Family pets do not necessarily make good therapy animals. Not all patients will want to get involved with therapy animals; conversely, some may like animals but allergies or autoimmune conditions prevent interaction.

Answer 1: Repressed emotions may surface during the biofeedback sessions; thus, the therapist would have to give support or refer the patient to an appropriate counselor.

Critical Thinking Activities 26. a. Obtain information on the patient’s use of complementary and alternative treatments. Try to avoid using the term “alternative medicine” because the patient may not view the use of herbs or other therapies as alternative or as medicine. Assess the patient’s belief system about health and treatment. Add findings to the pa-

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Answer Key 48

27.

tient’s record and inform the health care provider because some therapies could cause an interaction with medical treatment or be contraindicated for certain medical conditions. b. Refer to Cultural Considerations: Providing Culturally Appropriate Complementary and Alternative Therapy on p. 460.

The nurse’s beliefs may be very different than the patient’s; therefore, the nurse may have trouble supporting the patient’s choices because of potential dangers of interaction or delay in seeking standard medical treatment. Another potential issue is that the patient may intentionally withhold disclosure for fear of censure or criticism by the nurse or health care provider or the information may be unintentionally withheld because the use of the therapy may be a longstanding routine part of the patient’s life and would therefore not be reported. c. When teaching patients about CAM, the nurse may include information on the safe use of therapies, positive and negative effects, contraindications to use, reputable sources for purchase, interactions with medical therapy, and when to seek medical treatment. a. None of these patients are currently good candidates for relaxation therapy. The patient with dementia will have trouble focusing. It is unlikely that she would have the ability to concentrate on the stimuli or understand the instructions. It is possible that an advanced nurse specialist could design a specialized relaxation program for her, but the standard techniques included in Box 17-1, p. 456 are not likely to work, and may actually increase her agitation. b. The college student is concentrating on studying and solving current math problems; therefore, his mind is not passive enough to turn away from his goal. It is likely that he lacks the ability to focus on your instructions or to attend to the stimuli because he is under the influence of “uppers.” This patient would be a good candidate for relaxation therapy once his system is clear of the drugs. c. The retired military officer demonstrates some rigidity in his way of dealing with the world and his personal issues. It

appears that he is not receptive to the nurse’s help at this time. The nurse could consider teaching the techniques to the wife. It is likely that his tension is affecting her.

CHAPTER 18—PAIN MANAGEMENT, COMFORT, REST AND SLEEP Fill-in-the-Blank Sentences 1. noxious 2. chronic nonmalignant 3.

6 4. perception 5. endorphins True or False 6.

False. There is no predictable relationship between tissue injury and pain.

7.

False. Approximately 50% of people who suffer moderate to severe pain will continue to suffer, primarily because nurses fail to assess pain.

8.

False. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs)—the nonopioid analgesics—are the most widely available and frequently used analgesic group.

9.

True 10. False. Older adults require about the same amount of sleep as younger people, but are more likely to achieve it in separate episodes.

Multiple Choice 11. Answer 2: Respiratory rate is already low and respiratory depression is a side effect of opioid medication.

12. Answer 3: For chronic pain, such as the pain that accompanies arthritis, NSAIDs are most commonly used. Their better-characterized actions are peripheral, where they are thought to exert analgesic effects.

13. Answer 3: The epidural opioids have side effects including urinary retention, postural hypotension, pruritus, nausea, vomiting, and respiratory depression.

14. Answer 1, 3, 4, 5: Meperidine is used much less frequently for any patients, but older adults are even more prone to have side effects because of reduced kidney function.

Morphine sulfate is generally not used for chronic pain. NSAIDs are not the first choice for older adults, because of the risk for gastric and renal toxicity. Combinations of opioid

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Answer Key 49

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drugs would not be a good choice of therapy for older adults because of drug-drug interactions and additive effects.

Answer 1: The nurse implements measures to alter the sensory impulses, which help close the gate and block pain impulses, by providing back rubs, applying warm or cool compresses, and using auditory and visual distractions.

Answer 3: Assessing and reassessing the patient’s pain is one of the key concepts under the new TJC standards. The other actions are also important nursing responsibilities that the nurse would routinely perform.

Answer 2: The nurse should help the student recognize that an assessment of pain should precede any interventions. Based on the student’s report of the patient’s description of pain, the nurse may decide to ask the other questions or they may need to return to the patient’s room and conduct additional assessment.

Answer 3: Guided imagery is the process of helping a patient recreate a time and place where he/she felt relaxed, happy, and peaceful. The nurse must be skilled in this process to help the patient activate memories of sights, sounds, smells, and emotions. Firm and light strokes are used during massage.

Electrical stimulation of the skin is used in transcutaneous electric nerve stimulation.

Biofeedback uses specialized equipment to help the patient identify and learn to control responses to stress and stimuli.

Answer 4: The biggest advantage is that the patient gains some feelings of control over his/her own pain and many of the therapies can be performed at home once the patient learns to master the techniques. The other options are also relevant to the noninvasive techniques.

Answer 1: There is a possibility that the TENS unit could interfere with a cardiac pacemaker, so the health care provider should be alerted to discuss the possibility with the patient.

Answer 3: The maximum dose for acetaminophen is 4000 mg in 24 hours, so if the patient receives the medication every 4 hours over the course of 24 hours, he/she will get 6 doses or 6000 mg. So the nurse should call the health care provider to clarify the order.

Answer 3: The intramuscular route is more likely to cause respiratory depression than

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the other routes. In addition, the child is more likely to be opiate-naïve.

Answer 2: Normeperidine is eliminated by the kidneys and is a particularly poor choice for patients with sickle cell disease because most have some degree of renal insufficiency.

Answer 4: Cancer patients require long-term repeated doses of opioids for pain management and this results in accumulation of the metabolite in meperidine, normeperidine. The active metabolite in meperidine, normeperidine, sometimes produces irritability, tremors, muscle twitching, jerking, agitation, and seizures. Meperidine (Demerol) is used much less frequently than in the past, because there are other opioid medications that are safer. At home, patients cannot be monitored as closely as they are in an acute care facility, so those who need long-term therapy must be offered treatments that they can manage in the home setting. Young healthy patients have also had adverse reactions to meperidine (Demerol).

Answer 4: Duloxetine (Cymbalta), an antidepressant, is used for control of the pain associated with diabetic neuropathy. NSAIDs, such as ketorolac tromethamine (Toradol), tramadol (Ultram), and acetaminophen (Tylenol) are considered as good pain relievers for mild to moderate pain, but are not as effective for neuropathic pain, which can be difficult to treat.

Answer 1: Physical tolerance and physical dependence do occur in many patients after 1-4 weeks of regular opioid administration.

Recognize that these effects are expected with long-term opioid treatment, but do not confuse them with addiction. Chronic pain is defined as lasting longer than 6 months.

Answer 3: Diuretics should be taken early in the day. Otherwise, the patient will have to rise frequently at night to go to the bathroom.

Patients can have varied success with different NSAID medications, but sleep disturbance is not a typical complaint. A recent increase in opioid medication should actually help the patient to get more rest and sleep. Antiemetics are usually taken before meals. Some antiemetics cause drowsiness and should help the patient rest and sleep.

Answer 2: Rotating days to nights creates the biggest disruption because the body will continuously try to adapt to the biologic rhythm of sleep. Night shift work is also associated with health problems.

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Answer Key 50

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Answer 4: An automatic blood pressure cuff can be applied to an extremity and left in place. This allows the nurse to check the blood pressure and pulse without having to wake the patient to apply and remove the cuff. The machine does not replace the nurse.

The nurse must still enter the room every 2 hours, read the machine, count the respirations, and ensure that the cuff has fully deflated. If the provider has ordered q2h vital signs, it is likely that the patient is unstable or that the provider anticipates that the patient may develop a problem. Explaining the procedure to the patient is appropriate; however, do not suggest to the patient that the process will end after 12 hours. It would be better to tell him that the provider will evaluate the pattern of vital signs at the end of 12 hours and then make a decision based on that data. Telling the UAP to be quiet and quick is an option if there is no automatic cuff or if the patient cannot tolerate the continuous presence of the cuff.

Answer 4: First the nurse assesses patient’s usual methods for dealing with difficulty sleeping. Based on assessment findings, the nurse may elect to use the other options.

Critical Thinking Activities 31. a. To fully assess the patient’s pain, the nurse should follow up with questions about the severity, location, duration, possible cause, relief measures, exacerbating factors, prior history, and degree of interference with ADLs. b. If the nurse does not respond to the patient’s pain, the patient’s trust may be eroded and there could be physical setbacks, such as delayed healing. c. To reduce the patient’s pain, the nurse can provide comfort measures (e.g., application of heat or cold), administer medications as ordered, encourage the patient to report the pain, provide emotional support, maintain a clean and quiet environment, and reduce stress.

32. a. NREM sleep is necessary for body tissue restoration and healthy cardiac function.

REM sleep is important for brain and cognitive function; therefore, interruption of REM sleep will interfere with memory and learning. See Box 18-5, p. 480 for additional information.

33.

b. Patient will sleep at least _____ hours per night while in the hospital. c. Nursing interventions to promote sleep include determining the patient’s usual sleep patterns, limiting interruptions during the night, providing a quiet darkened room, maintaining comfort, emptying trash and removing dietary trays promptly, offering a back rub, changing linens or dressings, administering medication as ordered, and offering noncaffeinated beverages. a. Many factors contribute to a patient’s lack of comfort, which manifests in many forms, including anxiety, constipation, constricting edema, depression, diaphoresis, diarrhea, abdominal distention, dry mouth, dyspnea, fatigue, fear, flatus, grief, headache, hopelessness, hyperthermia, hypothermia, hypoxia, incontinence, muscle cramping, nausea, pain, powerlessness, pruritus, sadness, singultus, thirst, urinary retention, or vomiting. b. Helping the patient cope with the cause of discomfort may have been as simple as changing the wet linen, offering a glass of water, or obtaining a warm blanket. You may have used therapeutic communication to help the patient deal with anxiety, depression, fear, grief, hopelessness, or powerlessness. You may have administered pain medication or other medication to relieve noxious symptoms such as nausea and vomiting.

CHAPTER 19—NUTRITIONAL CONCEPTS AND RELATED THERAPIES Matching 1. b 2. d 3. a 4. g 5. i 6. c 7. f 8. e 9. j 10. h Short Answer 11. The six classes of nutrients are carbohydrates, fats, proteins, vitamins, minerals, and water.

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Answer Key 51

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They function in the body to provide energy, build and repair tissue, and regulate body processes. a. Protein: 4 kcal/g, 10% to 35% b. Carbohydrate: 4 kcal/g, 45% to 65% c. Fats: 9 kcal/g, 20% to 35% a. Food source: Egg yolks, liver, milk, carrots, winter squash, sweet potatoes, spinach, collards, kale, broccoli, apricots, cantaloupe. Function: Vision, epithelial tissue integrity, growth, reproduction, embryonic development, immune function.

Symptoms of deficiency: Night blindness, xerophthalmia, increased infections, follicular hyperkeratosis. Symptoms of toxicity: Fatigue, headache, nausea, vomiting, blurred vision, liver abnormalities, bone and skin changes. b. Food source: Fortified milk, fortified margarine, egg yolks, liver, fish. Function: Maintain blood calcium and phosphorus balance. Symptoms of deficiency: Rickets (children)—abnormal shape and structure of bones. Symptoms of toxicity: Calcification of soft tissues. c. Food source: Green leafy vegetables, milk, dairy products, liver, meat, egg yolks, green tea (synthesis by intestinal bacteria).

Function: Formation of blood clotting factors. Symptoms of deficiency: Increased prothrombin time; in severe cases, hemorrhaging. Symptoms of toxicity: None exhibited. a. Food source: Milk, cheese, milk products, green leafy vegetables, broccoli, legumes, fish with bones, fortified cereals. Function: Formation and maintenance of bones and teeth, blood clotting, nerve conduction, muscle contraction. Symptoms of deficiency: Osteoporosis (adults)—weak, more porous bones. Stunted growth in children. Symptoms of toxicity: Constipation, increased risk in males for urinary stone formation, reduced absorption of iron and zinc. b. Food source: Sweet potatoes, fruits, vegetables, fresh meat, legumes, milk. Func-

c.

tion: Nerve conduction; muscle contraction, including the heart; fluid and acidbase balance. Symptoms of deficiency: Severe: cardiac dysrhythmias, muscle weakness, glucose intolerance. Moderate: increased blood pressure, risk of kidney stones, increased bone loss. Symptoms of toxicity: Cardiac arrest.

Food source: Salt, processed foods, small amounts in whole unprocessed foods.

Function: Fluid and acid-base balance, nerve conduction, muscle contraction.

Symptoms of deficiency: Cramps, mental confusion, apathy, appetite loss (usually secondary to diarrhea or disease). Symptoms of toxicity: Hypertension in susceptible individuals, increased calcium excretion.

True or False 15. False. As adipose tissue, fat helps insulate the body from temperature extremes and serves as a cushion to protect organs and other tissues from being bumped or jarred.

16. True 17. False. Increased fluid intake is a common dietary treatment for renal calculi (kidney stones) and urinary tract infection.

18. True 19. True 20. False. Current American Heart Association recommendations for healthy individuals older than 2 years are to obtain 25% to 35% of total calories from fat, with less than 7% of total calories from saturated fats and less than 1% of total calories from trans-fatty acids.

21. False. In the United States, nearly 35% of adults and over 16% of children and adolescents are obese.

22. False. If unable to aspirate, first try looking for kinks or occlusions and attempt to flush the tube with 30 mL of water.

23. True

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Answer Key 52

Table Activity 24. See Table 19-3, p. 492.

29.

Interpretation of Numerical Value

Numerical Value LDL Cholesterol <100

Optimal

100-129

Near or above optimal

130-159

Borderline high

160-189

High

≥190

Very high

Total Cholesterol <200

Desirable

200-239

Borderline high

≥240

High

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HDL Cholesterol <40 men; <50 women

Low

Figure Labeling 25. See Figure 19-7, p. 522.

Multiple Choice 26. Answer 1: Vitamin K can affect clotting times; thus the patient should be assessed for ingestion of typical amounts of vitamin K sources and be advised to keep consumption at a consistent rate so that the medication can be adjusted accordingly.

27. Answer 2: Bleeding gums is one sign of vitamin C deficiency; citrus fruits, broccoli, tomatoes, and peppers are some sources for vitamin C. Milk, egg yolks, and liver supply vitamins A, D, and K. Cereals, legumes, and nuts supply vitamin B1 (thiamine). Poultry, fish, and brown rice supply vitamin B6. See Table 19-4, p. 495 for additional information.

28. Answer 4: Vitamin B12 is primarily found in foods of animal origin; therefore, the person eating the vegan diet is most likely to need vitamin B12 supplements. The patient who is trying weight loss plans should be assessed for weight loss goals and advised to see the health care provider. The patient who eats very few fruits and vegetables needs counseling about healthy diet. Eating small amounts of a wide variety of foods is a good strategy to meet nutritional needs without taking supplements.

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Answer 1, 2, 5: Animal products, eggs, meat, fish, and milk supply complete proteins.

Peanuts and beans are good sources of incomplete proteins.

Answer 1: Vitamin A is a fat-soluble vitamin and can be stored in the body; potentially it can cause death. The others are water-soluble.

Vitamin C could cause diarrhea and abdominal cramping.

Answer 2: Sources of zinc include red meat, liver, eggs, seafood, cereal, whole grains, and legumes.

Answer 2: Any liquid that can by seen through is considered okay for a clear liquid diet.

Answer 4: In diabetes, the body does not produce or properly use insulin. Insulin is a hormone needed to convert sugar, starches, and other carbohydrates into the energy for daily life. Fat and sodium restrictions are frequently used for patients who are at risk for cardiovascular disorders. Protein restrictions are used mostly for patients with kidney or liver problems.

Answer 3: The patient is describing symptoms of lactose intolerance and there is a higher incidence among Asian-, African-, and Hispanic-Americans and American Indians. Food allergies are more likely to cause itching or swelling of the mucous membranes. MyPlate guidelines generally direct people to eat a variety of foods in modest portions. Asking if others are having similar symptoms is a good question if food poisoning is suspected.

Answer 4: The nasogastric tube pressing against the eustachian tube causes obstruction and edema. It is best prevented by turning the patient from side to side frequently, at least every 2 hours.

Answer 2: Patients should be assisted to a sitting or high Fowler’s position to prevent aspiration. The other actions are correct.

Answer 1, 2, 3, 5, 6: Ability to chew, swallow, and take fluids should be assessed. Dietary intake related to health problems or culture should also be assessed. Ability to obtain and prepare own food would be relevant for a community-dwelling patient, but meals are typically prepared in long-term care facilities.

Answer 3: The nurse must assess how the patient is tolerating the liquid diet before offering soft foods. This would include assessing bowel function and subjective sensations. The patient is likely to be hungry for something

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Answer Key 53

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besides liquids, but desire for food does not necessarily correlate with what the bowel can tolerate. Assessments should be made before calling the provider or the nutritionist.

Answer 2: At approximately 4-6 months of age, depending on the infant’s development, it is possible to introduce solid foods into the diet. The child is usually started on iron-fortified rice cereal. Fruits are added next, then vegetables, and then meats.

Answer 4: Diuretics, such as furosemide, chlorothiazide, and hydrochlorothiazide can contribute to depletion of potassium, magnesium, and calcium.

Answer 1, 3, 4, 5, 6: Assisting, recording, observing, communicating, and monitoring are nursing responsibilities related to nutrition.

Designing dietary plans for chronic health problems should be done by a dietitian because many health problems require a balance of calories and nutrients with disease condition and patient preferences.

Answer 1: Ten ounces of chicken breast is an excessively large portion according to MyPlate.

Answer 2: Helping the patient understand the application of the DRIs to personal health is a strategy to help him remember the information. DRIs do replace RDAs, but are not exactly the same because DRIs combine RDAs, Adequate Intake (AI), Tolerable Upper Intake Level (UL), and the Estimated Average Requirement (EAR) of each nutrient. RDAs did target the adult American; however, RDAs were also made for other age groups (e.g., children and elderly) and for pregnant/lactating women.

Answer: 225 g carbohydrates; 75 g for protein; 33.3 g for fat 1500 ÷ 0.60 = 900 kcal in carbohydrates 1500 ÷ 0.20 = 300 kcal in protein 1500 ÷ 0.20 = 300 kcal in fat 900 kcal for carbohydrates ÷ 4 kcal/g = 225 g for carbohydrates 300 kcal for protein ÷ 4 kcal/g = 75 g for protein 300 kcal for fat ÷ 9 kcal/g = 33.3 g for fat Answer 4: Protein is the single most important nutrient for building and repairing tissue; however, the patient will need a wellbalanced diet in order to recover.

Answer 1: Corn and potatoes are complex carbohydrates that break down more slowly and provide energy for a longer time. Milk, fruits,

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49.

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honey, table sugar, and chocolate are simple sugars that supply quick energy because they require less digestion. Electrolyte drinks would be important on hot days during prolonged periods of exercise.

Answer 4: Water-soluble fiber foods help to bind the cholesterol in the digestive tract.

Insoluble fiber found in wheat bran, celery, lettuce, and pears helps to soften stool and speed transit of foods through the digestive tract. Oranges provide more fiber than orange juice. White rice will slow movement of solid material through the digestive tract.

Answer 2: Sudden increase in dietary fiber can cause bloating, gas, and constipation, so patients should be advised to add fiber foods slowly and to drink a lot of water. Contacting the health care provider is always good advice when starting a new dietary change, but returning to old dietary habits should not be encouraged in this case. Osteoporosis and anemia can be caused by excessive fiber, but there are many benefits of a reasonable fiber intake, so the nurse should not scare the patient by making statements that do not necessarily apply to the patient’s situation.

Answer 4: Saturated fats increase the risk for atherosclerosis. However, none of these chronic health problems is improved by eating too much fat.

Answer 2: Monounsaturated fats are thought to lower LDL (bad) cholesterol. The other options are incorrect. Avocadoes are high in fat, so the nurse should remind the patient to limit total fat intake to 20% to 35%.

Answer 2: If the patient is able to describe a plan of self-management, it means that he/ she understands the sources of cholesterol and is ready for self-care; thus the nurse can reinforce the plan. Asking the patient to describe a typical 24-hour period is the second best option, because it provides assessment data as to areas the patient needs to “watch.”

Offering a food list is a good option if the patient is unsure how to proceed. “Do you understand?” is a closed question. The patient may be embarrassed and just say yes.

Answer 2: Albumin is a plasma protein. Albumin level is lowered in poor nutritional states and should improve with nutritional therapy.

Hemoglobin and electrolyte values are also associated with nutritional status of various minerals. White blood cell counts reflect immune system reaction.

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Answer Key 54

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Answer: 67 g First convert pounds to kilograms 185 ÷ 2.2 = 84 kg 84 kg × 0.8 g/kg = 67 g Answer 3: Iron deficiency anemia is the most prevalent nutrition problem in the world.

In addition, adolescence, menstruation, and a lack of animal products in the diet will increase the risk for iron deficiency anemia.

There is a higher incidence of anorexia nervosa among teenage girls; however, choosing a vegan diet is considered a healthy choice, whereas anorexia nervosa is a mental health disorder. Rickets is caused by a vitamin D deficiency. Marasmus is a protein deficiency.

Answer 3: Patients with severe illness or injury or with prolonged starvation will have negative nitrogen balance and manifest muscle atrophy. Being NPO and fasting do create a negative nitrogen balance state, but temporary protein deficiency should not cause obvious physical changes. Pregnancy creates a positive nitrogen balance as tissues are built.

Answer 4: Kwashiorkor is a severe protein deficiency. The swelling is caused by fluid shifting related to hypoalbuminemia. It is likely that the children have many other nutritional deficiencies.

Answer 3: Citrus fruits supply vitamin C and an additional 35 mg/day of vitamin C is encouraged because smoking increases oxidative stress.

Answer 1: Stomach acidity decreases with age and with antacid use. This decreased acidity blocks the absorption of vitamin B12 from foods. Intrinsic factor is required for vitamin B12 absorption, and may be missing after stomach surgery. Both vitamin B12 and intrinsic factor are required to prevent pernicious anemia. Heme iron prevents iron deficiency anemia. Antacids do interfere with the absorption of many medications and nutrients; advise patients to follow directions of health care provider.

Answer 3: Iron poisoning can be fatal and many children’s supplements will contain iron. Vitamin C can cause some gastrointestinal disturbances. Poison Control will ask the child’s weight, amount ingested, time, and product name. Inducing vomiting in this case is not harmful, but probably not helpful either, because the chewable form is readily digested and absorbed.

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Answer 4: Children under age 2 should not be given low-fat milk because they need the fat content. For the other patients, low-fat milk would be preferred over whole milk.

Answer 3: If the child helps prepare the food it gives him a role and helps him increase feelings of control. Meal and snack times should be set times. Children’s servings should be smaller than adult servings. Offering the family food is not a bad strategy, but if every meal is a struggle, then offering nutritious foods that the child likes will meet nutritional needs and make mealtimes more pleasant. In addition, children often have a very narrow range of preferences and introducing new foods should be done slowly.

Answer 4: If the information is relevant to current interests, the recipient is more likely to pay attention. In this case, most adolescent girls are interested in their appearance. Delaying the discussion would be ideal for teaching purposes, but this is not always realistic or possible. Explaining the science of physiology and nutrition is more likely to appeal to a nursing, medical, or nutrition student. Assessing interest in other health topics is okay, but this is just another means for delaying the discussion about nutrition.

Answer 3: The UAP’s intentions were good and long-term care facilities are trying to liberalize the diet for residents. In addition, acknowledging holidays with special foods helps residents to maintain cultural and social norms. The meals could be adjusted for the remainder of the day to allow for the cupcakes to be part of the total intake. Collecting the cupcakes would be demeaning and demoralizing for the residents and the staff. However, reminding the UAP to check first before handing out food is appropriate.

Answer: Weight in kilograms divided by height in meters squared. See Figure 19-5, p.

511.

Answer 4: Encouraging the patient to set small and realistic goals is the most important thing for successful weight loss. Strict adherence to diet or exercise goals can seem overwhelming at first and it is unlikely that the patient can start with 60 minutes of exercise or strictly adhere to 1500 kcal every day.

Supplements may be needed, but taking these is the easier part of the weight loss program, so emphasizing this point is usually not necessary.

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Answer Key 55

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Answer 1: Body mass index of ≥40 is considered morbidly obese and would be considered valid reason for bariatric surgery. If BMI is 35 or higher, the patient might be considered if medical conditions such as diabetes are present. BMI of 23 is considered normal, so if weight loss of a few pounds was part of the treatment, diet and exercise would be prescribed. BMI of 17 is underweight; therefore, weight loss for this patient is not part of the therapeutic regimen.

Answer 4: Erosion of tooth enamel and the calloused knuckles are from frequent selfinduced vomiting, which is a behavior associated with bulimia nervosa. Hiding the food, throwing it away, or pushing it around the plate are behaviors exhibited in anorexia nervosa. Eating extraordinarily large amounts of food is a feature of binge eating.

Answer 4: Consistent mealtimes make the coordination of carbohydrate intake, insulin, or oral medication and exercise more controlled and predictable. Diabetic meal planning should be individualized. Fish is good, but should be baked or grilled, not fried. Monitoring and control of total carbohydrate intake is emphasized. Sugars and desserts are considered part of the total.

Answer 2: Milk has lactose, which is a sugar, and also supplies protein. Weakness, perspiration, and disorientation could be signs of heat related dehydration, in which case encouraging water would be appropriate. IV glucose is given if patients are unresponsive. Sucking on hard candy would be appropriate if no other source of glucose was readily available.

Answer 4: Steatorrhea is fat in the stool and occurs when there is incomplete digestion of fats. Carbohydrate-modified diets are prescribed for patients with diabetes. Proteinrestricted diets are used for patients with kidney or liver problems. Sodium-restricted diets are used for heart failure or hypertension.

Answer 2, 3, 4, 5, 6: Explaining, offering suggestions to relieve subjective thirst, and making sure that others know about restrictions are important interventions. Help the patient divide fluid over the 24-hour period to decrease subjective sensation of thirst.

Critical Thinking Activities 72. a. Patients who cannot chew or swallow; for example, in cases of coma, facial

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trauma or oral surgery. Anorexia from physical causes such as cancer. Psychiatric causes such as anorexia nervosa where the patient refuses food. The patient has a severe nutritional need, such as severe burns. b. Nursing assessments and interventions for enteral feedings: i. Assessment—Need for teaching, presence of abdominal distention, and bowel sounds ii. Gastric aspirate—pH = 0-4, appearing green, brown, or tan iii. Gastric residual above 150 mL— Return the residual, hold the feeding, wait 1 hour and reassess iv. Formula is cold—Warm the formula to prevent cramping v. Occlusion of tubing—Flush with 30 mL of warm water vi. After the feeding—Flush the tubing with 30-60 mL water and recap and secure the tube vii. Documentation—Amount and type of feeding, status of tube, patient tolerance, adverse effects, and teaching provided c. Irritation of mucous membranes, diarrhea, nausea, bloating, delayed gastric emptying, contamination, otitis media infection, aspiration, overhydration, fluid and electrolyte imbalance, and hyperglycemia. Clogged tubing or accidental removal can also be problematic. a. There is an increased need for nutrients during pregnancy because of rapid fetal growth and increased maternal metabolic needs, tissue growth, and blood volume.

Optimal nutrition during pregnancy reduces the risk of complications, premature deliveries, and low birth weight. b. For the pregnant woman, supplements of vitamin A for embryonic development and breast milk production and content; vitamin C for tissue formation and iron absorption; vitamin B6 for protein metabolism and fetal growth; and folic acid for prevention of neural tube defect and macrocytic anemia are recommended. Vitamin A is found in milk, egg yolks, green and yellow vegetables, and organ meats.

Vitamin C is found in citrus fruits, strawberries, broccoli, tomatoes, and green leafy vegetables. Vitamin B6 is found in

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Answer Key 56

milk, wheat, corn, liver, and meat. Folic acid is found in green leafy vegetables, oranges, liver, broccoli, asparagus, and fortified grain products. c. This woman is slightly underweight; therefore, it is likely that she would be encouraged by her OB-GYN to gain between 28-40 pounds. The idea of nutrient-dense foods should be discussed and encouraged, rather than empty-calorie foods. d. Things to be avoided by the pregnant woman are alcohol, caffeine, smoking, and drugs other than those prescribed by the health care provider.

CHAPTER 20—FLUIDS AND ELECTROLYTES Matching 1. b 2. e 3. f 4. a 5. h 6. i 7. c 8. g 9. d 10. j Short Answer 11. The intracellular fluid compartment is comprised of all the fluid inside the cells within the body and contains dissolved particles called solutes.

12. The extracellular fluid compartment contains any fluid outside the cells. It contains large amounts of oxygen and carbon dioxide as well as glucose, amino acids, fatty acids, sodium, calcium, chloride, and bicarbonate.

13. Interstitial fluid is found between the cells or in the tissues. Examples of interstitial fluid include lymph, cerebrospinal fluid, and gastrointestinal (GI) secretions.

14. Intravascular fluid is the plasma within the vessels. This fluid contains serum, proteins, and other substances necessary to sustain life.

The intravascular fluid usually carries nutrients and waste products between cells and tissues and makes up the remaining 7% of fluid volume.

Table Activity 15.

Electrolyte

Normal Value Range

Sodium

a.

125-145 mEq/L

Potassium

b.

3.5-5.0 mEq/L

Chloride

c.

96-106 mEq/L

Calcium

d.

4.5-5.6 mEq/dL

Phosphorus

e.

2.4-4.1 mEq/dL

Magnesium

f.

1.5-2.5 mEq/L

Bicarbonate

g.

22-24 mEq/L

Multiple Choice 16. Answer 4: Potassium is excreted through the urine; therefore, increasing urine output helps the body rid itself of excess potassium. IV calcium is given to patients with hypocalcemia.

Fluid restrictions are used for patients with hyponatremia. Foods high in potassium are given when the patient has hypokalemia.

17. Answer 4: Infusion of excess amounts of citrated blood (citrates bind to the calcium) causes hypocalcemia, and Chvostek’s sign is one of the signs.

18. Answer 1: Dairy products are the best source of calcium. Calcium is also found in some green leafy vegetables, but these sources are harder for the body to use.

19. Answer 2: When metabolic acidosis occurs, one of the compensatory mechanisms is an increased respiratory rate to rid the body of carbon dioxide. Removing carbon dioxide from the blood lowers the carbonic acid level and raises pH to create a more alkaline environment. Diaphoresis is not expected, because the patient is dehydrated. Urine output is likely to be decreased because of fluid deficit from diarrhea. The heart rate is likely to be increased also because of dehydration secondary to diarrhea.

20. Answer 3: Normal ph is 7.35; thus acidosis is identified. Paco2 greater than 45 is typical of chronic obstructive pulmonary disease.

21. Answer 3: Breathing into a paper bag helps the father to “rebreathe” some of the carbon dioxide that he is losing because he is hyperventilating. This will help correct the blood pH. 22. Answer 1: Aspirin is chemically acetylsalicylic acid. This medication will result in excessive acid in the body, resulting in metabolic aci-

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Answer Key 57

23.

24.

25.

26.

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dosis. Respiratory alkalosis is also likely as the body attempts to compensate for the acid overload.

Answer 1: Suctioning removes acids from the stomach and this is reflected in an elevated pH which indicates alkalosis. The Paco2 is normal or maybe slightly elevated if the body is attempting to retain CO2 and increase acid.

The HCO3– is elevated because the kidneys are attempting to excrete bicarbonate, but the kidneys are slower than the other response systems.

Answer 2: Weighing the patient daily is the best method to track trends of fluid gain or loss. It is essential that the patient be weighed the same time every day with the same amount of clothing. Assessing blood pressure and pulse can reflect changes in intravascular volume (i.e., hemorrhage). IV fluid intake provides insufficient information. Laboratory values are intended to reflect body elements such as electrolytes, proteins, or cell structures.

Therefore looking at laboratory values in context of the patient’s condition can contribute to understanding the pathology of fluid status, but this is not the best method to track trends of fluid increase or decrease.

Answer 1: Hypernatremia (sodium levels over 145 mEq/L) causes intracellular dehydration as fluid is pulled from the cells. Hypotonic solutions move into the cells, causing them to enlarge. The health care provider could order a hypertonic solution which pulls fluid from the cells if the patient had hyponatremia.

Isotonic solutions expand the body’s fluid volume without causing a fluid shift from one compartment to another and are given when the intravascular volume is low (i.e., hemorrhage).

Answer 3: Isotonic solutions expand the body’s fluid volume without causing a fluid shift from one compartment to another. These solutions are the most commonly used when the electrolyte balance is not the issue, but fluid replacement is needed. Hypotonic solutions move into the cells, causing them to enlarge. Hypertonic solutions pull fluid from the cells.

Answer 1, 2, 3, 4: Electrolytes serve in body metabolism, water and electrolyte balance, and regulation and formation of hydrochloric acid. Transportation of nutrients and wastes relies on the fluid component.

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Answer 4: Fresh vegetables contain minimal amounts of sodium. Minimizing or eliminating table salt is encouraged. Cheese and canned vegetables are high in sodium. Eating out is not necessarily discouraged, but the nurse should review the menu with the patient to make sure that selections are reasonable.

Answer 4: Patients who take loop diuretics must be cautioned about the signs of low potassium and advised about foods that provide potassium. Patients with small bowel obstruction are more at risk for hyponatremia. Renal failure often results in hyperkalemia. Excessive alcohol consumption is associated with hypocalcemia and hypomagnesemia.

Answer: 2 liters. One liter of fluid equals 2.2 pounds (1 kg); therefore, a weight loss of 2.2 pounds will reflect loss of one liter of fluid.

150 – 145.5 = 4.5 pounds 2.2 pounds × 4.5 pounds = 2.045 rounded to 2 1 liter x liters Answer 1: High levels of potassium (normal range 3.5-5.0 mEq/L) cause cardiac dysrhythmias and cardiac arrest. The nurse would immediately begin to monitor the heart. Foods and fluids with potassium would be withheld. Checking for medications that influence potassium level would be appropriate once the immediate danger has been resolved. IV calcium gluconate is given to patients who have hyperkalemia so the nurse would ensure that this is available, but the medication cannot be given until an order from the provider is obtained.

Answer 2: The patient’s calcium level is low and this increases her risk for bone weakness and other problems associated with osteoporosis. The other values are within normal limits.

Answer 1: Amphojel is given to patients with high phosphorus levels. The normal range is 2.4-4.1 mEq/dL; therefore, the value shows therapy has corrected the imbalance to the normal range. The other levels are also within normal limits.

Answer 1: All of these levels are on the lower end of the normal range and should be observed for continued downward trends; however, because the patient had surgery on the parathyroid glands, the nurse should be concerned about the calcium level in particular.

Loss of parathyroid hormone (parathormone) interferes with the absorption and utilization

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Answer Key 58

35.

36.

of calcium. Calcium levels below 4.5 mEq/dL can result in tetany and laryngeal spasms that could block the airway.

Answer 2: The blood buffer responds in a fraction of a second in an attempt to correct acid-base imbalance. When that system is exhausted, the lungs are the second line of defense and respiratory rate increases to compensate for metabolic acidosis. The kidneys are the third line of defense, but will take hours or days to correct the imbalance.

In DKA, urinary output is usually decreased because the patient is in a state of dehydration and the patient is generally tachycardic. If all systems fail, the pH will decrease.

Answer 3: Respiratory alkalosis can be related to rapid respiratory rates. The nurse would check the ventilator settings to ensure that they match the orders. If the ventilator settings are incorrect, the nurse would reset them. The RN and health care provider should be notified about the blood gas results and any action that was taken. Excessive secretions or a mucus plug are more likely to cause respiratory acidosis. Using the bagvalve-mask would be appropriate as a temporary measure if the nurse determines that the ventilator is malfunctioning.

Critical Thinking Activities 37. a. Older adults have changes in their body fluid amount, reduced kidney function, and may have increased sodium in their diet and decreased fluid intake. These individuals are at greater risk for dehydration and postural hypotension. b. Serum potassium of 3.4 mEq/L is low (normal range 3.5-5.0 mEq/L). The patient will need replacement potassium.

The patient should be closely monitored for signs of hypokalemia and laboratory values should be closely monitored during the replacement therapy. c. The following factors contribute to hypokalemia: vomiting (a), diarrhea (b), and diuretics (c). d. Refer to Box 20-4 on p. 544. Common signs and symptoms of hypokalemia include muscle weakness, leg cramps, nausea, vomiting, and reduced gastrointestinal function. Interventions include measuring I&O, monitoring patients on digoxin and diuretics, monitoring cardiac status, checking laboratory results, and

38.

administering supplements (diet, medications, IV). e. The normal range of sodium is 125-145 mEq/L. Therefore, the patient has a sodium level that is still within the normal range; however, the value is on the low end and the patient is losing sodium because of vomiting and diarrhea. The health care provider is likely to order intravenous solution that provides sodium such as normal saline or 45% saline. The nurse should monitor laboratory values and be alert for signs of hyponatremia. f. Refer to Box 20-1 on p. 542. Common signs and symptoms of hyponatremia include headache, fatigue, and postural hypotension. Interventions include measuring I&O, replacing sodium and fluids, and monitoring fluid losses. g. Output includes urine, diarrhea, nasogastric suction, drainage, and emesis. a. The nurse anticipates that the patient needs treatment for respiratory acidosis. b. Refer to Box 20-10 on p. 551. Signs and symptoms of respiratory acidosis include lethargy, disorientation, headache, decreased level of consciousness, dyspnea, tachycardia, and increased blood pressure. c. Treatment for respiratory acidosis includes intermittent positive pressure breathing (IPPB), low-flow oxygen, antibiotics (for underlying infections, if present), bronchodilators, hydration, and correction of the underlying problem.

CHAPTER 21—DOSAGE CALCULATION AND MEDICATION ADMINISTRATION Basic Math Review 1.

13⁄5 61 2. ⁄8 1 3. ⁄4 4.

7 7⁄12 1 5. ⁄6 1 6. ⁄12 7.

11⁄2 8.

71.849 9.

0.0833 10. 5.750 5.8 11. 1482.7750 12. 13.3 13. 0.50

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Answer Key 59

14.

15.

75% 2.5

Table Activity 16.

Metric

Apothecary

60 milligrams

1 grain

0.45 kilogram

1 pound

1 kilogram

2.2 pounds

30 milliliters

1 fluid ounce

500 milliliters

1 pint

1000 milliliters

1 quart

17.

a. 1 ounce b. 1 liter c. 1 quart d. 1 pint e. 1 grain f. 2.2 pounds g. 0.4 liters h. 0.002 milligrams i. 0.004 grams j. 20 kilograms k. 5000 micrograms l. 2.5 centimeters m. 62.5 centimeters n. 102 kilograms o. 240 milliliters p. 720 milliliters q. 0.25 milligrams r. 15 milliliters s. 30 milliliters

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3460 mL Intake 3910 mL Output 3150 mL 2 tablets 2 tablets 12.5 mL 0.4 mL 0.5 mL 0.8 mL 15 mg 10 mg 6.7 mg rounded to 7 mg (Note to student: You may observe some pediatric nurses or health care providers who do not round up for drug calculations. Also some drugs such as Lanoxin are very potent and require more precision; therefore, rounding is less appropriate.)

6.36 mg rounded to 6 mg 13 gtt/min 21 gtt/min 30 gtt/min 42 gtt/min 125 mL/hour 125 mL/hour Answer: 200 mL/hour (Note to student: In the clinical setting, you may see that some pumps will only go up to 199/hour.)

167 mL/hour

10 20 30

Matching 18. d 19. a 20. c 21. e 22. b

40 50 60 80 90

Clinical Application of Math 23. 62.5 centimeters 24. 90 centimeters 25. 95 centimeters 26. 72 kilograms 27. 26 kilograms 28. 27 pounds 29. 720 mL

100

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Answer Key 60

51. .20

59.

.40 .60 .80

60.

1.00 mL

Short Answer 52. See Box 21-5, p. 575.

53. See Box 21-6, p. 575.

54. A medication order should include patient’s name, date and time of the order, name of drug, dosage of drug, route of administration, time or frequency of administration, signature of health care provider, and any special instructions regarding the administration.

55. Factors that influence a patient’s response to a medication include age, weight, physical health, psychological status, environmental temperature, gender, amount of food in the stomach, and dosage form.

Multiple Choice 56. Answer: a. 4, b. 2, c. 1, d. 3 “STAT” has the highest priority. This type of order indicates an urgent or emergency situation. “Now” has a relative urgency; for example, the health care provider may want the nurse to give pain medication prior to starting a procedure, but the patient is not in critical danger. “One time only” is used for medications that are only given once; for example, medication that is given just before going to the operating room. The frequency of a “PRN” medication is based on the assessment of the patient’s condition.

57. Answer 4: One grain is equal to 60 mg; therefore, half of a grain is 30 mg.

58. Answer 3: Amount × Drip factor = gtt/min Time (in minutes) 500 mL ÷ 4 hours = 125 mL/hour

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125 mL × 15 gtt/min = 31.25 round to 31 mL/ min 60 min Answer 2: Greater trochanter of the femur, the anterosuperior iliac spine, and the iliac crest are the landmarks for the ventrogluteal site.

See Figures 21-14, p. 601 and 21-15, p. 602 for additional information.

Answer 2: ID bands should show the patients’ full name and generally will have an additional identifier, such as a patient number or birthdate. Asking patient to state his/her name is also recommended. Occasionally, mental status, language, or cognitive status will prevent use of this method. Asking another nurse about identity is a method that could be used in some cases, such as with long-term care residents who do not wear ID bands, but it is not a preferred method. Asking family members to verify names is also occasionally done, but again is not the preferred method.

Answer 4: For infants younger than 12 months, vastus lateralis is the preferred site.

Answer 4: A witness is required whenever a an opioid is wasted. Usually the pharmacy will not have to be notified, because opioids are stored on the unit. The medication cannot be “wiped off” and should not be administered.

Answer 3: The purpose of the Z-track technique is to prevent seepage of the medication back through the track of the needle. This method is preferred for medications that are irritating to the tissues.

Answer 2: The anterior aspect of the forearm is the most common site for tuberculin testing.

The upper outer aspect of the arm and the area around the umbilicus are common sites for subcutaneous injections. Middle third of the anterior thigh is an IM injection site.

Answer 4: Drip factors will vary by manufacturer, so looking at the package label and instructions is the best way to find the drip factor.

Answer 3: Inhaler medication is meant to be inhaled into the lungs. Spraying would result in a topical application to the mucous membranes of the mouth and throat.

Answer 1, 3, 4, 5: The extended-release and sustained-release beads are designed to dissolve and release the medication at different times; thus crushing the beads destroys the

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Answer Key 61

mechanism. Sublingual tablets are meant to be placed under the tongue and the medication is absorbed directly into the bloodstream.

Enteric-coated tablets are intentionally coated to delay absorption.

68. Answer 1: An idiosyncratic reaction is an unexpected reaction that seems to be unique to that individual, sometimes the opposite effect of what the medication is supposed to do.

Medications that augment action are synergistic. Need for higher dosage is evidence of tolerance to a drug. Development of a rash is likely to be an allergic reaction.

69. Answer 2: In the buccal route, medication is absorbed through the mucous membranes and into the circulatory system.

70. Answer 2: Most facilities allow a 30-minute window on either side of the designated time, so the nurse has from 8:30 am to 9:30 am. Starting with the most cooperative patients ensures that many of the patients will get their medication on time. If the nurse starts with a patient who needs a lot of help, then all of the medications will be delayed. Five patients with many medications is not an atypical load; however, if the nurse feels that the assignment exceeds abilities, the charge nurse/ RN should be notified at the beginning of the shift, not at the start of medication time. The nurse should alert the RN about the potential delay and then report back if the medications were delayed. Starting at 9:00 am is too late.

Many facilities require an incident report if the medications are delayed.

71. Answer 2: The total IV volume, 1000 mL, should infuse in 8 hours; therefore, the patient should be receiving 125 mL/hour. If it was started at 0800 hours (8:00 am), at 1400 hours (2:00 pm) the patient should have been receiving IV fluid for 6 hours; 125 mL/hour × 6 hours = 750 mL. 72. Answer 4: First, the nurse would recalculate the gravity rate (gtt/min) and then reset the flow rate so that 125 mL/hr is being delivered. The charge nurse should be consulted if the nurse is unsure about how to proceed.

In some facilities, this type of error requires an incident report. The charge nurse may also decide that someone should talk to the nightshift nurse, because it appears the IV was not checked after the fluid was started. In other situations, the health care provider would have to be notified, because the patient could suffer ill effects. The IV flow is behind sched-

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ule, but generally infusing the fluid to “catch up” is not recommended.

Answer 3: A precipitate indicates that the medications are incompatible, so the drug should be discarded. The nurse should have called the pharmacy prior to mixing the drugs. Administering the drug or verifying the order is incorrect, because incompatible drugs should not be given together. Rotating the syringe does apply in some cases, but not for incompatible drugs.

Answer 3: Patients are usually very familiar with the medications they have to take at home, so if there is a comment that suggests a difference it is best for the nurse to stop and find out why the medication looks different.

After checking, the nurse might consider using some of the other options. If there is a new medication, the nurse should take the opportunity to do patient teaching.

Answer 3: The RN or charge nurse should assume care of this patient because there is a risk for the patient to have a serious adverse reaction. During the first dose, the RN/charge nurse will frequently assess the patient’s reaction and if the patient remains stable, it would be appropriate for the LPN/LVN to give the subsequent doses. Refusing to give the medication is an option, but delays can be dangerous. For example, delaying antibiotics greatly increases the morbidity and mortality related to sepsis. The pharmacy is unlikely to have access to any records beyond what the nurse can access.

Answer 4: Fifteen tablets is an “unreasonable” number. Most medications come in a strength that approximates the typical dose for the typical adult patient; therefore, if the calculation exceeds 3 tablets, capsules, pills, etc., the nurse should automatically question the order. A reliable drug source will cite the typical dose range. Based on information of the typical drug dose, the nurse can contact the provider or the pharmacy as needed.

Answer 2: Inform the charge nurse, so that he/she is aware of events that are affecting a group of patients. The charge nurse may elect to give the medication her- or himself or may opt to delegate the duty to Nurse B. Giving medications to someone else’s patients is never ideal; however, delaying medication is also not good for the patients. If Nurse B is asked to give the medications, she would have to

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Answer Key 62

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use the six rights and quickly familiarize herself with the patient’s health conditions.

Answer 1: Suppositories will melt at body temperature and a soft suppository is more difficult to insert. The other actions are appropriate.

Answer 2: Inhalers usually deliver medication to the lungs; therefore, patients with asthma, emphysema, or chronic bronchitis are more likely to have this type of mediation order.

Patients with acute respiratory problems are also treated with inhalers until symptoms improve.

Answer 1: If the solution is viscous, the nurse would select a Luer-Lok tip, because greater pressure will have to be applied during the injection of solution. Higher syringe pressures will cause the slip tip to separate from the needle and the solution will spray out. The other factors are less important, although the physics of longer needles also requires higher syringe pressures.

Answer 3: If an existing IV has stopped, this suggests that something is wrong. The first thing that the nurse checks is the patient’s subjective sensation of pain, also assessing for infiltration. (Note to student: Infiltration does not always cause pain. Pain results from the type of solution or large infiltrations can put pressure on nerves.) The RN or health care provider should be notified if an infiltration is present. Before the nurse discontinues the IV, the nurse should troubleshoot the problem.

Repositioning the arm or the IV bag may help.

If the flow resumes, then it would be correct to recalculate drip rate and count the drops to regulate the flow.

Answer 3: There are no major blood vessels in the intradermal tissues. The purpose of aspirating is to determine if the needle has punctured a vessel. If the needle is within a vessel, the medication will be injected directly into the bloodstream. This technique is likely to be included in the procedure manual, but the nurse should understand the rationale that underlies nursing action. An intradermal needle is fine and short, but if the nurse has not selected an appropriate site, or improper technique is used, the needle could puncture a blood vessel.

Answer 2: Dyspnea and a weak thready pulse are possible signs of pulmonary embolus or anaphylactic reaction. This is a medical emer-

84.

gency. The other findings are less urgent, but still require the nurse’s attention.

Answer 2: Older patients have reduced kidney function and an increased risk for nephrotoxicity. If urinary output is reduced, this further damages the kidneys. Nephrotoxic effects will eventually affect mental status, but this would be a late sign. Vomiting could contribute to nephrotoxicity if fluid loss is not corrected. High blood pressure is associated with kidney problems; however, this is more associated with pathophysiology that develops over time.

Critical Thinking Activities 85. Home health safety for drug administration should include instructing the patient/family on proper storage and labeling, disposal of outdated drugs, compliance with prescribed dosage and schedule, not sharing drugs, and side effects that require notification of the health care provider.

86. Listen to the patient. Include the pharmacist as a resource to prevent errors. Prepare only one patient’s medications at a time and leave drugs in their labeled packages. Have another nurse calculate the dose and the rate, and compare your answers. High-risk drugs such as insulin and heparin warrant a second nurse to verify the accuracy of the dose prepared.

The need to quickly administer drugs does not outweigh safe practices. Always report errors. Review the literature for error reports from other facilities. See Box 21-7, p. 579 for safety tips.

87. Missing information: Date and time that order was written, route of administration, frequency of administration.

88. Whenever a medication is not supplied in the desired dose, the nurse must make a calculation. Any calculation is open to error; thus carrying a calculator is important. Working the problem out on paper helps the nurse to spot errors and is a way of recalculating the same problem. In addition, the new nurse is in training, so he/she is automatically less familiar with what the answer is “supposed to look like.” In this scenario, no one double-checked the calculation. Finally, it is apparent that this nurse was very distracted. Medication administration time is always hectic, but the nurse should develop habits that will sustain him/ her through chaotic times. Double-checking

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Answer Key 63

calculations and having a nurse recheck calculations should be automatic behaviors.

CHAPTER 22—CARE OF PATIENTS WITH ALTERATIONS IN HEALTH Word Scramble Scrambled Term

Unscrambled Term

Correct Clue

1.

zationcatheri

catheterization

b

2.

ymotso

ostomy​

h

3.

secef

feces ​

f

4.

lencetualf

flatulence ​

d

5.

tionimpac

impaction ​

i

6.

continencein

incontinence ​ e

7.

ationinfiltr

infiltration ​

c

8.

venintraous

intravenous

j

9.

vagela

lavage

g

10.

ssionpredecom

decompression

a

Fill-in-the-Blank Sentences 11. infection; occlusion 12. 3-5 13. 750-1000 mL 14. 60-80 mm Hg 15. 2-4 True or False 16. False. Teaching the patient effective coughing techniques and the implementation of suctioning will help to keep the patient’s airway patent.

17. True 18. False. Internal vaginal irrigation or douching should not be performed routinely as it tends to wash away protective agents.

19. True 20. False. It is imperative for the nurse to check for proper nasogastric tube placement before an irrigation or tube feeding; the tube can always be dislodged after x-ray verification.

21. False. Patients with urostomies are at high risk for skin impairment at the site due to nearly continuous urine drainage.

22. False. Oxygen does not explode or burn, but it does support combustion so flammable material combined with sparks or open flames increase the risk for fires.

Short Answer 23. (a) Right Task, (b) Right Circumstance, (c) Right Person, (d) Right Direction, and (e) Right Supervision/Evaluation, See Box 22-1, p. 614 for additional information.

24. (a) To maintain fluid volume if a patient is not taking in fluid or nutrients orally, (b) for fluid replacement if the patient is losing fluid through prolonged nausea or vomiting, (c) for medications, (d) for blood or blood products, and (e) for nutritional support.

25. IV therapy poses the risk of (a) infiltration, (b) phlebitis, (c) infection at the IV site or systemic infection, (d) fluid volume excess, and (e) bleeding at the IV site.

Clinical Application of Math and Conversion 26. Answer 870 mL 350 mL + 20 mL + 500 mL = 870 mL 27. Answer 500 mL 200 mL + 100 mL + 50mL + 150 mL = 500 mL 28. Answer 90 mL 30 mL/hour × 3 hours = 90 mL 29. Answer 250 mL 125 mL/hour × 2 hours = 250 mL 30. Answer 125 mL 475 mL – 350 mL = 125 mL Multiple Choice 31. Answer 4: This procedure requires an order from the health care provider. The student should check order for purpose, type of equipment, medications, or other specifics that apply to this patient.

32. Answer 3: Standard Precautions are based on the assumption that every patient is a source of infectious organisms, so hand hygiene before and after every patient encounter contributes to safety and infection control. The other options are important aspects of performing any procedure.

33. Answer 2: Raising the bed and lowering the side rail are primarily done so that the nurse does not have to stoop or reach. Raising the bed and lowering the side rail does not provide patient safety or contribute to patient comfort. Visualization is likely to be slightly better and most procedure manuals would recommend raising the bed, but nurse performs the action based on knowledge of body mechanics.

34. Answer 3: If a caustic substance enters the eye, the correct action is to immediately flush the eye with the cleanest fluid available. At

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Answer Key 64

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home this would be tap water. The nurse is also likely to perform the other actions at the appropriate time.

Answer 2: The pepper spray will cause severe pain and copious flushing is easier for the patient and the nurse if a Morgan lens is used.

Conjunctivitis is usually not irrigated unless allergens were applied directly to the eye area. Prolonged use of contact lenses would not be a reason for eye irrigation. Eye irrigations at home are more likely to be performed with an eye cup, or possibly a small syringe.

Answer 4: The elderly patient is reporting a symptom of cerumen impaction and this is a common reason for ear irrigation. The other patients have conditions that are contraindications for ear irrigation.

Answer 3: Cold applications will cause vasoconstriction and should not be used for patients with preexisting circulation problems.

Slight swelling immediately after an injury is not a contraindication for cold application.

The cold application is an adjunct to pain medication. If the patient believes that 20 minutes is too long, then the nurse would assess his rationale and help him adapt the therapy according to his preferences or document that he refused it, as appropriate.

Answer 2: The benefit of cold application is local anesthesia. Vasodilation and increased metabolism occur with heat applications. The viscosity of blood should not be affected. The decreased flow is due to vasoconstriction.

Answer 1: Generally the application lasts 10-20 minutes. The patient should not adjust the temperature because the skin will adapt to temperatures; increasing or decreasing for comfort could result in skin damage. The patient should not move the application because the purpose of therapy is to target structures that are directly beneath the application. The nurse must observe the area, but purpose of the application overrides the convenience of the nurse.

Answer 3: Heat causes vasodilation, so the distribution of blood is changing and the heart is having to work faster and harder to move blood.

Answer 1, 2, 3, 4: The nurse specifies the temperature, time, what to report, and asks to be notified about completion of therapy. The nurse would then evaluate the patient’s response. This cannot be delegated to the UAP.

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Answer 1: The patient should not lie directly on the pad, because it increases the risk for burns. The other actions are correct.

Answer 3: The tourniquet is applied to impede venous flow, but still allow arterial flow.

The other options are incorrect.

Answer 2: Phlebitis is an inflammation of the vein and as it progresses, the redness will travel up the vein. Edema can accompany phlebitis, but will also be seen in infiltration.

Cool skin and sluggish flow are more typical of infiltration.

Answer 1: Normal saline is always used to flush the tubing and to hang concurrently in the Y-tubing setup. Other solutions can cause the blood cells to lyse.

Answer 4: Although the patient needs fluid and could benefit from a larger gauge, the patient’s veins are more likely to accept a smaller-gauge catheter. (Note to student: Giving the patient some fluid will often increase the circulating volume and the veins will “plump up,” then a larger catheter could be inserted. ) Answer a, e, d, b, c: The nurse selects the tubing based on the needs of the patient and the type of infusion to be initiated. He/she removes the tubing from the sterile packaging, inspects it for kinks, and makes sure the roller or slide clamp is functional and closed.

Answer a, i, d, e, g, b, c, h, f: The nurse removes the correct solution from the sterile packaging; inspects for expiration date, leaks, or contamination. The tubing is removed from the package and inspected; then the clamp is closed. The nurse inverts the bag (holds it upside down) to allow easy access to the tubing insertion port. The insertion port cover and the cover from the tubing spike are removed. The spike is inserted into the port until the plastic diaphragm covering the port is pierced. The bag is positioned upright and the tubing drip chamber is partially filled. The clamp is controlled during priming. As the fluid fills the tubing, invert injection ports to fill them with fluid as well. Finally the clamp is closed.

Answer 2: The nurse would search for additional signs of fluid overload: dyspnea; a rapid, weak pulse; cough; disorientation; increased or decreased blood pressure; crackles; pitting edema; and decreased urine output.

If overload is suspected, slow the infusion and contact the RN and health care provider.

Weight gain is usually a good indicator or flu-

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Answer Key 65

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id overload; however, because the patient is having sudden-onset respiratory symptoms, this indicator is not as useful.

Answer 2, 4, 5, 6: The nurse inspects the IV site because signs of progressive local infection would suggest systemic infection. The IV can be discontinued and the tubing and catheter are saved for culture. The nurse looks for other sources of infection; recall that pneumonia and urosepsis are two major HAIs. While it is appropriate to review white cell count and temperature, these are generalized body responses that do not point to the specific source of infection.

Answer 4: Secretions are obstructing the air passages; suctioning will clear the airway.

Answer 4: Semi-Fowler’s position allows the patient to breathe easier and allows easy access for nurse. Sterile technique is required.

The outer cannula is not removed. Cotton balls should not be inserted into the tracheostomy.

Answer 3: If the balloon is inflated while it is in the urethra, it is possible to rupture the urethra, so the fluid is withdrawn and the catheter is advanced. If the catheter cannot be advanced, then it is withdrawn and the health care provider is notified of a possible obstruction. The catheter should not be pulled back without withdrawing the fluid. Inflation of the balloon should not cause discomfort; therefore, if discomfort occurs, the inflation must stop and the fluid must be withdrawn.

Answer 4: The meatus is cleansed and 2 inches of the catheter from the point where it enters the meatus is cleansed. The catheter should not have tension. The bag needs to be emptied at least once every 8 hours. The drainage bag should be below the level of the bladder, and never attached to the side rails.

Answer 2: Urine specimens are never obtained from the drainage bag. They should be obtained from the port. (Note to student: Even when the catheter is first inserted, if you obtain urine from the bag it would not be considered “midstream” because the first bit of urine would go directly into the bag.) The other actions are correct.

Answer 1: Digital stimulation can stimulate the vagus nerve which can cause bradycardia and hypotension, so a previous history of cardiac disease is of particular concern.

57.

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Answer 4: A compress is a moist dressing. The waterproof heating pad (e.g., Aquathermia) is used to retain the warmth.

Answer 2, 4, 5: Swelling and coolness occur because the fluid is flowing directly into the tissues. At some point, the fluid will become sluggish and stop, but for patients who have loose skin (e.g., some older patients), a significant amount of fluid will enter the tissues before the pressure within the tissues exceeds the pressure created by the IV flow. Warmth and redness are more associated with phlebitis.

Answer 2, 3, 6: Leaving the stabilization device (or tape that secures the device) in place decreases the risk of accidentally dislodging the catheter. Discontinuing the infusion and changing the IV site are correct if erythema or edema are present. Labeling allows other nurses to see when the dressing was last changed. The site is not palpated or covered with tape because that would increase the risk for infection. Putting tape over the transparent dressing obscures observation and it makes removal difficult.

Answer 3: The nurse hangs a new bag. Frequently, shift-change activities can take an hour or two for the oncoming shift. This is a courtesy for the next shift and is better for the patient.

Critical Thinking Activities 61. Before, during, and after the skill, the nurse implements the following: a. To identify the patient—Check the name band and ask the patient his/her name. b. To reduce the spread of microorganisms— Use Standard Precautions, especially hand hygiene, and surgical asepsis as indicated. c. To provide privacy—Close the door of the room and pull the curtain around the bed or table. d. To ensure patient safety—Monitor the patient carefully, keep the patient informed of his/her participation, return the bed to low position, place the call bell within reach.

62. If intravenous (IV) apparatus is positional, instruct the patient how to properly position arm to maintain flow. Teach to notify about redness, swelling, or discomfort at the site or if flow slows or stops, or if blood is seen

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Answer Key 66

in the tubing. Instruct how to ambulate with IV pole or stand. It is best to take tub bath, but showering may be allowed if the IV site is completely covered. Teach that IV pump alarms should not be silenced and the flow rate should not be stopped or changed. Remind patient not to lie on tubing or kink it.

63. Changes in cardiac and renal function related to the aging process or chronic conditions create the need for extreme accuracy in flow control and thus make the use of electronic infusion devices necessary. Older adults are more prone to fluid imbalances and fluid overload. If the patient is not able to tolerate the infusion of whole blood or red blood cells in 4 hours, it may be necessary for the blood bank to split the unit into two bags. Make sure to refrigerate the second bag during the infusion of the first.

Fragility of veins in the older adult patient increases risk of infiltration; use extra care in injecting bolus of medications; tourniquet may cause ruptured veins and/or bruising to occur. Opt to perform the venipuncture without the use of a tourniquet or use a blood pressure cuff to provide enough pressure for vein dilation. Use the smallest gauge catheter or needle possible. Avoid the back of the older adult’s hand or the dominant arm for venipuncture, because any problems at these sites greatly interfere with the older adult’s independence. With decreased subcutaneous tissue, the veins lose stability and may roll away from the needle. To stabilize the vein, apply traction to the skin below the projected insertion site. An angle of 5-15 degrees on insertion is helpful, because the veins are more superficial. Minimal use of nonporous tapes and skin protectant solutions is recommended.

Face the patient while speaking clearly and calmly to compensate for visual and hearing deficits. Short-term memory loss, depression, and confusion sometimes lead patients to remove the IV catheter or change their attitude or decisions about care. The adult patient who is competent and is properly taught about the benefits and risks of IV therapy has the right to refuse.

CHAPTER 23—LIFESPAN DEVELOPMENT Matching 1. b 2. e 3. a 4. g 5. c 6. f 7. d 8. j 9. h 10. i True or False 11. True 12. False. Interaction with the environment provides a means for them to acquire language skills.

13. False. The adolescent often requires increased hours of sleep to restore energy levels.

14. False. According to the Activity Theory, older people who are more socially active adjust better to aging.

15. True Short Answer 16. Factors contributing to the changed family include economic changes, feminist movement, better birth control, legalized abortion, postponement of marriage and childbearing, and increased divorce rate. Refer to Box 23-1 on p. 700.

17. A functional family is able to adapt to change, has coping techniques in place, and demonstrates a sense of commitment and purpose.

See Box 23-3, p. 702.

18. Family stress may be caused by chronic illness, working mothers, abuse, and divorce.

19. a. Engagement stage: couple considers marriage b. Establishment stage: adjusts to married and interdependent state c. Expectant stage: makes decisions surrounding pregnancy d. Parenthood stage: begins at the birth or adoption of the first child e. Disengagement stage: grown children leave home f. Senescence stage: older adult must cope with changes

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Answer Key 67

Table Activity 20.

Respirations (at Rest)

Age Group

Temperature

Pulse

Infants at 12 months

Wide variation

120/min

30/min

90/60 mm Hg

Toddler 1-3 years

98° and 99° F (36.6° and 37.2° C)

90-120/min

20-30/min

80-100 mm Hg systolic and 64 mm Hg diastolic

Preschooler 3-5 years

97° to 99° F (36.1° to 37.2° C)

70-110/min

23/min

110/60 mm Hg

School age 6-12 years

97° to 99° F (36.1° to 37.2° C)

55-90/min

22-24/min

110/65 mm Hg

Adolescent 12-19 years

97° to 99° F (36.1° to 37.2° C)

70/min

20/min

120/70 mm Hg

Multiple Choice 21. Answer 2, 3, 4, 6: Administering medication on time and showing respect to elderly patients are important to being a good nurse; however, Healthy People 2020 Health Indicators are more about improving the overall health of the general population. For additional information, see Table 23-1 on p. 698.

22. Answer 2: The nurse would continue the interview and assess the interaction between the wife and husband and how they are responding to each other. After additional assessment, the nurse might ask the husband to leave if the wife seems fearful to speak in front of him. The nurse could seek advice about cultural norms, but discontinuing the interview may be impractical. Directing the questions towards the husband is likely to feel awkward, but it is possible that the wife prefers that he provide the answers.

23. Answer 2: In the autocratic family pattern, the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. Mother assuming dominance would be a matriarchal family pattern. Uncle controlling finances would be the patriarchal family pattern. Children participating would be the democratic family pattern.

24. Answer 2: Height (length) increases by about 1 inch per month for the first 6 months.

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27.

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29.

Blood Pressure

Answer: 27 pounds. By the time the baby is 1 year of age, the birth weight has tripled.

Answer 1: The infant’s body is using nutrients according to a system of growth and development; thus fat reserves are accumulated in the first several months for insulation and a reserve of nutrition. Muscle and bone are expected to develop around 8 months.

Cephalocaudal growth is defined as growth and development that proceeds from the head toward the feet. Breast milk and formula supply the appropriate nutrients for the growth of young infants.

Answer 2: The signs and symptoms reported by the mother are the first expected evidence of teething. Massaging the gums and giving water are recommended for infant dental hygiene. Brushing the teeth is recommended after the first tooth has erupted. The nurse would advise the mother to contact the health care provider if the nurse believes that infant acetaminophen is needed to relieve discomfort. The nurse would not recommend medication to the mother.

Answer 2: Persistent crying during a usual sleep period indicates illness or some other type of discomfort. Whenever the infant is inconsolable with usual measures, the health care provider should be contacted. The other behaviors are normal and expected.

Answer 2: Infants use sensory impressions and motor activities to learn about the envi-

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Answer Key 68

30.

31.

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ronment; thus reaching for, tasting, and feeling objects with the mouth gives the child information. Clinging to parents is an intellectual function that occurs as the child learns to distinguish parents from others. Shoulder control prior to hand control is an example of proximodistal growth and development that originates in the center and moves toward the outside. Saying “me” and “no” is a toddler behavior.

Answer 1: An 8-month-old child is likely to demonstrate separation anxiety. This is a traumatic time for the parent and the child, but knowing that this is a normal behavior will help the mother feel less anxious and guilty.

An 8-month-old should have an established sleep/rest pattern; ideally the daycare staff will interact with the child so that nap pattern is maintained. Parallel play is a form of play used by toddlers. Assess mother’s feelings before validating guilt. It is likely that the mother will feel some guilt, but the mother may also want to return to work and it would be inappropriate to imply that she should feel guilty.

Answer 3, 4, 5: Introducing cereals first and then slowly introducing other foods allow the child and the parent to have new experiences and evaluate the outcomes. There is a possibility that the child could have a bad physical reaction or a dislike for a certain food, so the foods should not be mixed or introduced simultaneously. Early introduction of citrus fruits may contribute to the development of allergies; waiting until after 6 months is recommended.

Answer 3: Toddlers are unable to share because of their egocentric nature, so this mother is demonstrating expectations beyond the ability of the child. Harsh discipline techniques can be evidence of how the mother was treated as a child. The nurse would carefully assess for other risks factors, behaviors, and signs and symptoms before making any conclusions. Continuously retrieving a toddler will cause frustration for the child, but this mother is demonstrating anxiety about his safety. Rather than allowing the child to climb onto eating surfaces, the nurse could suggest that the mother redirect the child to climb on equipment that is designed for the purpose of climbing. Ignoring a fussy toddler is probably a strategy that this mother has

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developed to use if the child is not hurt, but is not getting his own way.

Answer 2: The toddler prefers ritualistic behaviors; therefore, the nurse would assess nighttime rituals and try to approximate them as much as possible (e.g., favorite bedtime story). Night bottles with milk or juice should not be encouraged because they contribute to dental caries. Amount of sleep is a relevant question, but it is more likely that he will have trouble falling asleep in a strange environment. Once he is asleep, he is likely to sleep for the accustomed period of hours. Keep explanations simple and honest.

Answer 3: Small hard foods have a greater potential for aspiration and choking. Reassure the mother that her nutritional logic is sound, but carrot sticks can be served when the child gets older.

Answer 4: Three-year-olds are usually able to carry on a conversation. Children do grow at their own pace, but if expected milestones are not being met, then consulting a health care provider is recommended. Reading and playing do help to expand vocabulary once the child is talking.

Answer 2: Preschoolers use imagination and are developing fine motor skills, and drawing is a way to communicate. The nurse should not offer the child a snack without the mother’s permission and advice because of potential allergies or food restrictions. Desire to “help” is more related to the school-age child. Talking to a child is always beneficial; however a 4-year-old is less likely to be able to independently entertain himself with a book.

Answer 2: The nurse should ask the age of the child because complaints of “growing pains” related to rapid growth are reported by school-aged children. Obvious growth in the long bones and increase in height of approximately 2 inches per year for both boys and girls are physical characteristics of the schoolage child. The other questions could help to identify contributing factors.

Answer 3: The school-age child is able to think logically and apply principles to specific cases. Using a helper is recommended for younger children, especially toddlers who are strong-willed. Magical thinking is also more relevant to younger children. Modesty and privacy are more important for adolescents.

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Answer Key 69

39.

40.

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44.

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Answer 1, 2, 4: Vision, dentition, and signs of scoliosis are recommended for routine screening. Hearing would be tested if the child showed some signs such as inattentiveness while being spoken to, speaking very loudly, or failing to attend to instructions. Cancer screening is recommended by the American Cancer Society for adults. HIV testing is not routinely done on children.

Answer 2: Give the child a role as a helper.

This increases feelings of control and appeals to the developmental task of industry. Praise is an important reinforcer of desired behavior.

Demonstrating on a doll is a method used for preschoolers. Coaching the parent would be a good choice if the child had to have ongoing dressing changes at home.

Answer 4: The child’s nonverbal behavior indicates to the nurse that something has happened that causes the child to feel fear, embarrassment, or possibly anger. The child has to trust the nurse before sharing the events associated with the strong feelings. The nurse should not promise confidentiality. Parents have to be informed about injuries and illnesses that occur at school and if there is some violence, bullying, or safety issue, the principal must be informed.

Answer 1, 2, 3: It is normal for the school-age child to have gradual gains in height and weight, although the full growth potential is yet to come during the adolescent and young adult periods. Nutrients and genetics could be contributing to the child’s shorter stature, but it would be inappropriate for the nurse to say this to the mother without first doing a dietary assessment and referring her to a genetic counselor.

Answer 4: The more concrete the plan, the greater the risk for committing suicide. The other questions are relevant because these are indicators of depression.

Answer 3: The nurse should follow up on the statement about sex education and reinforce that sex education has to be provided by someone. If they prefer to give the information at home, the nurse can offer to help with resources and communication methods. The other statements indicate that parents are helping teenagers by setting boundaries.

Answer 1, 2, 3, 4: Developing own value system should occur during adolescence. The other tasks are part of development during early adulthood.

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Answer 3: Generativity is accepting responsibility for and offering guidance to the next generation. Focusing on fears, concerns, and failures is evidence of stagnation, which is the opposite of generativity. Reviewing a personal will and belongings is more typical of late adulthood.

Answer 2: Visualization of half the field is a pathologic condition that is usually associated with stroke or damage to the brain. The other options are part of the normal aging process.

Answer 2: Reminiscing or reviewing one’s life and past accomplishments validates the meaning and importance of life. The other activities are important for the socialization and health of the elderly residents.

Answer 3: The nurse can see several of the problems, but additional assessment should be made for contributing factors, such as loneliness, poor dentition, poverty, food intolerances, and constipation. The nurse should also assess the patient’s ability to maintain a household and live independently. Based on assessment findings, the nurse may decide to use the other options.

Answer 1: Low-fat, low-sodium diet help decrease the risk of atherosclerotic heart disease and hypertension. Streptococcal pneumonia vaccine and coughing and deep-breathing are interventions for expected changes in the respiratory system. Frequent position changes help protect the skin.

Critical Thinking Activities 51. See Safety Alert, Safety Rules for Infants and Young Children, p. 711. Generally parents or those who care for young children will welcome suggestions about how to improve safety, so if you find areas that need improvement, remember to first give positive feedback about what they are doing correctly, then give suggestions for how to improve, then reinforce the positive again. Your assessments, suggestions, and teaching points could prevent an accident.

52. a. Some children are ready for toilet training at 18 months, but readiness may not occur in others until 24 months. The mother may need to wait several months and then try again. Bowel control precedes bladder control. Nighttime control is achieved after daytime control is accomplished.

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Answer Key 70

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b. The developmental task according to Erikson is autonomy versus shame; therefore, parents should give praise for accomplishments which help the child to build self-control and pride in accomplishments. Scolding and punishing statements create shame and doubt. c. While temper tantrums are difficult for parents, help the mother understand that her child is expressing frustration.

Encourage the mother to try to maintain a matter-of-fact attitude and reassure her that the tantrums will pass as the child learns other verbal and nonverbal ways to express feelings.

Refer to Table 23-4 on p. 729. Examples of changes that occur in the aging individual include: a. Sensory—presbyopia, presbycusis b. Integumentary—thinner skin, decreased moisture c. Cardiovascular—arteriosclerosis, increased blood pressure d. Respiratory—decreased gas exchange and ciliary action e. Gastrointestinal—decreased saliva, reduced peristalsis f. Genitourinary—prostate enlargement, drier vaginal tissue g. Musculoskeletal system—bones become porous, joint stiffness h. Neurologic—slowed reaction time, decreased pain perception a. Ability to cope may increase with aging because of successful experiences and strengths that have developed and matured over time; however, a decreased ability to cope may also be the result of perceived failures, multiple losses, and a sense of dissatisfaction. b. Intelligence and learning—The capacity to understand and learn can be maintained. c. Memory—Some loss of short-term memory may occur; past events are recalled.

Answers will vary according to your experience with that older person and your selection of a theory. For example, if a person has a long history of alcohol abuse, then the Wear-and-Tear theory may seem to apply. The person may physically look older than his/ her chronological age and have many health problems. If you selected someone you know who is very social and active, the Activity Theory could help explain how that active

person has a good life and seems satisfied and well-adjusted. Elders who self-impose a homebound lifestyle seem to be withdrawing from society as explained by the Disengagement theory.

CHAPTER 24—LOSS, GRIEF, DYING, AND DEATH Fill-in-the-Blank Sentences 1. loss 2. grief work 3.

Grief therapy 4.

Bereavement 5.

Mourning 6. confidence 7. pain; respiratory distress; confusion 8.

Euthanasia 9.

Autopsies 10. year Multiple Choice 11. Answer 2: The college student is experiencing a change related to growing up and going out on his own. He is losing the security and safety of home as he transitions to becoming more independent. The other people are facing situational losses.

12. Answer 4: A situational loss presents an opportunity to grow and develop. Evaluation of strengths and weaknesses is a way for the student to correct the negatives and repeat positives. The student has recognized that meeting criteria is a way to ensure future success. The other actions indicate that the “C” grade is still a threat to self-esteem and the student is continuing to emotionally struggle with that loss.

13. Answer 3: The nurse should assess the patient’s feelings about the experiences. Sense of presence is a normal grief response and can be comforting if the person sees the deceased as safe and at rest. The other options might be considered once further assessment is conducted.

14. Answer 4: In this uncomfortable situation, the nurse recognizes that each family member is expressing such intense grief that they are not able to help or consider the feelings of each other. Rather than separate them, the nurse would stay with them as a bonding force and allow expression of emotions. Once the yell-

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Answer Key 71

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ing, screaming, and sobbing begin to ebb, the nurse may decide to use the other options.

Answer 3: Talking about things they used to enjoy is the best indicator of the four, because reminiscence is a healthy way to think about the past. The other activities suggest that she is trying to keep him with her in the present environment.

Answer 4: First, the nurse acknowledges the pain and loss associated with the triggering factor. Taking the medication on a routine basis would be particularly difficult for the patient because the blame and guilt would recur.

The nurse would then perform an assessment and use appropriate interventions. Options 1 and 2 are false reassurances. In option 3, the nurse acknowledges feelings, but then offers a platitude.

Answer 3: A grief attack is an unexpected emotional or behavioral response to a routine event or behavior. It is even possible that seeing the hospice nurse reminded the son about the deceased patient. The nurse would calmly reassure the patient that over time, his emotions will become more balanced.

Answer 4: The nurse must assess on a frequent basis whether the family wants to participate in the patient’s care. The family members may have helped yesterday, but today they could be tired, upset, or distracted.

They may have fears related to actual or perceived change in the patient’s status, or repeatedly asking for assistance could be a sign of stress. Based on the initial assessment, the nurse may decide to use the other options.

Answer 2: For the dying patient and the family, short-term goals are encouraged as being more realistic and achievable; however, the nurse would not discourage expression of the other statements. The family and patient are going through a process and some denial at certain points would be considered a coping mechanism.

Answer 3: The patient is overwhelmed by all of the problems, so the nurse will have to use therapeutic communication and listen to what the patient has to say about each issue.

This will help determine which problem is the priority. Addressing pain is a logical place to start; however, there is a possibility that the other problems are more important to the patient. There is a possibility that the nurse may decide to ask the RN to take charge of the case because the issues and analysis of the diagno-

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ses are too complex. Reviewing the care plan is appropriate after assessment is performed.

Answer 1, 3, 4: When the patient nears death there are changes in vital signs, including (1) slow, weak, and thready pulse; (2) lowered blood pressure; and (3) rapid, shallow, irregular, or abnormally slow respirations. Mouth breathing occurs, which leads to dry oral mucous membranes. The patient often has a detached look in the eyes.

Answer 4: The nurse should consult the nursing supervisor. Active euthanasia is still illegal; even though the staff, the patient, and the family may all agree. If the provider gives the dose, there is still a possibility that the nurse could be liable for failure to intervene.

Answer 2: If the patient is DNR, the nurse would stay with the patient and perform comfort measures. All attempts should be made to bring the family to be with the patient. CPR or an IV fluid bolus would be inappropriate because of the DNR order.

Answer 4: The nurse has a responsibility to make sure that the family has the opportunity to talk to a qualified health care professional about organ donation. This is the law in most states, but also some families are comforted by being able to help other patients and families. The health care provider who certified death should not be involved in the removal or transplant of organs. The nurse is not responsible or qualified to certify death or to explain the organ donation and transplant process.

Answer 1, 2, 5, 6: Alleviating pain, meeting spiritual needs, giving comfort measures, and allowing decision-making are within the Dying Persons’ Bill of Rights. The patient should be consulted first about how much information he/she wants and if he/she wants to be included in the decision-making. The patient may seem indecisive, but this is normal under stressful circumstances and extra time should be allowed. The nurse may find that patients/families from different cultures have a different approach to information flow and decision-making. But in the United States, the health care team generally takes the approach that the patient will be included in the information and decision-making. The health care team can assist the patient with information about a living will or advance directives, but these decisions should be made by the patient

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Answer Key 72

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and the family. (See Box 24-8 on p. 751 for additional information.)

Answer 3: Advance directives are signed and witnessed documents providing specific instructions for health care treatment in the event that a person is unable to make these decisions personally at the time they are needed. Cardiac arrest, respiratory arrest, or other conditions that cause loss of consciousness or change in mental status would apply.

Answer 3: Children ages 5-9 years believe that wishes and actions can cause outcomes. (See Table 24-1 on p. 740 for additional information.)

Answer 1: The name and contact information of the person who will make health care decisions if the patient becomes unable to make those decisions should be on file. Generally, the facility likes to have a copy of the power of attorney on file. That person could be next of kin (e.g., spouse), but could be a sibling or adult child if the spouse is not able to make the decisions. The nurse should direct the patient and family to discuss and record wishes about death in a living will. b, e, a, c, d, f (See Skill 24-1 on p. 755 for additional information.)

Critical Thinking Activities 30. a. Goals—Patient will establish new relationships.

Patient will engage in activities with family and/or friends.

Interventions—Establish trust. Use active listening. Encourage verbalization of feelings.

Provide opportunities for interaction. b. Loss is when someone or something can no longer be seen. The patient is experiencing an actual loss. The severity of response varies, but the patient’s grief would be considered a natural response to the loss of her husband. Her feelings and behaviors would be considered a normal part of grieving unless they were prolonged (>2 years). The goal of grief is to resolve hurt and reestablish one’s life. c. Factors that influence loss include childhood experiences, significance of the loss, physical and emotional state, total loss experiences, view of loss as a crisis, duration and timing of the loss, suddenness

31.

of the loss, financial impact, availability of resources, cultural factors, personal attributes, and relationship to the object or person. d. This patient shows that the grieving process is influenced by physical functioning—the attainment of basic needs (food, air), sleeping patterns, discomfort, and overall general health state are being affected. Social aspects include the patient’s support systems. The family members should be available to help, but she is isolating herself. Members of the health care team can offer support; some patients need temporary distance from the family because of past relationships. Professional counseling is always an option. e. Assess such areas as sleeping patterns, body image, activities of daily living (ADLs), mobility, general health, medication use, and pain. Additional areas of concern include the basic needs of nutrition, elimination, oxygenation, activity, rest, sleep, and safety a. Nurse B may be experiencing bereavement overload because of multiple losses in the course of work with failure to adequately process them. On the other hand, Nurse B may be experiencing personal grief. Perhaps the dying patient reminds the nurse of a beloved grandparent and family’s response reminds her of how her own family responds. b. Nurse A can use effective listening skills, and help Nurse B to acknowledge personal limits and recognize when there is a need to get away and take care of herself. Nurse B might also need time and assistance to grieve over personal or professional losses. Although Nurse B is likely to be intellectually familiar with the grieving process, nurses frequently find themselves in the position of always having to give. Nurse A can help Nurse B to realize that receiving is also necessary to be effective. Nurses can cope with grief by identifying their own beliefs, trading off patients when overwhelmed, avoiding the “savior” complex, and setting limits.

(See Box 24-2 on p. 739 for additional information.)

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Answer Key 73

CHAPTER 25—HEALTH PROMOTION AND PREGNANCY Matching 1. i 2. g 3. b 4. d 5. c 6. e 7. j 8. a 9. h 10. f

18.

19.

Fill-in-the-Blank Sentences 11. mechanical injury; temperature; musculoskeletal 12. 10 13. purplish discoloration of the vagina, vulva, and cervix 14. biochemical or chromosomal abnormalities 15. 8; fetus Table Activity 16. See Table 25-5, p. 786.

Heart rate

Increases 10-15 bpm

Blood pressure

Remains at prepregnancy levels in first trimester (systolic) Slight decrease in second trimester (systolic and diastolic) Returns to prepregnancy levels in third trimester (diastolic)

Blood volume

Increases by 1500 mL or 40% to 50% above prepregnancy level

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Red blood cell Increases 18% mass Hemoglobin

Decreases

Hematocrit

Decreases

White blood cell count

Increases in second and third trimesters

Cardiac output

Increases 30% to 50%

Multiple Choice 17. Answer 1: Blurring and diplopia (double vision) can be associated with pregnancyinduced hypertension. The blood pressure and the symptoms should be immediately reported to the health care provider.

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Answer 4: At week 16, all organs and structure are formed; at week 24, the fetus weighs about 27 ounces; at week 19, head hair develops; and at week 20, the fetus has settled into a favorite position.

Answer 3: Swelling of the face is one of the danger signs that should be reported to the health care provider. Increased blood flow from high estrogen levels causes reddened palms or spider nevi. Increased blood volume is expected, but this alone does not cause water retention. Increased amounts of melanocyte-stimulating hormone cause benign changes in skin coloration.

Answer 2: Ptyalism is excessive salivation; sucking hard candy provides symptom relief.

The other options are strategies for dealing with heartburn.

Answer 3: Prolonged or repeated fetal temperature elevation may result in birth defects.

The other options may also occur, but are less associated with the first trimester and the problem of heat and humidity.

Answer 3: The goal is to experience 10 movements in a 1-2 hour period. Counting all of the movements in a 24-hour period would be very impractical. Mother’s activities such as eating or exercise could possibly influence the fetus, but ideally the mother should choose a quiet time to sit or lie down to count the movements.

Answer 1: Ten times in a row; three times a day is the recommendation. The other options are incorrect.

Answer 4: Note the intactness of the placenta; bleeding and infection can occur if fragments of the placenta are retained in the uterus. The placenta should be weighed and the presentation of the fetal side (Shiny Schultz) versus uterine wall (Dirty Duncan) should be noted.

Placental barrier refers to the ability of the placenta to filter bacteria and some other substances.

Answer 1: Ordinarily the cord would have three vessels: two arteries and one vein. One artery and one vein may be associated with fetal anomalies and requires follow-up. The other findings are expected.

Answer 2: At 12 weeks, the Doppler should be used to detect heart tones. The stethoscope can be used between 16 and 19 weeks. Transvaginal and abdominal ultrasound are usually not performed by nurses; however, transvaginal ultrasound is used in the first trimester,

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Answer Key 74

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and abdominal ultrasound is used later in the pregnancy. Ultrasound is used for examining additional factors beyond heart rate.

Answer 4: Remind the student that the patient should be sent to the bathroom to empty the bladder before she assumes a supine position.

The other steps are appropriate.

Answer 1: A stable or decreased fundal height may indicate intrauterine growth restriction (IUGR); an excessive increase could indicate multifetal gestation or hydramnios (excessive amniotic fluid).

Answer 2: Declining levels of human chorionic gonadotropin suggest a miscarriage.

Maternal serum alpha-fetoprotein is used to predict certain types of birth defects. A small sample of amniotic fluid could be tested for genetic factors such as sex and chromosomal abnormalities, health status, and maturity of the fetus. Chorionic villus sampling is used to detect genetic disorders.

Answer 4: The woman and partner can watch the imaging if they desire to do so. The bladder should be filled prior to the procedure to allow for better imaging. The lithotomy position is used during transvaginal ultrasound.

The procedure should not cause any pain or discomfort.

Answer 3: At least 2 fetal movements accompanied by 2 increases of 15 bpm in a 20-minute period indicate a healthy fetus. The mother is likely to express feelings of relief if she knows that the baby will not be at risk during the delivery. If the fetal heart rate does not increase with fetal movement, additional testing is needed and anxiety and uncertainty will continue.

Answer 4: Colostrum flow in the second trimester is considered normal. Suggest use of breast pads to control excessive flow. The premilk would be given to the infant because it contains antibodies, carbohydrates, and protein and has a mild laxative effect.

Answer 3: The nurse should be ready to assist the family with coping strategies if there are financial issues by offering referrals, emotional support, and networking to find additional resources. Ideally, the lack of insurance should not affect quality of care; however, the family may avoid prenatal care or refuse diagnostic testing if they are trying to save money. The nurse can activate the health care team to help the family make a plan that provides maximum quality of care at the minimum price.

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Answer 3: In the initial health history, information about chronic diseases, infectious disease, use of substances such as alcohol, or exposure to substances such as industrial waste should be obtained. Genetic counseling is a very involved process that should not be initiated until all of the relevant data have been collected and risk factors are evaluated.

Answer: The EDB is May 25, 2015. According to Nägele’s rule, start with the first day of the woman’s last normal menstrual period and count back 3 months, then add 7 days.

Answer: The parity of the woman is 4-3-0-0-3.

G: Gravidity, T: Term births, P: Preterm births, A: Abortions, L: Living children.

Answer 3: Hyperemesis gravidarum, which is excessive vomiting, can lead to dehydration, fluid and electrolyte imbalance, acid-base imbalance, altered kidney and cardiac function, and even fetal death. Small frequent meals are suggested for morning sickness and heartburn. Salivating and heartburn are gastrointestinal problems that may occur, but presence of these conditions does not help identify hyperemesis gravidarum.

Answer 2: Maternal smoking is associated with preterm delivery, low birth weight, and decreased intrauterine growth. Respiratory distress, infection, or fetal distress are serious problems that may occur, but are not necessarily associated with maternal smoking. No change in fetal heart rate during contractions is a sign of a healthy fetus; this is detected during the contraction stress test.

Answer 4: Pain and burning with urination signal a urinary tract infection. Infection is one of the dangers that require evaluation.

The other symptoms are likely as the pregnancy advances.

Answer 1: Increases in platelets and fibrinogen will contribute to clot formation. Decreases in hematocrit are mainly dilution due to increased circulating volume. The stressors placed on the kidneys during pregnancy may result in protein and glucose in the urine. This finding suggests gestational diabetes. Women with a history of cholelithiasis may experience increased cholesterol level, which is common during pregnancy.

Answer 1, 3, 5, 6: Traveling to areas with untreated water should be avoided if possible.

Airline policies regarding pregnancy vary.

Insurance coverage may not extend to foreign countries and there is additional anxiety if

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Answer Key 75

preterm labor starts when far from home. Use of seatbelt is always advisable. It is illegal to terminate someone because of pregnancy.

Magnetometers do not harm the fetus.

Critical Thinking Activities 42. a. Refer to Box 25-7 on p. 781. Areas for counseling are adaptation and discomforts that may be experienced, safety measures, exercise and rest, nutrition, sexuality, personal hygiene, danger signs, fetal growth and development, preparation for labor, preparation for baby, and diagnostic tests. b. Refer to Table 25-1 on p. 785. There are a number of drugs that should be avoided during pregnancy, including antiemetics, salicylates, stimulants, tranquilizers, opioids, antihistamines, vaginal antiinfectives, alcohol, caffeine, and tetracycline. c. The nurse instructs the woman to avoid smoking, alcohol, medications (unless prescribed), too much sitting or standing, heavy lifting, hot tubs, saunas, and spas. Also, sports or activities that require balance to maintain safety are not recommended; for example, surfing or skiing.

43. a. Presumptive signs of pregnancy are subjective in nature. These signs are frequently attributed to pregnancy, but they may also indicate other conditions not related to pregnancy. Probable signs indicate a high likelihood that the woman is pregnant. These findings are objective in nature and can be confirmed by an examiner. Still, these signs are not 100% reliable indicators. Positive signs occur only with pregnancy and cannot be attributed to other physiologic occurrences. Positive signs definitively identify the presence of the fetus. b. Presumptive signs—amenorrhea, breast changes, quickening, nausea and vomiting Probable signs—Hegar’s and Goodell’s signs, uterine enlargement, positive pregnancy test Positive signs—visualization of the fetus 44. First encourage expression of feelings and validate feelings by using verbal and nonverbal responses. Assess methods of coping that worked in the past and help the patient recognize that she has experience in overcoming obstacles and that past methods can be applied to the current situation. Assist the pa-

tient to problem-solve by helping her to clearly define problems, delimit problems as much as possible, set small goals, and develop an action plan. Encourage the patient to engage in self-care activities that will boost her spirit and appearance, such as buying an attractive new blouse or getting a haircut. Encourage the patient to find things that she likes about herself and then help her to enhance those qualities, such as wearing a pair of earrings that bring out the blue color of her eyes.

Educate her about the bodily changes that are occurring and reassure her that some of the changes, such as the hyperpigmentation, will resolve after delivery. Finally, encourage her through the first trimester, because as the pregnancy progresses it is likely that she will start to feel better about herself and the pregnancy.

CHAPTER 26—LABOR AND DELIVERY Matching 1. d 2. e 3. b 4. c 5. a Fill-in-the-Blank Sentences 6. first trimester 7. hospital; birthing center; home 8. availability of trained personnel 9. midwives 10. matured and ready for birth 11. oxytocin stimulation; progesterone withdrawal; estrogen stimulation; fetal cortisol 12. progressive cervical dilation and effacement 13. passageway; passenger; powers; position of mother; psyche 14. molding True or False 15. True 16. False. The mechanical theory is based on the principle that once a hollow-body organ reaches a certain state of distention, it will spontaneously contract and empty; therefore, one woman giving birth to large and small infants contradicts the principle of the mechanical theory.

17. True 18. True

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Answer Key 76

19.

False. No pushing until the cervix has dilated because this may result in swelling or tearing of the cervix and may ultimately slow the birthing process.

Figure Labeling 20. See Figure 26-5, p. 803, Multiple Choice 21. Answer 1: Lightening refers to when the fetus settles into the pelvis. This places more weight on the urinary bladder, so urinary frequency is expected. The space in the chest cavity actually opens up, so breathing should improve. Decreased fetal movement should not occur and leakage of amniotic fluid is not expected to accompany lightening.

22. Answer 3: The nitrazine test is positive for amniotic fluid; labor should start within a few hours. If not, the health care provider is likely to induce labor. Precipitous labor is rapid labor that lasts less than 3 hours. She could go home, but she should be preparing to activate the birth plan.

23. Answer 2: Braxton Hicks will increase in frequency, duration, and intensity as the pregnancy progresses. Backache is expected, but headache is not expected and could be a sign of hypertension.

24. Answer 4: Renewed energy for nesting behaviors can occur. Nausea and diarrhea are not uncommon and weight loss of 1-3 pounds may occur. Depression is not expected at this time.

25. Answer 2: Pelvimetry involves the use of xray films and would be used for nonpregnant patients who are planning to conceive, but have a history (injury or rickets) that could affect the shape of the pelvis. Palpation could be used for the patient in the first trimester.

For multiple pregnancies or other soft-tissue evaluations, ultrasound would be used.

26. Answer 1: While transverse lie only occurs in 1% of pregnancies, multiple pregnancies weaken the abdominal wall and thus transverse lie is more likely to occur in these patients. Pelvic contracture or placenta previa also increases the risk. When the fetus is small, position changes are frequent and lie seldom changes towards term because of space. Longitudinal is spine parallel to spine and is the most common lie. Breech presentation is affected by lie.

27.

Answer 4: The health care provider can relieve pressure on the cord by putting on a sterile glove and holding the presenting part off of the umbilical cord. Mother could be assisted into a modified Sims, Trendelenburg, or knee-chest position. Cesarean birth and monitoring for fetal distress are also likely.

28. Answer 3: Massaging the fundus is done to restore muscle tone. Atony (relaxation) can be caused by overstimulation. This is not desirable, because a firm fundus is less likely to bleed. Separation and expulsion of placenta complete the third stage of labor and the health care provider will assist as needed.

Massaging will help expel clots, but observation is used to determine number and size.

29. Answer 2: Upright positions (walking, sitting, kneeling, or squatting) promote cardiac output and reduce pressure on the great vessels, thereby promoting placental perfusion.

Left lateral side-lying is the position of choice if the mother is tired and wants to lie down.

Knee-chest position is used if there is suspected cord compression. Lithotomy position is usually used for hospital deliveries.

30. Answer a. 5, b. 3, c. 2, d. 4, e. 7, f. 1, g. 6: Figure 26-14, p. 811.

Engagement occurs when the biparietal diameter of the fetal head crosses the pelvic inlet. Descent is the downward progress of the presenting part. Flexion occurs as the chin tucks and the occiput presents to the maternal pelvis. Internal rotation enables the fetal head to progress through the maternal pelvis. Extension occurs when the occiput passes under the symphysis pubis. External rotation occurs as the shoulders and body move through the birth canal. The delivery ends with expulsion, in which the body of the infant leaves the pelvis.

31. Answer 4: The transitional phase is the last phase of the first stage of labor. Mother should be alert and talkative in the latent phase and less talkative in the active phase.

Confusion and disorientation is not expected and may signal problems with oxygenation and perfusion.

32. Answer 2: Contractions are expected every 3-5 minutes. With 4- to 7-cm dilation. Pain will be manageable, but is intensified compared to earlier. Desire to walk is more likely in the latent phase.

33. Answer 2: Early, or latent, phase: slow, deep chest or abdominal breathing, 6-9 breaths/

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Answer Key 77

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min; inhale through nose and out through pursed lips. Middle, or active, phase: Slow acceleration then deceleration of breaths through contraction; breaths shallow; approximately 16-20 breaths/min. Transitional phase: 4-6 pants followed by a blow for duration of contraction. Remind patient to take deep, cleansing breath before and after contraction to increase oxygen intake.

Answer: 7 (See Table 26-5, p. 819.)

Answer 3: Ambulation before rupture of membranes is encouraged because it provides distraction and tends to strengthen the effectiveness of labor. Full bladder can slow labor.

Supine position is more uncomfortable and can compress the vena cava. Enemas are not given if vaginal bleeding is present.

Answer 1: Stop the infusion and contact the health care provider if there are signs or symptoms of complications, such as changes in FHR; bradycardia; tachycardia; arrhythmias; or excessive frequency, duration, or pressure of contractions.

Answer 2: Yellow-stain is associated with fetal hemolytic disease or intrauterine infection.

Hydramnios is an excessive amount of fluid.

Port wine color is associated with abruptio placentae. Greenish-brown is associated with a breech birth.

Answer 2, 3, 4, 5: Birth plan includes information about the pregnancy-related changes the mother will experience, fetal development, labor, delivery, and the postpartum period.

Ideally, discussions of when to get pregnant or genetic counseling are included in the preconception counseling.

Answer 3: Uterine relaxation could result in postpartum hemorrhage. Glycopyrrolate (Robinul) is given to reduce secretions and decrease the risk of aspiration. Citric acid (Bictra) is given to reduce the acidity of secretions.

Abdominal pain is likely to be associated with the procedure, not the anesthetic.

Answer 2, 3, 4: Hypertension, diabetes, and history of stillbirth or fetal demise are reasons for induction. For rupture of membranes 2 hours ago, the patient is likely to be advised to walk and wait to see if contractions will begin. Placenta previa and herpes simplex infection are contraindications for induction.

Answer 1, 3, 4, 5: Indications for cesarean birth can be maternal or fetal. The major maternal indications for cesarean delivery are cephalopelvic disproportion, previous cesar-

ean delivery, breech presentation, medical conditions that would endanger the mother’s health such as cardiac complications, abnormal conditions of the placenta such as placenta previa, infections of the vaginal canal, and pelvic abnormalities. Major fetal indicators are fetal oxygen deprivation, prolapse of the umbilical cord, breech presentation, malpresentations such as transverse, and congenital anomalies.

Critical Thinking Activities 42. a. The admission assessment includes history of pregnancy, medical history, review of the prenatal record, interview of the patient (progress of labor, preparation), physical examination, and performance of diagnostic tests (urinalysis, blood work).

See Box 26-5, p. 821. b. Assessment includes contractions, fetal heart rate, cervical changes, vaginal discharge, degree of discomfort, and psychosocial reaction. c. Monitoring includes vital signs, uterine tone, vaginal drainage, and status of perineal tissues every 15 minutes for the first hour and then every 30 minutes for the second hour.

43. External monitoring uses external transducers on the maternal abdominal wall to assess FHR and uterine activity. It does not require rupture of membranes or cervical dilation. An intrauterine catheter is used to monitor frequency, duration, intensity, and resting tone of uterine contractions. Fetal distress resulting from hypoxia is indicated by nonreassuring FHR patterns. These patterns can include a progressive increase or decrease in the baseline FHR, progressive decrease in baseline variability, tachycardia (more than 160 bpm), severe bradycardia (less than 100 bpm), persistent late decelerations, and severe variable decelerations with slow return to baseline. Another indication of fetal distress is greenish-stained amniotic fluid in a cephalic presentation.

44. Birth is a time when nurses and other health care providers are exposed to a great deal of maternal and newborn blood and body fluids. Wash hands before donning gloves and after performing procedures and removing gloves. Wear gloves (clean or sterile, as appropriate) when performing procedures that require contact with the woman’s geni-

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Answer Key 78

45.

talia and body fluids, including bloody show (e.g., during vaginal examination, amniotomy, hygienic care of the perineum, insertion of an internal scalp electrode and intrauterine pressure monitor, and catheterization). When assisting with a birth, wear a cover gown and a mask with a shield or protective eyewear. Cap and shoe covers are worn for cesarean birth but are optional for vaginal birth in a birthing room. Drape the woman with sterile towels and sheets as appropriate. Help the partner put on coverings appropriate for the type of birth, such as cap, mask, gown, and shoe covers. Wear gloves and gown when handling the newborn immediately after birth. Use an appropriate method to suction the newborn’s airway. a. Memories of sexual abuse can be triggered by intrusive procedures such as vaginal examination; losing control; being confined to bed and “restrained” by monitors, intravenous lines, and epidurals; being watched by students; and experiencing intense sensations in the uterus and genital area. Survivors of abuse may react in panic or anger, may take control of everyone and everything related to childbirth, may be submissive and dependent, or may retreat by mentally dissociating. b. Increase sense of control by explaining all procedures and why they are needed, validating needs and requests, asking permission to touch, accepting her reactions to labor, and protecting privacy by covering body and limiting the number of people involved in her care.

CHAPTER 27—CARE OF THE MOTHER AND NEWBORN Fill-in-the-Blank Sentences 1. puerperium 2. involution 3. distensible 4. bathing; activity; dietary 5. placenta 6.

48; 96 7. depression 8. attachment (bonding) 9. learned

Table Activity 10.

Assessment of Newborn

Normal Value

Head circumference

13-14 inches

Relationship of head to chest circumference

Head circumference is 1 inch larger than the chest

Temperature

97.6° F to 98.6° F

Pulse

120-160/min

Respirations

30-60/min

Blood pressure

60-80/40-50 mm Hg

Multiple Choice 11. Answer 4: Shock results in generalized decreased oxygenation of tissues; thus giving supplemental oxygen is a priority intervention. Raising the head of the bed is not advised, because this decreases perfusion of the cerebrum. Oxytocin may be increased rather than decreased if uterine atony is contributing to the blood loss. Over-massaging the fundus can contribute to uterine atony.

12. Answer 1: The mother should perform sponge baths for 7-10 days, until the cord comes off.

The other options are correct cord care.

13. Answer 2: The diaper is applied loosely.

Health care providers may also recommend cloth diapers for the first week. The yellow crust is not removed and may persist for 2-3 days. Bleeding is assessed every hour for 12 hours. Petroleum gauze is not needed when a Plastibell is used because the plastic bell covers the glans and prevents the tissue from sticking to the diaper.

14. Answer 4: The bathwater should be approximately 100° F (37.7° C) and the infant’s heat loss should be controlled because infants have a relatively large ratio of skin surface to body mass. The vernix caseosa should not be vigorously removed because it is attached to the protective layer of the skin. Mild soap and water are recommended for cleaning the perineum in conjunction with every diaper change. Bathing every other day is usually sufficient.

15. Answer 4: The first postpartum visit is usually scheduled around 6 weeks. Menses resume at 6 weeks in about 45% of nonnursing mothers.

Breastfeeding should not be considered a reliable method of contraception. Discomfort and

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Answer Key 79

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bleeding will occur if the episiotomy is not healed.

Answer 3: The infant can latch on more readily if the mouth surrounds the areolar tissue.

Alternate breasts with each feeding and allow suckling for 10-15 minutes for each breast.

To break suction, the finger is placed under nipple, rather than pulling child away from breast.

Answer 3: Tenderness and redness of the breast may indicate mastitis; thus this symptom should be reported. Temperatures greater than 100.4° F (38° C) and lochia that has a foul odor or a bright-red color should also be reported. The fundus should feel very firm, like a softball.

Answer 2: For mothers who are bottlefeeding, applications of covered ice packs are recommended for relief of engorgement.

The mother should not manually pump the breasts, because this will stimulate milk production. Engorgement usually occurs about 3 days after giving birth and mothers who select bottle-feeding still have to take measures to suppress milk production in the first part of the postpartum period.

Answer 1, 2, 4, 5: At birth, the skin is covered with a yellowish-white, cream cheese–like substance called vernix caseosa. Another common finding is lanugo (downy, fine hair characteristic of the fetus, between 20 weeks of gestation and birth). Good skin turgor and tissue elasticity are expected. Desquamation at birth is considered a sign of postmaturity.

Answer 3: Have the mother hold the baby to minimize stress and take vital signs. Immediately report assessment findings to the health care provider, because a weak, high-pitched cry can signal health problems such as infection or neurologic disorders.

Answer 1, 2, 4, 5: Acrocyanosis can last for 7-10 days. It is most commonly observed when the infant becomes cold. Mottling, a lacy pattern with dilated vessels on pale skin, is also common. Another normal variation is called the harlequin sign; half of the newborn’s body appears deep red and the other half appears pale as a result of vasomotor disturbance. This looks alarming, but is not harmful. Epstein’s pearls on the hard palate are a result of epithelial cells and disappear spontaneously within a few weeks. Jaundice occurring sooner than 48 hours after birth is termed pathologic jaundice. This type of jaun-

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dice is not normal and may be the result of a maternal-fetal blood incompatibility. Further assessment of jaundice is required.

Answer 2: Lochia serosa, a pinkish to brown drainage, is a sign of placental healing. Lochia serosa follows lochia rubra (bright-red drainage with small clots) that occurs immediately after delivery. After day 7, there is progression to slight yellow to white drainage. Lochia should always have a fleshy odor, never a foul odor.

Answer 4: Retroperitoneal hematomas are the least common, but are the most dangerous because they are caused by laceration of vessels near the hypogastric artery, secondary to rupture of a cesarean scar.

Answer 3: Enemas and suppositories are contraindicated for women who have third- or fourth-degree perineal lacerations. The other treatments would be appropriate Answer 2: The bottle should be filled with warm tap water about 100.4° F (38° C). The contents of the whole bottle should be used for each cleaning. Cleaning with toilet tissue is not recommended, but the area should be patted dry with tissue after flushing with the Peri bottle. Twice a day for 20 minutes is the recommended time for a sitz bath.

Answer 3: Elevated platelet count increases the risk for thrombus formation. Early and frequent ambulation is key in preventing this problem. Patients who have had excessive blood loss (low hematocrit and hemoglobin) can have fatigue. Elevated white blood cell count is typical with infection. A low platelet count would potentiate hemorrhage.

Answer 1: A full bladder places pressure on the uterus and can prevent normal contraction, which controls bleeding, especially in the early postpartum period. In the late postpartum period, continued distention results in urinary stasis, which contributes to infection.

Rectocele and uterine prolapse can be complications from perineal lacerations that are not properly repaired. Kidney dysfunction is not expected. Painful intercourse can be the result of not waiting for the episiotomy to heal or for normal vaginal lubrication to resume. Patients should be taught Kegel exercises to prevent future episodes of urinary incontinence.

Answer 3: Patients can experience gestational hypertension, so check the blood pressure and compare it to previous measurements.

The nurse reports findings to the health care

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Answer Key 80

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provider. Leakage of cerebrospinal fluid can create a headache after epidural or spinal anesthesia. The health care provider may decide to order an analgesic. The nurse should not indicate to the patient that headaches are normal or likely to spontaneously resolve.

Answer 1: In postpartum patients, profuse diaphoresis is expected in the first week, especially at night. Low blood sugar, fever, and respiratory distress can also cause patients to be very diaphoretic. If the patient has a history of any chronic health problems or if the patient appears to be in distress, the nurse could use the other options.

Answer 2: It is a normal part of development for a 15-year-old to be concerned about her appearance and to be concerned about her relationship with her boyfriend. Support her sense of self-esteem first. If she is secure about herself and her relationship with her boyfriend, she will be able to care for the infant. If she is not interested in learning about swaddling, the lesson can be postponed. She should not be badgered into holding the baby or judged for wanting to look nice.

Answer 4: The nurse assesses bowel function by auscultating for bowel sounds; asking about passage of gas; and assessing for pain, distention, or discomfort. Protocols or clinical pathways give guidance, but they do not eliminate the nurse’s clinical judgment. Dietary is not responsible for selecting or withholding foods related to medical therapies.

The nursing staff must ensure that the patient consumes foods and fluids that are appropriate to the diet therapy. The health care provider relies on the nursing staff to assess the patient’s readiness to advance foods and fluids.

Answer 1: Weight-loss diets are not encouraged. Breastfeeding mothers should follow the same diet as they followed while pregnant (i.e., an additional 300-500 kcal/day with 2-3 L of fluid). Non-breastfeeding mothers are expected to return to their prepregnant weight in about 6-8 weeks.

Answer 2: Patient is likely to experience some dizziness and orthostatic hypotension because of blood loss, anesthesia medications, splanchnic engorgement, and pain. Assisting her to a sitting position and pausing allows the nurse and patient to assess whether standing is possible and also allows the body a few minutes to physiologically compensate for the

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position change. The other options are also good safety measures.

Answer 1: An epidural causes regional anesthesia, so loss of sensation in the lower part of the body is expected. Change of mental status is not an expected side effect of an epidural block, but may be the result of medications such as morphine. Blood pressure is more likely to decrease rather than increase, but all changes should be reported. Low-grade fever is not expected, although some women may experience shivering or chills.

Answer 2: First the nurse would check for signs of dehydration, because the patient is likely to be dehydrated from blood loss, perspiration, and being NPO. Giving fluids may resolve the slight temperature elevation. Checking lochia and urine and looking for other sources of infection would be more likely after the first 24 hours, particularly if the temperature is greater than 100.4° F (38° C). Checking the fundus is part of the routine assessment, but is less related to temperature elevation at this point.

Answer 3: Discharge will pool in the vaginal vault and when the patient stands there is a sudden increase of flow; however, the nurse should always do a firsthand assessment of the lochia and the patient’s response. Explanations to the patient are always appropriate.

Reinforce to the UAP that reporting symptoms is always correct; although in this case, the symptoms are benign and expected.

Answer 4: If the baby grasps only the nipple, there is insufficient pressure on the lactiferous glands. If the baby is unable to suckle, then manually pumping the breasts is an alternative. Bottle feedings are also a possibility, but decreased frequency and regularity of breastfeeding may suppress milk production.

Engorgement usually resolves in 48 hours and manual expression of milk should help relieve the discomfort.

Answer 3: First assess the father’s feelings and knowledge; then based on the assessment, a plan can be developed to include him in the care of his wife and infant. The dominant grandmother seems to be interfering, but there may be cultural or familial issues that affect her behavior. This family may benefit from counseling, but roles may become more clear as the initial excitement wears off. If the father desires to be more active in child care, teaching should begin as soon as possible.

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Answer Key 81

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Answer 2: For mild pain, acetaminophen is usually sufficient. Morphine and codeine cause constipation; however, codeine may be combined with acetaminophen preparations to create a strong analgesic. If so, the nurse should preemptively assist the patient with measures to avoid constipation. Aspirin can interfere with clotting.

Answer 1: Whenever there is an increased number of unfamiliar faces on the unit, the staff must be extra-vigilant because of the increased movement in and out of the unit.

The infant must be protected at all times and the nursing staff must always be aware that abduction could happen at any time.

Answer 3: Low-set ears may indicate a chromosomal disorder. This finding should be reported. Molding is related to compression of the malleable cranium during birth and this should resolve within 1-2 days. Strabismus is crossed eyes and nystagmus is an abnormal lateral movement of the eyes. Both are commonly seen because of the immaturity of the newborn’s nervous system.

Answer 4: Hair tufts, dimples, and masses should be reported to the health care provider so that an abnormality of the spinal column can be ruled out. Lanugo is the fine hair that covers the baby, but the hair tuft is not an expected feature of lanugo. Vernix caseosa is the white cheesy substance that covers newborns. It is attached to the skin, so it is usually left in place for 48 hours, then gently washed off. Skin and hair discolorations are related to genetic factors, so the nurse must increase awareness of normal variations for different groups.

Answer 2: Vitamin K (AquaMEPHYTON) is routinely administered to compensate for the temporary lack of intestinal flora. Prothrombin levels are low at birth, which increases the risk for bleeding, but vitamin K should correct this. Rho(D) immune globulin (RhoGAM) is given to mothers for Rh incompatibilities.

Bowel movements are monitored, but not for the purpose of measuring blood clotting factors.

Answer: 420-480 mL/day Fluid needs are high: 140-160 mL/kg/day 6.6 pounds ÷ 2.2 kg/pound = 3 kg 140 mL/kg/day × 3 kg = 420 mL/day 160 mL/kg/day × 3 kg = 480 mL/day

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Answer 1: Neonates will have high levels of insulin, which can cause hypoglycemia. If the blood glucose level is 40 mg/dL or lower, sterile glucose water is given. Oral feedings of sterile water are given to bottle-fed babies to assess for ability to swallow and anomalies of the digestive tract. Breastfeeding would be the second best option if sterile glucose water was not immediately available (delivery in the field). Intravenous dextrose is given to patients who are unresponsive and unable to swallow.

Answer 3: If stool is not passed within 24 hours after birth, the health care provider should be notified. The other stool conditions are considered normal.

Critical Thinking Activities 47. The postpartum nurse should be advised about the name of the primary care provider; gravidity and parity; age; anesthetic used; medications given; duration of labor and time of rupture of membranes; oxytocin induction or augmentation; type of birth and repair; blood type and Rh status; rubella immunity status; syphilis and hepatitis serology test results; intravenous (IV) infusion of any fluids; physiologic status since birth; description of fundus, lochia, bladder, and perineum; infant’s sex and weight; time of birth; pediatrician; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.

48. Changes that occur in body systems after delivery: a. Cardiovascular—decrease in blood volume and cardiac output b. Urinary—initial diuresis, possible retention c. Gastrointestinal—hemorrhoids, constipation d. Endocrine—reduction in estrogen and progesterone levels e. Integumentary—reduction of hyperpigmentation, increased elasticity

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Answer Key 82

CHAPTER 28—CARE OF THE HIGH-RISK MOTHER, NEWBORN, AND FAMILY WITH SPECIAL NEEDS Crossword Puzzle 1.

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M G D M O O N R 4 O D B 5 Z H Y P E R B I L I R U B I N E M I A Y Z D 6 7 G H K Y I 8 O C E R C L A G E T T R O Y 9 10 B I L I B L A N K E T T O R C H C I I 11 12 C E C L A M P S I A T T 13 14 15 16 P H O T O T H E R A P Y M O R T A L I T Y E R N N 17 L U A H Y D R A M N I O S L S S P A 18 P R E E C L A M P S I A C A

Fill-in-the-Blank Sentences 2. prematurity; low birth weight 3. choriocarcinoma 4. fallopian tube 5. uterine 6. respiratory distress syndrome True or False 7.

True 8.

True 9.

False. Use of oral contraceptives is controversial because of the increased risk of thromboembolic disease in the immediate postpartum period (first 4 weeks).

10. False. A prominent feature of postpartum depression is rejection of the infant, often caused by abnormal jealousy.

11. False. The woman who is addicted to opioids may have infections that compound the risk to the infant, including hepatitis; septicemia; and STIs, including AIDS. Short Answer 12. Refer to Box 28-1 on p. 876. Examples of highrisk factors in pregnancy: a. Biophysical—genetic, nutritional, medical, and obstetric disorders b. Psychosocial—smoking, caffeine, alcohol, drugs, psychological status

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Sociodemographic—low income, lack of prenatal care, age, parity, marital status, residence, ethnicity d. Environmental—exposure to infections, radiation, chemicals Refer to Box 28-2 on p. 877. Examples of factors that place the postpartum patient and newborn at risk: Mother—hemorrhage, traumatic labor and delivery, infection, psychosocial factors, abnormal vital signs, previous medical conditions Infant—respiratory distress, poor Apgar score, cardiovascular disease, congenital abnormalities, neuromuscular dysfunction, hypo- or hyperglycemia, hyperbilirubinemia, preterm, low birth weight, feeding problems A preterm infant usually demonstrates froglike/flaccid posture; ruddy color; head appearing large in comparison to body; pliable bones of skull with large, flat fontanelles; thin, translucent skin; lots of lanugo; pliable ear cartilage; small genitals; weak cry; and immature or absent reflexes.

Multiple Choice 15. Answer 3: Missed: The fetus dies and growth ceases, but the fetus remains in utero. Amenorrhea continues, but no uterine growth is measurable. In fact, the uterus may decrease in size. Septic: Malodorous bleeding, elevated temperature, and cramping may be present; cervical os is opened; and abdominal tenderness is typical. Incomplete: Some, but not all, of the products of conception are expelled.

Inevitable: Bleeding increases and the cervical os begins to dilate. Membranes may rupture.

16. Answer 4: In hyperemesis gravidarum, excessive nausea and vomiting may result in electrolyte, metabolic, and nutritional imbalances.

Relief of painful uterine contractions would be a goal for abruptio placentae. Absence of fetal withdrawal symptoms is relevant for infants of mothers who abused alcohol or drugs. Prothrombin times, partial thromboplastin times, and platelet counts are monitored for patients who develop disseminated intravascular coagulation.

17. Answer 2, 4, 6: UAP can measure and report amount and frequency of emesis, assist with oral hygiene, and can weigh the patient. Initially, patients are NPO until the vomiting subsides; IV fluid is used for hydration and electrolyte replacement. The nurse must as-

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Answer Key 83

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sess for dehydration; this cannot be delegated.

Bedrest is usually not ordered for this condition.

Answer 2: Patients with placenta previa are treated conservatively with bedrest to include bathroom privileges. The rationale being that the placenta could migrate upwards before delivery. Patients with hyperemesis gravidarum are given clear liquids after the vomiting subsides. Painless bright-red bleeding is a sign of placenta previa, but continued bleeding is not expected and will lower the hemoglobin and hematocrit. Tocolytic drugs are used for patients with cervical incompetence.

Answer 4: Continuous headache, upset stomach, and blurred vision are associated with eclampsia and an upset stomach is a warning sign of impending seizure activity.

Answer 3: Hyperglycemia in the fasting portion of the test is blood sugar > 92 mg/dL. Frequent urination would accompany high blood sugar. The other signs/symptoms are typical of hypoglycemia.

Answer 2: The nurse knows that vaginal examinations can increase the bleeding, so she would stop the inexperienced provider and take him/her aside and remind of the potential complication. The other actions are correct.

Answer 4: Abruptio placentae is considered an obstetric emergency. The patient is likely to have lost a significant amount of blood and is considered unstable while being prepared for a cesarean birth.

Answer 2: If the mother and the father are both Rh negative, than the newborn will also be Rh negative.

Answer 1: Excessive or rapid weight gain, particularly when accompanied by edema, should be reported promptly. Edema is typically described using a scale of 1+ to 4+.

Answer 4: In cases of severe preeclampsia or eclampsia, medication therapies including magnesium sulfate (MgSO4) may be prescribed parenterally to prevent seizure activity.

Answer 1: The pregnancy is likely to be unplanned; thus the self-care measures and the physical and hormonal changes that accompany pregnancy have probably not been considered. In addition, the adolescent has to combine developmental tasks with the new role of becoming a mother or may face the decision about adoption.

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Answer 4: Exposure to cat feces is a source of Toxoplasma gondii, a protozoan that can cause toxoplasmosis.

Answer 1: One of the main features of PPD is a seeming lack of interest in the baby. The mother may demonstrate annoyance at having to care for the baby or exhibit a lack of maternal feelings. The mother may also have thoughts about harming self and child.

Answer 3: Disseminated intravascular coagulation (DIC) is a potentially life-threatening disorder that results from alterations in the normal clotting mechanism.

Answer 3: Fundal massage is a measure to counteract uterine atony. One nurse can perform the massage and check for response. If bleeding continues, another nurse calls the provider about suspected hemorrhage and for an order to start oxytocic medications.

Answer 2: To detect a hematoma, the nurse would examine the perineal area. Taking the blood pressure and saving linens is appropriate if blood loss is suspected, but these measures do not help to locate the source. Palpating the abdomen would be appropriate to assess internal bleeding, but not for suspected hematoma.

Answer 2: The nurse would call the health care provider and ask for clarification. Blood pressures under 160/100 mm Hg may not be medicated because of impaired perfusion to the fetus.

Answer 2: Abdominal palpation could traumatize the liver and cause subcapsular bleeding. The other assessments should be performed.

Answer 3: Although mastitis can occur at any time, engorgement and milk stasis frequently precede mastitis, when feedings are skipped or when breastfeeding is suddenly stopped.

Antibiotics and cold packs are used if the condition occurs. Increasing fluid intake is recommended to facilitate milk production.

Answer 2: Perinatal infection is rare, so the mother would usually be treated and cleared, and then according to federal guidelines the danger to the infant will have passed. Infants are tested at birth and treated with medications for preventive therapy. The infant’s medication can be stopped when the mother and relatives are treated and show no evidence of disease.

Answer 3: The process of labor would be stressful to the mother’s cardiac system, but

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Answer Key 84

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oxygen therapy seems to have been sufficient in this case. The second stressful period to the mother’s heart will be the 48 hours after birth as the extravascular fluid returns to the blood system, so the nurse would be vigilant during that period to watch for cardiac decompensation. Based on findings from frequent assessments, the nurse may decide to talk to the provider about PRN oxygen, telemetry, or transfer to the CCU. Answer 4: Early ambulation is encouraged for all patients to prevent thrombotic problems.

If DVT occurs, the affected leg is elevated.

The legs are never massaged, because of potentially dislodging the thrombus. Oral anticoagulants are given as part of the therapy for patients who develop DVT or those who continue to have high risk for DVT. During hospitalization, the patient may receive subcutaneous injections of anticoagulant medications such as enoxaparin or heparin.

Answer 2: If the father is Rh negative, the neonate will also be Rh negative. If the father is Rh positive, the nurse will ask the mother about other pregnancies and occasions for receiving RhoGAM. Amniocentesis would warrant RhoGAM if the father is Rh positive.

5. Provide oxygen by mask at 8-10 L/min.

7. Notify the health care provider that a convulsion has occurred.

3. Note the time and sequence of the convulsion.

4. Insert an airway after the convulsion, and suction mouth and nose.

1. Remain with the woman and press the emergency bell for assistance.

6. Observe fetal monitor patterns for bradycardia, tachycardia, or decreased variability.

2. If the mother is not on her side already, turn her onto her side when the tonic phase begins.

Critical Thinking Activities 40. a. Ideally, the blood pressure readings are taken 2 times 6 hours apart. The readings should be taken with the woman seated and ensure the cuff size is appropriate.

The nurse would observe for generalized edema of the face, hands, and ankles.

Periorbital edema may mark a more ominous finding. The nurse should weigh the patient and test the urine. In mild preeclampsia, urine testing frequently shows

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1+ to 2+ albumin readings. The nurse should also ask about accompanying symptoms such as headache, visual disturbance, or upset stomach. The infant’s status is also monitored. b. Treatment includes bedrest and a balanced diet with protein and moderate sodium intake. a. Diagnostic tests include 1-hour diabetes screening, glucose tolerance, glycosylated hemoglobin, finger sticks, and fetal surveillance (biophysical profile, stress tests, alpha-fetoprotein, ultrasound). b. The complications of gestational diabetes are: Maternal—infections, difficult labor, vascular problems, azotemia, ketoacidosis, pregnancy-induced hypertension Fetal—stillbirth, spontaneous abortion, hydramnios, large placenta, alteration in size for gestational age, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress

CHAPTER 29—HEALTH PROMOTION FOR THE INFANT, CHILD, AND ADOLESCENT Short Answer 1.

Strategies to promote dental health include: a. Infant—The nurse instructs parents to clean the oral cavity by wiping the teeth and gums with a damp washcloth; use a small, soft-bristled toothbrush when more teeth come in; avoid toothpaste; initiate fluoride supplementation after 6 months; ensure proper nutrition; prevent bottle caries (no propping of bottle at bedtime). b. Preschooler—Parents must assist with dental hygiene, provide professional dental care, continue fluoride supplementation, screen for malocclusion problems. c. Adolescent—Continue good dental practices, correct malocclusions.

2. a. Infant—Encourage breastfeeding, introduce baby foods as recommended, begin with rice cereal, use prescribed baby formula. b. Preschooler—Encourage high-nutrient foods such as fruits, vegetables, whole grains, and low-fat dairy and protein products. c. Adolescent—Provide nutritionally dense foods and snacks.

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Answer Key 85

3.

Barriers to proper immunization include lack of insurance and funding, lack of transportation, lack of education about the importance of immunizations, and personal and cultural beliefs.

True or False 4.

True 5.

True 6.

False. Fluoride supplementation is recommended at age 6 months if the water supply is not fluoridated.

Multiple Choice 7.

Answer 1: Asking about plans is a way for the nurse to assess the adolescent’s knowledge and thoughts about sexual relations.

This question is a segue into the discussion of sexual relations as an event that is coming and how to prepare for it. The other questions are also useful, but they are closed questions and offer less opportunity for the adolescent to take the lead in what he/she wants to know about sexual behavior.

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Answer 2: The Healthy People 2020 goals are designed to target the whole population and they cover a wide range of topics. All of the options contribute to the achievement; however, teaching groups of people about general health promotion for children is a way to have greater impact compared to helping individual patients with single issues.

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Answer 4: A child is more likely to develop good health habits if adults, particularly parents and close family members, practice healthy habits on a routine basis. The other options are also recommended as health promotion points.

10. Answer 2: All of these children have risk factors, but the 9-year-old has a daily routine of eating high-calorie, high-fat foods. This increases the risk for developing poor eating habits. The 13-year-old also has risk for obesity because of inactivity, but 2-4 hours may be acceptable if the child is eating healthy food and spending at least an hour per day in physical activity. If parents have to work fulltime, there is less time for meal preparation or other health promotion activities; however, a 3-year-old is likely to prefer finger foods and this type of food requires less preparation. A 17-year-old boy is likely to eat large amounts and still feel very hungry because of the growth spurt that occurs during adolescence.

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Answer 3: Rice cereal is recommended as the introductory food.

Answer 3: Because the toddler is working through autonomy and initiative, give choices about nutritionally dense food. Bargaining is more likely to set up a power struggle. Competitive or game-like approaches will appeal more to school-agers. Presenting cause and long-term effects will have little meaning for the toddler who lives in the now.

Answer 4: Developmentally, the adolescent wants to be accepted by the peer group and appearance is very important. It’s impractical to tell the daughter that she can’t go out without sunscreen and unilateral pronouncements are likely to create a climate of defiance. Information about the risks for skin cancer are not particularly meaningful to adolescents who believe they are invulnerable. Comparing the child’s characteristics to another child puts the child in a powerless position.

Answer 2: Children age 6-12 months have the greatest risk for aspiration, because they put everything in the mouth as a way to investigate the properties of objects.

Answer 1, 3: The American Heart Association recommends a maximum of 7% of daily calories to be fats. Fat-free or 2% milk would be recommended. Physical exercise for 60 min/day is also recommended. Grains should not be excluded from the diet. Children will have bodily changes during adolescence, but overweight children often grow up to become overweight adults.

Answer 4: The child understands that parked cars and curbsides are not good areas for playing. Parents should help the child review when he can play outside and who must accompany him. The helmet should always be worn, regardless of anticipated distance. Running out into the street to get a ball should be discouraged, even if the child does “stop, look, and listen.” Drivers anticipate people at crosswalks, but are less aware of children who are running out into the middle of the street.

Answer 2: The toddler is going to use his/ her new motor skills to investigate grandma’s house. Grandma is more likely to have drawers and cabinets that contain dangerous household substances and prescription drugs that are easily accessible. The infant will potentially ingest anything on the floor.

The school-age child and adolescent could potentially be exposed to toxic fumes, but are

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Answer Key 86

unlikely to consume materials that they are working with.

Critical Thinking Activities 18. Regular physical activity lowers the death rates for adults and reduces the risk for developing heart disease, high blood pressure, diabetes, and colon cancer. In children, physical activity increases bone and muscle strength and helps decrease body fat. Psychological benefits include improvement in self-esteem and reduction of stress and depression. The nurse can promote physical activity in children by educating parents, teachers, school administrators, and daycare providers and by being a good role model.

19. a. Interventions for this nursing diagnosis include counseling parents to store medicines in containers with childproof caps, store harmful substances out of reach or in locked cabinets. Educate parents about calling the Poison Control center. Remind that syrup of ipecac is no longer recommended. b. Examples of strategies that may be implemented to prevent accidental poisonings include: Never referring to medication as candy and keeping it out of the reach of children (childproof containers) Storing harmful substances (e.g., cleaning supplies) out of reach or locked away Inspecting the home for possible sources of lead contamination Keeping toxic plants out of reach Keeping emergency phone numbers available Educating older children about safety hazards 20. Behaviors associated with teen smoking include use and approval of smoking by peers or siblings, smoking parents, accessibility of tobacco products, low self-esteem, and exposure to advertising for tobacco products.

Nurses should support legislation that restricts the sale of tobacco products to minors.

Nurses should help adolescents understand the risks involved in smokeless tobacco: lip, gum, throat, and stomach cancers.

People who smoke should be advised that the damaging smoke is often trapped in clothing, drapes, and household furnishings and that environmental tobacco smoke results in increased risk for heart and lung disease,

particularly asthma and bronchitis in children. The nurse should be aware of available resources and promote their use. For example, the American Cancer Society (ACS) offers programs and resource materials aimed at educating children and adolescents concerning the dangers involved in tobacco use. These programs are available at no cost to schools, civic organizations, and health care professionals.

CHAPTER 30—BASIC PEDIATRIC NURSING CARE Fill-in-the-Blank Sentences 1. pure milk 2.

Women, Infants, and Children (WIC) 3. respect; collaboration; support 4. are able; are not able 5.

5 True or False 6.

True 7.

True 8.

False. The American Academy of Pediatrics recommends breastfeeding exclusively for 6 months; then after 12 months, discontinuation of breastfeeding is a personal choice.

9.

True 10. False. Children, like adults, will engage in activities for distraction as a method of coping with pain.

11. False. Newborns have the most rapid metabolism and a fracture at birth could unite in as little as 3 weeks compared to 8 weeks for an 8-year-old.

12. True Short Answer 13. (a) Preventing disease or injury; (b) assisting children, including those with a permanent disability or health problem, to achieve and maintain an optimum level of health and development; and (c) treating or rehabilitating children who have deviations from an optimal state of health.

14. (a) Admission, (b) blood tests, (c) the afternoon of the day before surgery, (d) injection of preoperative medication, (e) the moments before and during transport to the operating room, and (f) return from the postanesthesia care unit (PACU).

15. Gain the trust of the parents by (a) reviewing and interpreting information from the

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Answer Key 87

health care provider as needed, (b) asking the parents whether they have any questions, (c) conveying concern for the parents’ well-being, (d) listening and being available, and (e) respecting them as experts on their child and soliciting their input.

Figure Labeling 16. See Figure 30-8, p. 955. Each face is for a person who has some pain. The nurse points to each face and says, “This face has no hurt.

This one hurts a little bit. This one hurts a little more. This one hurts even more. This one hurts a whole lot. This one hurts the worst.

Now you pick which face matches your pain.”

26.

Table Activity 17. Vital Signs (Averages) (See Table 30-3, p. 940.)

Heart Rate/ min

Respirations/ min

Newborn

120

35

70/50

1-11 months

120

30

90/60

2 years

110

25

96/68

4 years

100

23

100/70

6 years

100

21

105/70

10 years

90

20

108/70

12 years

88

20

110/70

16 years

70

20

120/70

Age

Blood Pressure

Clinical Application of Math and Equivalents 18. Three inches is approximately 8 cm and his growth is within the normal range.

19. 280 mL 20. 95 mm Hg; formula for children age 1-7 years: 90 + the age in years 21. 20 mL; 1 gram equals 1 mL of urine 22. 240 mL; 1 ounce is equal to 30 mL 23. 4 mL is equal to 4 cc Multiple Choice 24. Answer 3: The nurse empowers the mother by pointing out correct actions during a stressful event. This reinforces the mother’s confidence and encourages her efforts. The other responses are also okay if used at the correct time, but responding to the mother’s source of distress (fear of incompetence) is the first action to empower her.

25. Answer 3: The parent is the expert on the child’s behavior and her advice should be

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incorporated into the plan of care. This action demonstrates respect for the mother as an equal in the decision-making. Making suggestions, teaching, and projecting warmth are all important, but note the directionality of these actions is from nurse to parent. Asking for advice refocuses the direction from mother to nurse.

Answer 1, 2, 3, 5, 6: The selected method is based on the child’s ability to cooperate; for example, infants cannot hold an oral thermometer under the tongue. Parents may or may not object to rectal temperatures, but their wishes are considered. Adolescents will object to rectal temperatures because of modesty, whereas the preschooler does not like intrusion of objects. If there is a possibility of sepsis or acute infection, the need for accurate temperature overrides other considerations.

The chosen route should be the least traumatic and still fulfill the purpose. Parents’ lack of familiarity with the route would not be a deciding factor because the nurse will explain procedures and equipment as a routine action.

Answer 1: See Table 30-3, p. 940 for additional information.

Answer 1: A 1-year-old has a three- or fourword vocabulary. It usually includes “mama” and “dada.” Infants babble, coo, and mimic sounds. In toddlerhood, more words are understood than expressed. Children usually know 25-50 words by 18 months, but by 2 years they often know more than 250 words.

Answer 1: For a 12-year-old, P 88, R 20, BP 110/70 are considered average for the age. P 124, R 32, BP 126/66 indicates a hypermetabolic state such as fever or stress. The nurse should conduct additional assessment.

Answer 2: Infant likes toys that bang, shake, or can be pulled; enjoys playing “peek-a-boo.”

At birth, visual acuity is normally 20/300 to 20/400. Bladder control may not be achieved until age 3. Doubles weight by 6 months; triples weight by 1 year.

Answer 1: The experience of the injection is best compared to a familiar sensation. “Don’t move” is a negative way to phrase the instructions. Rephrase in a positive way: “You can help me by holding very still,” or “Mommy is going to give you a big hug.” Don’t offer a choice when there is no choice. Try to avoid the word “shot.”

Answer 3: Tell the child that the medicine tastes a little strong and the sweet juice will

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Answer Key 88

33.

34.

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wash away the taste. The syringe method is usually used for infants or resistant toddlers.

The ice pop could also be used in conjunction with the sweetened juice, but requires a little more preparation for correct timing. If the child is allowed to sip the liquid at will, it decreases the chance that he/she is going to willingly consume the entire dose.

Answer 1, 2, 6: Only water should be used around the eyes. Cotton-tipped swabs should not be inserted into the ear canal. The foreskin is not retracted because of potential for bleeding and damage. The other actions are correct.

Answer 4: If the school-age child has been told that he will be asleep for the procedure, he is likely to compare the explanation to normal sleep, so the nurse should explain the concept of “special sleep.” Handling the mask is appropriate for younger children, but the school-age child needs a simple explanation of how the mask works. Talking to a peer would be appropriate for an adolescent. Reassurance about safety and necessity is an empty response that is not very useful to patients who can process information.

Answer 3: The mother should try to instill regular and typical family patterns of eating, so that meals are associated with desired behaviors. Leaving food out creates an expectation that meals and food are at the whim of the child. Restraining in a high chair will create frustration for everyone. Five-hour time increments are excessive for most people; toddlers will eat more if they are given small, frequent meals.

Answer 1, 4: The birth weight should double by age 6 months and it is likely that the infant is enjoying rattles and peek-a-boo. Active exploration of environment will occur at an older age and parallel play is characteristic of toddlers. Breastfeeding is recommended as the exclusive food source until at least 6 months.

Answer 2: The vastus lateralis is good site because the chance of damaging underlying structures is less likely. The site is also the most developed in an infant, which is desirable. Ease of exposure is not a factor. Pain is equal at this site compared to others.

Answer 3: Children will exhibit concern when others are crying, but apprehension could be a sign that the child is experiencing some abuse.

The other children are exhibiting normal behaviors for developmental age.

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Answer 2: Around 9 or 10 months, the child will start crawling. The parents should be encouraged to look around their house to see what the infant will encounter as he crawls around; thus they can prepare the environment in anticipation of this new milestone.

Answer 2: The nurse would first give the stethoscope to the child, so that he/she can handle it and play with it. Assistance of a helper will not be useful in this procedure, because resistance and screaming will make auscultation impossible. If the assessment is not possible, the nurse would ask about functions and symptoms related to bowel function such as eating, vomiting, bowel movements, flatus, or abdominal pain.

Answer 3: The nurse counts respirations first, because handling the infant can precipitate agitation or activity. Blood pressures are usually not taken until age 3.

Answer 1, 2, 5, 6: Three flexion creases are expected, so referral to a specialist is warranted. Tufts of hair along the spine can be associated with spina bifida. Lack of babbling at 9 months could indicate a problem with hearing. Tongue protrusion is associated with cognitive impairment. Newborns and young infants prefer en face position. Bumping into obstacles at age 1 is normal because of visual acuity.

Answer 2: The nurse would describe the type of stool that is expected for breastfed babies.

Answer 3: The concentration of proteins and minerals in whole milk taxes the infant’s immature kidneys, so it is not recommend before the age of 1 year.

Answer 3: Honey has caused infant botulism and this mother was well-informed. The other elements are acceptable.

Answer 2: The infant demonstrates an active interest in getting nutrition from alternative sources. Comparing children to standards or to siblings is a way for parents to understand time frames for readiness. Returning to work is a valid reason for the mother’s readiness to wean.

Answer 2: The American Academy of Pediatrics recommends cholesterol testing for children whose parents or grandparents have total cholesterol levels of 240 mg/dL or higher or whose parents or grandparents have had heart attacks or been diagnosed with blocked arteries at age 55 or earlier in men, or age 65 or earlier in women.

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Answer Key 89

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49.

50.

Answer 1: The health care team first seeks out and treats immediate injuries. The other options are likely to follow once the team has ensured physical safety.

Answer 4: The child is allowed to assume a position of comfort and perceived safety, then the nurse gets on the child’s eye level.

This position creates less threat. Making faces could be perceived as a threat. In addition, whenever the nurse stands in the doorway, it gives the impression that the nurse is getting ready to leave. Sitting on mom’s lap is a good strategy, but touching is never the first action for any patient. Putting chairs in a small circle would be a good strategy for an adolescent.

Answer 1: The nurse compares the sensation of wearing the electrode to a known sensation of a band-aid and allows the child to handle it. Being hooked to a machine sounds scary, as does the idea of being electrocuted or having someone watch your heart.

Critical Thinking Activities 51. a. The nurse can reduce anxiety for the child and parents during hospitalization by: Orienting them to the unit and explaining routines.

Introducing them to the staff and roommate.

Providing tours and audiovisual aids.

Having the child handle equipment and supplies.

Allowing the child to keep his own clothes or toys.

Encouraging parents to visit and stay.

Explaining procedures and the status of the child. b. Strategies for communicating with a child include: Using a calm, unhurried voice Speaking clearly; being direct and specific Stating directions in a positive way Focusing communication on him Talking to the child and the parents Using play as a method to initiate conversation Listening to and observing the child at play Looking for opportunities to offer the child choices Being honest Explaining in a concrete manner

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a.

Refer to Box 30-4 on p. 938. Guidelines for the pediatric physical examination include: Performing the examination in an appropriate area Providing time for play and becoming acquainted Observing behaviors that signal readiness to cooperate Using techniques to promote cooperation Beginning the examination in a nonthreatening manner Using the “paper doll” technique Involving the child in the examination process b. The nurse can have the child assist with the auscultation of the lungs by: Asking the child to “blow out” the otoscope light or flashlight Placing a cotton ball in the child’s palm and asking the child to blow the ball in the air Placing a small tissue on the top of a pencil and asking the child to blow the tissue off Having the child blow a pinwheel, party horn, or bubbles The pediatric nurse should enjoy working with children of all ages. He/she must be able to provide care to the child while also identifying family stressors and providing care for other members of the family. The nurse must have specialized skills, including excellent assessment skills, the ability to establish trust, teaching ability, and the ability to serve as a patient advocate. A pediatric nurse serves as a role model for children by demonstrating appropriate health promotion and prevention behaviors such as maintaining good nutrition, a healthy lifestyle, and personal hygiene, or for parents by exhibiting age-appropriate responses to children. What the nurse needs most is the ability to recognize and appreciate the uniqueness that each child or adolescent brings to the nurse-patient relationship.

CHAPTER 31—CARE OF THE CHILD WITH A PHYSICAL AND MENTAL OR COGNITIVE DISORDER Matching 1. c 2. g

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Answer Key 90

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Table Activity 30. Clinical Manifestations of Dehydration (See Table 31-1, p. 1008.)

a i f e b j d h

Assessment

Fill-in-the-Blank Sentences 11. 20 mm Hg 12. 12 13. deficient 14. 90% 15. Reed-Sternberg 16. infections 17. 600 to 1200 18. drug True or False 19. True 20. True 21. False. Cryptorchidism, which is undescended testes, requires surgical fixation of the testes.

22. False. Essentially, the nutritional needs of children with diabetes are no different from those of unaffected children. Children with diabetes require no special foods or supplements.

23. True 24. True Short Answer 25. (a) Increased pulmonary blood flow, (b) decreased pulmonary blood flow, (c) obstruction to systemic blood flow, and (d) mixed blood flow 26. (a) Pulmonary stenosis, (b) ventricular septal defect (VSD), (c) right ventricular hypertrophy, and (d) overriding aorta 27. (a) The decrease in RBCs causes anemia, (b) neutropenia leads to infection, and (c) the decrease in platelets causes bleeding.

28. (a) Bacterial, (b) viral, (c) mycoplasmal, (d) foreign body aspiration 29. E: Enlarge the nipple, S: Stimulate the suck reflex, S: Swallow fluid appropriately, R: Rest when infant signals with facial expression.

Signs and Symptoms

Skin

Cold, dry, gray, loss of turgor

Mucous membranes

Dry

Eyes

Sunken

Fontanelles

Sunken

Behavior

Lethargic

Pulse

Rapid, weak

Blood pressure

Low

Respirations

Rapid

Figure Labeling 31. A hip dysplasia is usually assessed by the nurse upon finding uneven thigh and gluteal folds. When placed in the prone position, there is limited abduction of the hip on the affected side. A weight-bearing infant may have the affected leg shorter than the other, with evident limping. Refer to Figure 31-21a, p. 1025.

Clinical Application of Math and Conversions 32. 3.6 kg 7 pounds = 3.2 kg 15 pounds = 6.8 kg 6.8 – 3.2 = 3.6 kg 33. 2.6 mL 40 mg × 7 mg = 2.625 rounded to 2.6 mL 15 mL x 34. 35 mL. The volume of fluid in milliliters is equal to the weight of the fluid measured in grams.

Multiple Choice 35. Answer 1: The clinical signs and symptoms of mild to moderate anemia (hemoglobin: 6-10 g/dL) are often vague and nonspecific and include irritability, weakness, decreased play activity, and fatigue. When hemoglobin falls below 5 g/dL, the child will have anorexia, skin pallor, pale mucous membranes, glossitis, concave or “spoon” fingernails, inability to concentrate, tachycardia, and systolic murmurs.

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Answer Key 91

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Answer 1: Murmurs are heard as the blood moves through the defective structures.

Answer 3: Surgery is generally required because the defects are structural so diet, exercise, and medication will not correct the defects.

Answer 3: Iron deficiency anemia is the most common.

Answer 2: The ascorbic acid in citrus fruits or juices enhances iron absorption.

Answer 1, 3, 4: A breastfed infant should start iron supplements at 4 month of age. Preterm infants have less iron reserve to begin with, so they also need supplements. A 16-year-old girl who is dieting will have iron deficiency related to menstruation, so she should also have supplements. It is recommended that a toddler obtain the necessary iron by eating lean meats, legumes, and fortified cereal. The 10-month-old is eating commercial infant cereal, which is the best solid food source of iron.

Answer 3: The trip to the beach is less likely to include the usual precipitating factors: infection, fever, hypoxemia, dehydration, high altitudes, cold, or emotional stress.

Answer 3: The nurse recommends to the mother the best toy would be swim fins. The other toys offer a bigger risk for falls and injuries that could cause bleeding.

Answer 4: In idiopathic thrombocytopenia purpura, the platelet count is lowered and this increases the risk for bleeding, even if injuries are minor.

Answer 2: Any person with an active infection should not enter the room. Also, the 3-yearold who has symptoms of a cold is likely to touch, crawl, climb, and desire to play with his/her sibling. Pregnancy is not a contraindication. Parents should routinely shower and change clothes before coming to the hospital to visit. The 5-month-old is not infectious; however he/she is likely to have a weaker immune system and parents should reconsider exposing him/her to the hospital environment.

Answer 2: Most exposed infants up to 18 months of age will test positive for HIV antibodies, but it is unclear whose antibodies are being detected during this time. In infants younger than 18 months, a polymerase chain reaction (PCR) test, which actually tests for HIV, not for the antibody, is available to de-

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finitively diagnose HIV infection early in this age group.

Answer 3: The nurse reflects back the thoughts of this young person who is facing this life-altering chronic disease. This is the best response, because it indicates to the adolescent that the nurse is really listening and understands his concerns. This response also invites continued discussion. The other responses are more likely to dissuade the adolescent from further disclosure.

Answer 1: Nonsteroidal antiinflammatory drugs (NSAIDs) are the first line of drug treatment. Stronger NSAIDs are tried if over-the-counter medications do not work.

Corticosteroids could be used to decrease inflammation. Slower-acting antirheumatic drugs (SAARDs), disease-modifying antirheumatic drugs (DMARDs), and tumor necrosis factor (TNF) blockers are added in that order if previous drugs are not working.

Answer 3: Suctioning is based on assessment of lung sounds and noting excessive moisture in the tube. Infant could also show signs of irritability and fussiness. Facility policy will not stipulate specific time frames and the health care provider relies on the nurse to make a clinical judgment about need for suctioning.

The neonate is not able to cough up secretions.

Answer 3: Parenteral nutrition is ordered to reduce the risk of aspiration. Bottle-feeding and breastfeeding interfere with respiration and all enteral methods increase the risk for aspiration.

Answer 4: The nurse first tries to explain the rationale for not prescribing the antibiotics.

The nurse may have to give additional explanation about superinfections. If the mother is still dissatisfied after the nurse’s best effort, the nurse can contact the health care provider.

Answer 2: Rheumatic fever and acute glomerulonephritis are associated with a history of untreated streptococcal infections.

Answer 2: This increase of pulse could signal hemorrhage, which is the chief concern in the postoperative period. The other reports are also of concern and indicate that the UAP needs to be instructed on positioning (semiFowler’s), and fluids (no red or purple fluids that would confuse the observation of bleeding). Active running and playing should be discouraged in the immediate postoperative period.

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Answer Key 92

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Answer 3: The nurse would intervene if the inexperienced health care provider started to examine the throat by using a tongue blade because this could trigger a laryngeal spasm and cause respiratory arrest. The child should sit on the mother’s lap for psychological safety, because crying could also cause a spasm. The diagnosis is based on symptoms, preceding history, and diagnostic studies.

The operating room could be notified in case emergency intubation is required.

Answer 3: A cool-mist humidifier helps relieve cough. Liquids are given so that secretions are thinned and easier to expectorate.

Antibiotics and cough suppressants are not usually prescribed.

Answer 4: The nurses who are assigned to care for children with RSV should not also care for high-risk patients. This is an additional measure to prevent cross-contamination.

The other option is to put all of the patients in the same room, but five patients in one room is likely to exceed the occupancy space in most modern hospitals. The children are not in reverse isolation, but personnel with minor infections should alert the charge nurse so that the staff is used to best advantage. Caring for patients who are in isolation is more timeconsuming, which is one reason that all isolation patients are usually not assigned to one nurse.

Answer 4: Cystic fibrosis is a multiorgan disease, but pulmonary complications and pulmonary failure are the usual cause of death.

Answer 3: Clear fluids, including water or dextrose and water, are given first and then there is a gradual progression to formula. If the mother intends to breastfeed, she should be directed to pump the breasts until the infant is able to feed directly from the breast.

Answer 2: It is acceptable to offer a commercially available oral rehydration solution in small amounts for the first 4-6 hours following the onset of diarrhea. The American Academy of Pediatrics no longer recommends withholding food or fluids for 24 hours following the onset of diarrhea or administering the traditional BRAT diet (bananas, rice, applesauce, and toast or tea).

Answer 3: Umbilical hernias usually show spontaneous closure by 2 years of age in small defects (less than 2 cm); surgical closure is performed if the condition persists after age 2-5 years or for defects larger than 2 cm.

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Answer 4: Immediate surgical repair of the diaphragm with replacement of the herniation is required because severe respiratory distress develops within hours after birth.

Answer 3: Pharmacologic therapies include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), metoclopramide (Reglan), or proton pump inhibitors (PPIs) such as omeprazole (Prilosec) and lansoprazole (Prevacid) to reduce acid secretion.

Answer 2: The kidney function must be verified because nonfunctional kidneys contribute to hyperkalemia. For presence of crackles or wheezes, the nurse would notify the health care provider if a high flow rate of fluid had been ordered. Bowel sounds are likely hyperactive because of the diarrhea. Bowel sounds can be hypoactive if the patient is hypokalemic. If the patient were hyperglycemic, the nurse is likely to notify the health care provider before starting the potassium, because elevated blood sugar can be accompanied by hyperkalemia; for example, in diabetic ketoacidosis.

Answer 1, 2, 3: The nurse is trying to determine if the child has a learned repression habit, which may come from holding back the urge because it is painful to defecate. Some children will ignore the urge if they are too busy playing and other children may hold the urge because of an embarrassing incident at school. A 5-year-old has insufficient information to have insight into cause of constipation.

Offering fruit versus medicine sounds like a threat and is not the most therapeutic approach.

Answer 3: If the barium enema was successful in reducing the intussusception, normal bowel functions will return as indicated by the presence of bowel sounds and the passage of stool containing the barium.

Answer 4: Adrenocortical steroids (prednisone) are ordered to reduce the proteinuria and subsequently the edema. Bedrest is ordered initially. A good protein intake is needed to offset the loss of protein through the urine. Dietary restrictions include a low-salt diet and restricted fluids.

Answer 1: Congenital hypothyroidism can result in permanent cognitive impairment. Poor outcomes are usually attributed to noncompliance.

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Answer Key 93

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Answer 4: Hyperthyroidism is rare in young children, primarily affecting young adolescents.

Answer 4: Treatment of clubfoot consists of manipulation and the application of a series of short leg casts.

Answer 1: Atopy refers to an allergy for which there is a genetic or inherited predisposition.

A familial history of asthma, allergic rhinitis, or dry skin is often present. Food allergies and abnormal skin function are implicated by association.

Answer 4: Vesicles on an erythematous base are observed in varicella. Pinpoint red spots with white specks in the buccal cavity are observed with rubeola (measles). A pinkish-red maculopapular rash that begins on the face is observed with rubella (German measles).

A rose-pink macular rash on the trunk is observed for roseola infantum (exanthema subitum).

Answer 1, 2, 4: The child with idiopathic scoliosis will have unequal hip height and shoulder height, scapular and rib prominence, and a posterior rib hump that is visible when the child bends forward at the waist.

Answer 4: Left untreated, the child is at risk for amblyopia (lazy eye; reduction or dimness of vision, especially in which there is no apparent pathologic condition of the eye), in which there is a loss of visual acuity.

Answer 2: The skin becomes thick and leatherlike with repeated scratching.

Answer 1, 3, 4, 6: Padded side rails are for safety to prevent injury if extremities or head are moving around uncontrollably. Loosening restrictive clothing facilitates breathing. Turning the head prevents aspiration. Staying with the child is for safety and observation. Moving the child to the bed is not necessary and picking him/her up may actually increase the risk for falls for the nurse and the child. Pushing a tongue blade between the teeth during the seizure is not recommended; however, after the seizure is over, the nurse could insert an oral airway to prevent the tongue from falling back into the throat and occluding the airway.

Answer 2: In infants, measurement of the head circumference is the most important diagnostic technique. It is important to measure the head circumference routinely in all infants. Any measurement that crosses one or

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more grid lines within a 2- to 4-week period is suggestive of hydrocephalus.

Answer 4: The child with ADHD is often easily distracted by extraneous stimuli, so a calm and quiet space with limited objects will offer fewer distractions. The other strategies may cause him to get more excited. If the child is physically tired, he may seem to have less energy to bounce about, but he will also have less energy for learning.

Answer 1: Tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), trazodone (Desyrel), sertraline (Zoloft), bupropion (Wellbutrin), venlafaxine (Effexor), and paroxetine (Paxil) are helpful in alleviating symptoms Answer 2: The child with an IQ of 40 can be trained to independently do activities of daily living. (1) Mild (educable cognitive-impaired), IQ of 50 or 55 to approximately 70; (2) moderate (trainable cognitive-impaired), IQ of 35 or 40 to 50 or 55; (3) severe, IQ of 20 or 25 to 35 or 40; and (4) profound, IQ below 25.

Answer 1: The behavior is considered a type of stress response. The parents and the child should be reassured that he is okay and that he must return to school. Encourage parents to be firm and not negotiate with the child.

Answer 1, 4: In working with children with autism, remember that change and stimulation are very stressful for them, so familiar possessions and routines are best. Communicate directly, limit direct eye contact, and don’t touch or hold unless the child signals that it is okay to do so. There is no cure, but some children will be able to achieve a level of independence.

Critical Thinking Activities 81. a. The nurse would advise parents not to smoke. Bed sharing, adult beds, sofas, and soft bedding such as pillows or quilts, stuffed animals, or towels potentially create a risk for accidental entrapment and suffocation. Do not overbundle the infant; dress the infant in light clothing and keep the room at a comfortable temperature.

Infants should always be placed on their back for sleep until one year of age. Offer the infant a pacifier when sleeping to reduce the risk of SIDS. b. SIDS occurs more often in males and in siblings of SIDS victims. Incidence is increased in winter months, with peak inci-

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Answer Key 94

82.

dence occurring in January. Native Americans and African Americans are most often affected, and there is an increased occurrence in lower socioeconomic classes. The cause of SIDS is unknown, but SIDS is often associated with poor prenatal care, premature birth, low birth weight, multiple births, and CNS and respiratory dysfunctions. There is also an association between SIDS and smoking, drug addiction, and maternal age of younger than 20 years. Breastfed infants have a lower incidence of SIDS. Sleep position has been associated with SIDS, along with congenital abnormalities, including sleep apnea and depressed ventilator response to increased carbon dioxide or decreased oxygen levels. Sleeping in a prone position possibly predisposes the infant to oropharyngeal obstruction or affects ventilatory arousal.

Soft polystyrene-filled mattresses or pillows have the potential to cause suffocation in the infant sleeping in a prone position.

There are a large number of risk factors and some parents could be offended if the nurse is careless about presenting the information. The nurse could opt to say, “Because we care about all babies, we give all parents the same information about preventing SIDS” or “The cause of SIDS is unknown, but your baby has several risk factors that have been associated with SIDS.” Or “Would you like additional information about SIDS and risk factors?”

The nurse is likely to decide that the approach will need to be modified for individual parents; assessment of responsiveness to information is essential. a. Signs/symptoms—tightness in chest, wheezing, shortness of breath, tachypnea, dyspnea, coarse breath sounds, restlessness, anxiety, dark red color of the lips, cyanosis, paroxysmal cough, fatigue, and diaphoresis b. Diagnostic tests—physical examination, pulmonary function tests, laboratory studies, and radiographic examinations c. Medical treatment—medications (metered-dose inhalers) including bronchodilators and steroids, chest physiotherapy, and allergy testing

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d. Nursing interventions—vital signs, hydration, positioning (high Fowler’s), adequate rest, breathing exercises, teaching to avoid allergens and undue exertion a. Most common cause—bacterial infection b. Classic signs and symptoms—positive Kernig’s and Brudzinski’s signs, nuchal rigidity c. Diagnostic test—lumbar puncture to test cerebrospinal fluid (CSF) d. Medical treatment—IV antibiotics, isolation, fluids, antipyretics, seizure precautions e. Preventive measures—Hib vaccine, prophylactic rifampin a. Sources of lead—lead-based paint or caulking, contaminated soil and dust, drinking water that comes through lead pipes b. Prevention—recognition of sources/hazards, community education c. Screening—blood levels, history, and environmental assessment for all children ages 6 months to 6 years d. Parent guidelines to reduce lead levels— Restrict access to hazards, reduce dust, wash hands and toys, run water from cold water tap, avoid certain pottery and ceramic ware, provide regular meals. a. What are your fantasies about suicide?

When have these thoughts occurred?

How long have you been having these thoughts?

Do you have a plan?

Do you have access to the means to carry out the plan?

Have you shared your thoughts with your parents or any other adults? b. The threat of suicide should always be taken seriously. If the child tries to laugh it off or minimize the threat, the nurse would gently explain the need for followup as an act of caring and concern. The nurse would also tell that child about who must be informed. In this case, the parents will need to be informed first and a health care provider should be identified by the parents. If there is a policy at the school for informing school administrators the nurse would follow those instructions. In extreme cases, for example, if the child threatened to leave or to harm self or the nurse, the police could be summoned and

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Answer Key 95

the child could be escorted to the hospital for her own safety.

a.

CHAPTER 32—HEALTH PROMOTION AND CARE OF THE OLDER ADULT Short Answer 1.

Refer to Table 32-3 on p. 1075. Examples of changes in the integumentary system are decreased vascularity, sebaceous gland function, sweat gland function; subcutaneous fat thickness; hair pigment and growth; and hormone production.

2.

Refer to Table 32-4 on p. 1077. Changes in the gastrointestinal system are an increase in dental caries and tooth loss, and decreases in gag reflex, muscle tone of sphincters, gastric secretions, and peristalsis.

3.

Refer to Table 32-5 on p. 1081. Changes in urinary function are a decrease in the number of functional nephrons, blood supply, muscle tone, and tissue elasticity, and an increase in prostate size.

4.

Refer to Table 32-6 on p. 1083. Examples of changes in cardiovascular function are a decrease in cardiac output and elasticity of heart muscle and blood vessels, and an increase in atherosclerosis.

5.

Refer to Table 32-7 on p. 1085. Changes in the respiratory system are decreased body fluids, number of cilia, tissue elasticity, and number of capillaries, and increased calcification of cartilage. Kyphosis, muscle weakness, and thoracic rigidity have an influence on respiratory function.

6.

Refer to Table 32-8 on p. 1087. Changes in musculoskeletal function are decreases in bone calcium, fluid in intervertebral discs, blood supply to muscles, joint mobility, and muscle mass.

7.

Refer to Table 32-9 on p. 1090. Changes that occur in the endocrine system are decreases in pituitary excretions, production of thyroidstimulating hormone, production of parathyroid hormone, production and utilization of insulin, and release of testosterone, estrogen, and progesterone.

8.

Refer to Table 32-10 on p. 1091. Reproductive changes include decreased estrogen levels, increased vaginal alkalinity, decreased testosterone, and decreased circulation.

9.

Refer to Table 32-11 on p. 1093. Sensory changes that occur with aging are:

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Vision—decreased number of eyelashes, decreased tear production, increased discoloration of lens, decreased tissue elasticity, decreased muscle tone b. Hearing—decreased tissue elasticity, decreased joint mobility, decreased number of hair cells in inner ear c. Taste and smell—decreased number of papillae on tongue, decreased number of nasal sensory receptors Refer to Table 32-12 on p. 1095. Neurologic changes are decreases in number of brain cells, number of nerve fibers, and number of neuroreceptors

Table Activity 11. Refer to Table 32-13, p. 1097.

Multiple Choice 12. Answer 1: Patient used to be very engaged with life, but shows a gradual withdrawal from interaction, and the people who know him support this behavior. In the Exchange theory, there is also reduced interaction, but it is based on decreasing value of interaction. In Activity theory, older adults develop a positive concept of self and find new roles.

In Continuity theory, personality remains the same, and behavior becomes more predictable as people age.

13. Answer: 1770 calories/day. (Note to student: If you based your calculation on 14 calories/ pound the answer would be 1820/day.) In a real clinical situation, you might opt to tell the patient to aim for 1800 calories, because it would be an easier number for the patient to remember.

14. Answer 3: Unilateral sudden onset of a cold foot on either side suggests an arterial clot that should be reported for further evaluation. Tissue damage will occur within hours.

Progressive edema suggests fluid retention, the gradual progression makes this symptom somewhat less urgent. Excessive warmth suggests an inflammatory process. Cramping of calf muscles after exertion is also characteristic of arterial insufficiency. All of these symptoms should be reported to the health care provider.

15. Answer 1: Dysphagia is difficulty swallowing, so swallow precautions need to be performed to prevent aspiration, which could lead to pneumonia. Aphasia is difficulty understanding words, which may improve as the condi-

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Answer Key 96

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tion improves. Presbyopia is farsightedness resulting from a loss of elasticity of the lens of the eye. Akinesia is hypoactivity.

Answer 3: Getting up once a night to urinate would be considered normal for this patient, but a change of pattern to 4-5 times a night suggests possible infection or other causes that need medical treatment. The other options are good suggestions for dealing with the routine inconvenience of nocturia.

Answer 2: Antibacterial soaps are harsh and will worsen the pruritus. The other options are all correct interventions for pruritus.

Answer 1: Patients with dysphagia will frequently do better with semi-solid foods, rather than thin liquids. Feeding quickly, placing in a low Fowler’s position, or talking while eating increase the risk of aspiration.

Answer 1: Alendronate (Fosamax) is prescribed for the treatment of osteoporosis. Fractures can occur from routine activities such as bending or lifting; thus gentle handling is necessary. Purse-lipped breathing is useful for patients who have COPD. Frequent pulse checks would be appropriate for patients with cardiac disorders, fluid imbalance, or for any who are critically ill or injured. Kegel exercises help patients who have stress incontinence.

Answer 4: Kyphosis is a curvature of the spine that decreases overall air exchange and secretions are retained. Heartburn is related to decreased muscle tone of sphincters in the GI tract. Swelling of the ankles can be caused by decreased heart function or fluid retention; for example, from renal system problems. Weak stream of urination is related to incontinence or enlarged prostate.

Answer 1, 2, 3, 5: Primary prevention focuses on the strengths, resources, and abilities of the person; thus modifying lifestyle factors and getting recommended vaccinations are included. Treatment of disease to prevent further deterioration is considered secondary prevention.

Answer 3: When a certain amount is reached, Medicare recipients must pay 100% of the cost of prescriptions up to a yearly maximum out-of-pocket limit. After the maximum limit is met, the coverage gap ends and the prescription plan pays a percentage of the cost of covered drugs again. The statement about the dentist is not true. Generic medications are less expensive and therefore preferable if okay with prescriber. The Affordable Care Act has

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yet to demonstrate advantages or disadvantages, but at this point it is unwise for seniors to trust that all is well.

Answer 4: Conflict within the family is an additional source of stress and her comment suggests that others are complaining but not helping. The other statements indicate that the daughter is experiencing some strain; however, there is evidence of coping and adaptation.

Answer 3: Setting realistic short-term goals empowers people to move forward and accomplishment increases self-esteem. Cheerful behavior will come across as insensitivity to loss and grief; thus it is inappropriate at this time. Being alone and thinking about losses will exacerbate the problem. This behavior should be limited. Assessment of patient’s and family’s feelings and thoughts about living together should be assessed before making this type of suggestion.

Answer 2: Shifting the patient’s weight mimics movement that would normally occur. The other options may also be appropriate, but are not as important as repositioning.

Answer 1, 2, 3, 5: Having the patient slide across wet linens creates a shearing force that damages underlying tissues. Tape should be used very sparingly, because the skin is easily torn when tape is removed. Patient should be handled gently; firm grip on the forearm is likely to cause bruising. Asking for lifting help is appropriate.

Answer 2: Diminished gag reflex increases the risk for choking and aspiration. Function of other reflexes is unrelated to gag reflex in this circumstance. Pain in the neck area is not anticipated with a diminished gag reflexes.

Nutritional status would be a consideration if the patient is having ongoing difficulty swallowing.

Answer 4: Encourage whole grains, fruit and vegetables, and high-quality protein. Fats, refined sugars, and products made with white flour offer more calories with less nutritional value. Fruits are preferred over juices because fresh fruits offer more fiber and less sugar per serving.

Answer 2: Controlling incontinence is the issue; thus proposing a voiding schedule is the most useful suggestion. Use of adaptive devices are for patients who have trouble holding or grasping a cup. Dividing fluid is used when patients are on fluid restriction. Edu-

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Answer Key 97

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cating about fluid intake is the second best option and many people recognize that they need to drink more fluid, but have a variety of excuses for not doing so.

Answer 1: Gastric motility can slow with age, so exercise is one way to stimulate peristalsis.

The other options are interventions that address loss of appetite and difficulty achieving adequate nutritional intake.

Answer 2: Being overweight could contribute to gastric reflux and achieving ideal body weight will help to solve the problem. Patients who do not drink milk need education about alternative calcium sources. Changes in bowel habits or sores that won’t heal need additional medical evaluation, possibly for cancer or other disorders.

Answer 3: Assess the bowel pattern first; problems are often reported when there is a minor deviation from what is perceived as normal elimination. Other options might be considered based on assessment findings.

Answer 1, 4, 5, 6: Blood pressure medication, body mass index of 18.5-24.9 kg/m2, adequate sleep, and avoiding secondhand smoke are appropriate measures. Complex carbohydrates and vegetable protein are desirable. Exercise is recommended for most days of the week.

Answer 4: Patients with COPD frequently have thick sputum, which is difficult to cough up. Making sure that patients are well hydrated is the best way to thin secretions. The other options are good teaching points for patients with COPD to help ensure adequate oxygenation.

Answer 3: The nurse should assess for other signs and symptoms, especially those indicating a source of infection such as urinary tract infection or pneumonia.

Answer 2: Assess for other injuries before attempting any interventions or reporting to health care provider. Resist the urge to immediately put the patient back into bed. Additional helpers are needed and injuries can be worsened by movement.

Answer 2: The symptoms that the patient described are characteristic of adult-onset diabetes and hyperglycemia is the laboratory result that is expected. Elevated thyroidstimulating hormone level would be associated with hyperthyroidism. Elevated estrogen level is not expected for a 56-year-old woman; thus follow-up studies would be required.

Elevated serum cholesterol is a risk factor for

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coronary artery disease, which could be concurrent with diabetes.

Answer 3: Total cholesterol level of 130 g/dL increases risk for cardiac disease and saturated fat should contribute no more than 7% of calories/day. Fluid and fiber are more directly related to bowel function, but this is generally good advice. Body mass index is important, but people with normal or below-normal weight can have elevated cholesterol levels.

Answer 1: Levothyroxine is used to treat hypothyroidism. Without the medication, the symptoms of hypothyroidism will return.

Heat intolerance, diarrhea, and weight loss are symptoms of hyperthyroidism.

Answer 4: Generally, questions about sexuality should occur after talking about other body systems. This allows time for the nurse to establish rapport with the patient and feelings of discomfort should decrease. If the patient gives permission, this may also decrease the nurse’s feelings of discomfort. Asking for help is appropriate if unable to complete a task.

Self-assessment should occur before the occasion to interview arises.

Answer 1: As the patient reads the newspaper out loud, note accuracy of content and the distance that the patient holds the paper while reading. Ask if the print seems clear. Suggest a follow-up appointment as appropriate. Yellowing of the lens may affect color perception.

Noting pupil reaction is not incorrect, but this data is less relevant.

Answer 4: Primary open-angle glaucoma occurs very gradually and painlessly; visual loss begins with deteriorating peripheral vision.

The other symptoms are associated with acute angle-closure glaucoma which is a medical emergency that requires immediate attention to prevent blindness.

Answer 2: Sitting directly in front of the patient allows the patient to watch the lips and to look at facial expressions. Standing in front of the window creates a glare that interferes with visualization of the nurse’s face and lips.

Sitting beside the patient may be culturally offensive; also visualization of nurse’s lips will be difficult. Standing over the patient frequently occurs in the hospital, but this is never the best position from the patient’s point of view if it can be avoided. In addition, continuously leaning in to eye level would be very poor body mechanics for the nurse.

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Answer Key 98

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Answer 1: Sudden change of behavior suggests a medical problem such as infection, or a metabolic, oxygenation, or perfusion disorder.

The health care team needs to quickly identify the cause and initiate treatment. The patient is temporarily restrained because of heightened risk for injury to self or others. Other patients are also at risk for injury, but their issues should be managed without restraints.

Answer 2: Parkinson’s disease is characterized by tremors, muscle rigidity, and hypoactivity. Intellectual function is not impaired.

Patients with Parkinson’s disease may have trouble articulating pain, but the disease itself is not characterized by pain.

Answer 3: Hemianopia is blindness in half the visual field; thus if patient does not turn head to look at the whole tray, only half of the food will be visualized. Sitting up and focusing on chewing and swallowing are strategies for dysphagia. Difficulty manipulating utensils or small objects is related to hemiplegia.

Answer 1, 2, 4, 6: An increased number of medications (including over-the-counter), prescribers, or pharmacies contribute to risk for the patient. A pill box is a reminder tool that will not prevent polypharmacy, but may prevent overdosing or underdosing due to forgetfulness. Seeing the primary health care provider on a regular basis is a good way to prevent the problems associated with polypharmacy.

Answer 4: The nurse should follow up to find out the meaning of “whatever they want with you.” This is a cryptic statement that could underscore a minor issue or possible abuse.

Being left alone may need investigation if there appears to be a safety issue; however, the patient could be lonely. This is not an abuse issue, but the daughter may need suggestions about increasing social opportunities for her mother. Being invited to visit or asking for lunch are benign comments that could be related to the patient’s age.

Answer 3: Explaining the benefit of ambulating is the best response. Negotiating for promises of future behavior invites manipulation.

Being defensive or shifting the responsibility to the helath care provider invites further arguments.

Answer 3: One of the goals is to reduce emergency visits due to falls. Checking blood pressure at least every 4 hours and reporting new symptoms are expected actions related to

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good nursing care for any patient. Breast selfexamination should be done monthly.

Answer 2: OBRA requirements include comprehensive resident assessments, increased training requirements for unlicensed assistive personnel (UAP), greater number of nursing staff, availability of social workers, standards for nursing home administrators, and qualityassurance activities. Availability of an ombudsman is from the Long-term Ombudsman Program which is a national effort to support the rights of residents and facilities. Disrepecting a resident is related to residents’ rights.

Dealing with employees who disrespect others is usually the responsibility of the nurse manager. Immediate reassignment of a room would be a common event.

Critical Thinking Activities 52. Examples of nursing assessments are: a. Integumentary—Observe skin for signs of dryness, tears, lesions; observe condition of hair and nails. b. Cardiovascular—Observe for edema and chest pain, monitor vital signs, check peripheral pulses. c. Respiratory—Observe respiratory effort, monitor for activity tolerance. d. Gastrointestinal—Observe integrity of oral cavity, assess characteristics of bowel elimination, check intake and output (I&O) and weight. e. Urinary—Observe for frequency, quantity, color, or discomfort when urinating. Ask about incontinence or problems with retention or difficulty passing urine. f. Musculoskeletal—Determine ability to perform activities of daily living, range of motion; check for muscle weakness, paralysis, and pain. g. Neurologic—Observe behavior and responses; check for presence of pain; identify level of awareness. h. Vision and hearing—Observe for eye irritation or discomfort. Ask about blurring, decreased night vision, or sensitivity to glare. Assess visual acuity and use of corrective lenses. For hearing, ask about subjective loss of hearing. Note behaviors, such as turning up volume on television, or failing to respond when spoken to.

Note balance when walking or performing position change.

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Answer Key 99

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a.

Do you have sensations of heartburn or nausea?

How’s your appetite?

Describe your typical 24-hour dietary pattern. Any changes?

Have you recently gained or lost weight?

If so, how much and over what time period?

Have you had any pain or cramping? If so, please describe.

What is your typical bowel pattern? Any changes? If so, please describe.

Have you noticed a change in the color or consistency of your stool? If so, please describe. b. For some patients, gastric reflux can be controlled by eating small meals, avoiding eating before bedtime, elevating head of bed, and maintaining ideal body weight. For the older adult with constipation, the nurse should promote adequate fluid intake, exercise, and a diet that contains fiber. Such foods include vegetables, fruit, and whole-grain bread. a. There is no right or wrong answer to this type of question. Your reaction to this question is likely to be based on personal experiences. Consider that the nurse appears to have entered the job with an open mind. At that point, she had no reason to judge people according to age or any other criteria. She was open to the experience of interacting with and learning from others. After she begins to feel more comfortable, she gravitates towards people whom she likes and enjoys. This is normal and expected behavior. The older staff members are then defined as being rigid and slow. Based on their behavior, the nurse then superimposes that impression on the older nursing student. Thus, it appears that the nurse is guilty of ageism, at least toward the nursing student. b. In order to make the situation better, let’s go back to where the nurse decides that the older staff members are rigid and slow. This small sample of older nurses may be excessively rigid and slow, but they are coworkers so focusing on their strengths, rather than their deficits, would be one strategy. If there is truly a problem (i.e., patient safety), then talking to the nurse manager is another option. The nurse could also examine her own values

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to see if there are cultural, ethnic, or age factors that are influencing perception of others.

Finally, the nursing student deserves a chance that is not clouded by the behavior of others.

The husband and wife are in the age group that has high risk for falls. The wife has already fallen once, so the nurse would gather information about what contributed to that fall, because history of falls is a risk factor.

Both take blood pressure medication, so orthostatic hypotension may be a problem. Areas of the house are dark and there are many possessions in the house that may create obstacles (and need upkeep). Stairs are problematic. For suggestions for fall prevention, see Safety Alert, p. 1101.

CHAPTER 33—CONCEPTS OF MENTAL HEALTH Fill-in-the-Blank Sentences 1.

Mental illness 2.

50 3. schizophrenia 4. psychotherapeutic 5. housing; crisis Multiple Choice 6.

Answer 2: Displacement occurs when emotions are expressed toward someone or something other than the actual source of the emotion. Projection is attributing to others undesirable characteristics that the person has, but does not want to admit possessing.

Identification incorporates a characteristic (thought or behavior) of another individual or group. Reaction formation is conscious behavior completely opposite to the unconscious process.

7.

Answer 4: Regressive behavior is demonstrated by a return to behavior of an earlier age or stage of development. Laughing about abuse would be a manifestation of dissociation. Acting as though incontinence did not occur is an example of repression. Aggression can be sublimated by competitive participation in sports.

8.

Answer 2: Anxiety can be defined as a vague feeling of apprehension that results from a perceived threat to the self. Stress is the nonspecific response of the body to a demand.

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Answer Key 100

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Crisis can be defined as an unstable period in a person’s life characterized by the inability to adapt to a change from a precipitating event.

Mental illness or disorder is a manifestation of dysfunction (behavioral, psychological, and biologic).

Answer 1: The adolescent who is participating in activities and has reasonably good grades is demonstrating success at school, which is a possible positive factor. The other three adolescents have some evidence of dysfunctional relationships: extreme sibling rivalry, lack of mother-child bonding at birth, and excessive parental expectations.

Answer 2: Setting small realistic goals is evidence of good mental health. Denial (“don’t have any problems”) is way of coping, but for substance abusers it is the most common overly used defense mechanism. If one’s behavior is contingent on another’s success, then the relationship is not healthy. Rationalization is another defense mechanism and the speaker may also be projecting feelings of being judged. Both can be used as excuses for continued substance abuse.

Answer 3: In every care setting on a daily basis, the nurse will care for patients who are vulnerable to stress, anxiety, and depression.

In addition, recall that more than 50% of the population in the US is likely to have a mental health disorder in their lifetime. The other options are also true or partially true.

Answer 2: The superego guides moral action and allows the nurse to think and act at the highest level of abstraction. The ego is realitybased and would cause the nurse to be focused on duties, although the id may mediate to cause the nurse to ignore requests if those requests cause unpleasantness or threats to self-interest. The id would minimize an error, because it would be easier and less painful than taking responsibility for it. Obtaining CEUs is a reality-based activity driven by the ego.

Answer 3: The nurse could recall the memory, but generally the memory, especially the painful parts, is repressed. This repression allows the nurse to have a relatively happy life. The unconscious level holds memories that are not readily recalled. The conscious level allows vivid thoughts and memories. The id part of the personality would drive attempts to experience pleasure and block pain.

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Answer 3: Panic level of anxiety is demonstrated by extreme terror, possible immobility, and a potential danger to self and others. The patient who is assisting another with a wheelchair is using mild anxiety to problem-solve and move towards productive action. The patient walking towards the safe area is probably arguing to relieve tension and increase feelings of control. The patient who is searching for the wedding ring recognizes that there is a problem, but severe anxiety is distorting her ability to make a logical judgment.

Answer 4: If test results have a greater impact on future life events, than the degree of anxiety is likely to be higher. The student who has done well over the semester has a positive history with studying and testing. This student probably would have done better with sleep, but knows that he/she is likely to be okay. The student who sees the test as another hurdle is not threatened by the testing process, but is more likely to see the test as a relatively mundane event. The smart, busy student is also likely to have a lot of stress because of the multiple stressful factors, but this student may have developed coping strategies over time that have helped him/ her juggle multiple stressors. For example, the student may recognize that excellent grades are less important than passing grades when considering the context of his/her life circumstances.

Answer 3: When a patient enters the hospital, he/she loses normal social, employment, and family roles. Normal clothes, daily routines, and control over own body are taken away.

Acknowledging difficulties and offering self are two forms of therapeutic communication. Offering to call the health care provider deflects the patient’s concerns away from the nurse. Suggestion of wearing own clothes is okay, but the nurse should assess first, because the clothes may be the smallest issue.

Leaving an angry patient does not help meet emotional needs.

Answer 2: First the nurse would assess for factors that may constrain the patient from fully participating in social interactions. Based on the assessment findings, the nurse may use the other options.

Answer 2: “Did something happen?” Is a closed question and generally open questions are preferred; however, the child is young and may have some difficulty fully articulating a

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Answer Key 101

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problem at school. The nurse would assess the child’s nonverbal behavior as he/she answers the question. The other questions might also be used during the interview if there seems to be a problem at school.

Answer 1: Validating the son’s feelings helps him to recognize that even though the situation is complex, he is not alone. Listening to him is supportive and therapeutic. The nurse could consider using the other options to assist this family.

Answer 4: Standing close allows the nurse to assess the wife’s needs and nonverbal behavior. Closeness, touching, and hugging can be therapeutic if the wife is receptive to physical touch from nursing staff. The nurse would ask if the wife needs assistance to notify family/ friends before initiating the call. Making the patient comfortable and pain-free will help to comfort wife, but first the nurse should address the wife’s immediate emotional distress.

Antianxiety medication is not needed at this time.

Critical Thinking Activities 21. a. In a mild anxiety state, the body is readied for action and reaction to danger.

Stressful demands are addressed with problem-solving and constructive action.

Mild anxiety is common and actually useful in situations where motivation results in purposeful action. For example, it is likely that most nursing students are mildly anxious prior to an examination, so they focus on the material and devote more time to studying. b. In moderate anxiety, tension is increased, but perception is decreased. The person is alert to specific information and may feel irritable with some physical signs such as headache or increased vital signs. An example of moderate anxiety is the person who has waited all day long in an airport after repeated delays in flights and has a relatively urgent need to reach his/her destination. c. Severe anxiety manifests as a narrowing of perceptual field, with distortions in communication and a feeling of impending danger. An example of severe anxiety is a bystander at the scene of a fatal accident who is trying to call 911, but is having trouble clearly communicating the situation to the dispatcher.

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d. Panic anxiety is characterized by terror, possible immobility, and potential for harm to self or others. An example of panic would be a woman trapped in a burning building who is unable to move or follow the directions of rescuers. e. Possible coping responses are overeating, oversleeping, overfunctioning (e.g., working excessive hours), drinking, smoking, withdrawal, seeking out someone to talk with, yelling, exercising or performing other physical activity, fighting, pacing, or listening to music. Defense mechanisms are listed in Table 33-1, p. 1117. f. Examples of healthy coping could be seeking someone to talk to. This behavior is reinforced by encouraging and identifying people who are willing to listen and be supportive. Exercise is another example of healthy coping; help the person identify how he/she feels after exercise and encourage regular “preemptive” physical activity. The circumstances of unhealthy behaviors such as drinking or smoking should be identified. This will help the individual recognize when and how the stress causes these unhealthy responses. a. Refer to Box 33-7 on p. 1120. Assessment of emotional status includes the person’s general appearance, behavior, speech pattern, thought content, mood and affect, sensory function, insight and judgment, and potential for harm to self or others.

Also ask the husband how Martha used to respond to stress or change when she was younger. Current behavior may be an exaggeration of behavior at a younger age. b. Older adults may experience social isolation, exaggeration of personality and behaviors, losses related to role, depression, and addictions. Care must be taken in assessment not to mistake changes that occur with aging, such as sensory changes, as manifestations of disorientation or maladjustment. For Martha, withdrawal and helplessness may be a result of the recent changes or losses experienced during hospitalization.

The mentally healthy individual can successfully adapt to change, set realistic goals, problem-solve and enjoy life. Being able to juggle the schedule, assignments, and demands of nursing school would be an ex-

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Answer Key 102

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ample of successful adaptation to change. Deciding to enter nursing school and graduate within the designated amount of semesters is a realistic goal. Balancing your finances with tuition and cost of living is an example of problem-solving. Enjoying life is more difficult in nursing school, but it is likely that as a nursing student, you are enjoying the interaction with classmates.

In theory, deinstitutionalization was intended to be a humane and rational way to address the needs of patients with mental illness. The idea was to have patients return to live and function in the community with supportive services. Unfortunately, the lack of funding and abrupt closure of facilities resulted in large numbers of people being turned out into the streets with few skills and no resources.

People with chronic mental illness do better if family is available to remind them about medication, appointments, etc., and to help them navigate the community mental health system. The prison system has had to absorb some of these individuals for behavioral issues that are more related to mental health disorders than to criminal intent.

CHAPTER 34—CARE OF THE PATIENT WITH A PSYCHIATRIC DISORDER Matching 1. e 2. h 3. a 4. j 5. b 6. c 7. i 8. f 9. d 10. g Fill-in-the-Blank Sentences 11. disorganized thinking 12. anhedonia 13. alogia 14. flat affect 15. Apathy 16. multiaxial True or False 17. False. They usually do have insight.

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False. Behavior that indicates a persistent desire to be the opposite sex is termed transsexualism.

False. One in every 10 are affected.

True

Multiple Choice 21. Answer 2: During the manic phase, the patient will display excessive energy; thoughts will rapidly shift from topic to topic. Physical motion can be excessive to the point of exhaustion. In the acute phase, the nurse must assist the patient to stay focused enough to eat and rest as much as possible. Inconsistency increases contention and agitation.

22. Answer 4: Drug therapy using clomipramine (Anafranil) has been of great value in treating OCD. 23. Answer 2: Reduced salt intake is a possible contributor to lithium toxicity.

24. Answer 4: The best response is to state reality and then the nurse conducts further assessment. The nurse may try to find the underlying feeling, but should try to phrase questions that do not validate the reality of voices. For example, “What is the reason for not eating?”

If the patient persists in talking about the voices, then redirecting is appropriate. For example, “Ignore the voices and come and help me wipe off the lunch table.”

25. Answer 3: The nurse recognizes that going to meet the wife (who is dead) could be a veiled suicide threat, a metaphor, a casual remark, or part of a hallucination or delusion. Because of the potential for suicide, this patient needs priority assessment. The nurse also needs to assess the content of the message from God as a possible command hallucination to harm self or others.

26. Answer 4: Hallucinations are considered a positive symptom; sensory distortion without a stimulus. Nurse should assess the patient for possible sources of body odor or infection, as there is also a possibility of illusion, which is a misinterpretation of a real stimulus. Avolition is a negative symptom. Akathisia is a side effect of some antipsychotic drugs.

27. Answer 2, 4: Schizophrenia is frequently accompanied by psychotic features that can include paranoid delusions, hallucinations, and severe disorganized thinking. Phobias are usually associated with anxiety disorders.

Mania is usually associated with bipolar dis-

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Answer Key 103

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order. Redoing is a behavior associated with compulsions.

Answer 2: The patient is compelled to drive back and check the lock. The patient is obsessed by the thought of disordered towels.

Voices in the head are a type of hallucination.

Being afraid of spiders is a phobia.

Answer 4: The woman is hypomanic and is likely to feel very good about herself and the world. At this point she has less incentive to seek medical attention, even though she could progress to mania.

Answer 1, 2, 4: A person with neurosis remains oriented to reality, with some degree of distortion of reality manifested by a strong emotional response to the trigger event. Various complaints of nervousness or emotional upset, compulsions, obsessiveness, and phobias are common with a neurosis. A neurotic person will often exhibit poor self-esteem and have social relationships that suffer due to the various complaints noted. Being out of touch with reality and having impaired judgment are more associated with psychosis.

Answer 1: The information has to be shared with other team members to activate a multidisciplinary plan. Disclosures of harm to self or others cannot be kept in confidence. Suggesting a spiritual advisor may be appropriate after assessing the patient’s spiritual beliefs.

Documentation and verbal discussions will both occur.

Answer 3: Talk to the patient first to assess the gift-giving. Giving valued sentimental items in conjunction with “remember me” could be a signal of suicidal intent. The other options might be used after the initial assessment.

Answer 2: All of these people are having stress related to a life event, but psychologically, the person who has just been released from prison faces the greatest changes in integrating back into society and is likely to have fewer resources or skills to help him/her adapt.

Answer 2: Patients who have schizophrenia display concreteness and will have trouble with metaphors or similes or idiomatic language. Patients with dementia will also demonstrate concreteness. (Note to student: The nurse might consider talking to the staff member about use of language forms when talking to patients. The goal of the unit is to move patients toward normal everyday conversation, but it is also likely that other patients would

35.

36.

37.

38.

39.

have laughed at the patient who hopped around.)

Answer 2: The nurse would talk to the teenager and assess for other symptoms such as affect, emotional lability, and speech patterns. Content, consistency, and rationality of beliefs and ideas may also give information.

The nurse can then point out to the neighbor the normal findings and reinforce the need to follow up with the provider. Advise the neighbor to tell the provider about family history. Comparing current behavior to previous behavior is not very useful, because normal adolescent behavior is generally quite different from previous ages. The neighbor should be able to independently judge whether the son’s religious beliefs are consistent with the rest of the family.

Answer 1: Psychosomatic illness refers to a physical disorder arising as a result of a psychological trigger. Posttraumatic stress disorder is related to experiencing an extreme life-or-death event that results in symptoms that recur with triggering stimuli. Generalized anxiety disorder is characterized by excessive worrying about daily aspects of normal life.

Bulimia nervosa is an eating disorder.

Answer 4: The nurse can acknowledge that the feeling of being listened to would create anxiety and fear. The other actions make it appear that the nurse also believes that “they” are listening. Moving to the garden could be an option, but the nurse would say, “I don’t think there is a problem with the intercom, but it’s nice day; we could go to the garden if that would be more comfortable for you.”

Answer 4: The nurse’s goal is to reflect reality in the most accurate way possible, thus the nurse makes a general statement about how television advertisements affect all viewers. The nurse needs to recognize that ideas of reference are theorized as demonstrating the patient’s need to feel special. “He wasn’t really talking to you” demeans the patient’s feelings. “You can’t buy it right now” is reality, but signals the nurse’s agreement that the advertisement was just for the patient. Asking about interest in motorcycles is possible if the nurse feels that the patient would benefit from a “normal” conversation topic.

Answer 2: The nurse must first assess what the patient considers as disturbing. Although closing the door, turning off lights, and decreasing sources of sound are good general

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Answer Key 104

40.

practices, the patient with an anxiety disorder may actually become more anxious if left alone in the dark to contemplate tomorrow’s surgery.

Answer 2, 3, 4: A very small amount of current induces a controlled and brief grand mal seizure. Confusion and memory loss are expected, but both are transient. The patient does not experience pain and the treatments are frequently done on an outpatient basis.

Critical Thinking Activities 41. a. Refer to Box 34-1 on p. 1130. Warning signs of suicide are withdrawal from family or friends, talking about death or suicide, giving away prized possessions, drug or alcohol abuse, personality changes, signs of depression, and previously failed suicide attempts. b. Refer to Box 34-1 on p. 1130. Assess both patients for a plan and means to carry out the plan. (Note to student: A detailed plan with a realistic means to carry it out increases the risk.) Precautions to be implemented for the elderly resident include removing articles that could be used for suicide (shoelaces, sharps), removing furniture, moving patient close to nurses’ station, checking the patient every 15 minutes, obtaining order for 1-to-1 observation as necessary, instructing visitors not to leave gifts, making sure all medication is swallowed, attending the patient during meals (silverware), and making frequent therapeutic verbal contact. The patient with quadriplegia will need some different interventions. For example, family counseling may be needed, because the resident may try to enlist someone from the family to assist in the suicide.

The resident could also stop eating or start refusing treatments such as antibiotic therapy for infections or even routine hygienic care. Frequently checking the patient and therapeutic communication are necessary, even if the nurse determines that the likelihood of suicide attempt is low because of the quadriplegia. Both patients may benefit from additional consultation by the clinical nurse specialist.

42. a. Possible outcomes for a patient with depression are verbalization of feelings, completion of ADLs, participation in

group activities, and no evidence of suicidal thoughts. b. Specific treatments for a patient who is depressed are antidepressant medications, participation in group activities, promotion of self-care (hygiene, grooming), and electroconvulsive therapy (ECT) if the medication is not effective. c. Medications typically used for the depressed patient are Prozac, Desyrel, Elavil, Tofranil, Zoloft, and Effexor. d. Side effects: hypotension, anticholinergic effects, dry mouth, increased or decreased appetite, headache, blurred vision, changes in heart rate/rhythm

Nursing actions: vital signs, check BP, candy or gum for dry mouth, advising patients on MAOIs to avoid foods with tyramine (red wine, beer), monitoring overall effects CHAPTER 35—CARE OF THE PATIENT WITH AN ADDICTIVE PERSONALITY Matching 1. c 2. e 3. f 4. a 5. i 6. b 7. d 8. g 9. j 10. h True or False 11. False. It is possible to suffer from more than one addiction at the same time. An example is the alcoholic person who is also a smoker and a compulsive gambler.

12. True 13. False. There has been a decrease in alcohol use over the years that experts attribute to education of the public and laws set forth to limit availability to minors.

14. True 15. True 16. False. Marijuana is the most commonly used illicit drug in the United States.

17. False. Currently, there is no mandatory reporting for suspected abuse. Healthcare Integrity and Protection Data Bank (HIPDB) requires

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Answer Key 105

federal and state government agencies (including nursing boards and health agencies) to report all final adverse actions taken against a health care provider, supplier, or practitioner.

Short Answer 18. (a) Excessive use or abuse, (b) display of psychological disturbance, (c) decline of social and economic function, and (d) uncontrollable consumption, indicating dependence.

19. (a) Low stress tolerance, (b) dependency, (c) negative self-image, (d) feelings of insecurity, and (e) depression Table Activity 20. Disorders Associated with Alcoholism (See Table 35-1, p. 1149.)

System

Disorders

Gastrointestinal (GI)

Gastritis; pancreatitis; cancer of mouth, esophagus, and stomach; esophageal varices; GI bleeding; malabsorption of nutrition; ascites

Hepatic

Hepatitis, cirrhosis, fatty liver, liver failure, hepatic encephalopathy

Cardiovascular and blood disorders

Hypertension, enlarged heart, high cholesterol, heart failure, portal hypertension, low blood sugar, anemia, poor clotting ability, increased susceptibility to infection

Respiratory

Decreased cough reflex, aspiration pneumonia

Uroreproductive

Prostatitis, impotence, urinary flow problems

Musculoskeletal

Myopathies, bone fractures from falls, joint damage from injury

Neurologic

Neuritis, organic brain diseases such as Wernicke’s encephalopathy and Korsakoff’s psychosis, nerve palsies, gait changes, shortterm memory loss

Multiple Choice 21. Answer 4: A blood alcohol level of >500 mg/ dL (>0.50%) will cause respiratory depression

22.

23.

24.

25.

26.

27.

28.

29.

and respiratory arrest in most people. See Table 16-1, p. 433 and Table 35-2, p. 1159 for additional information.

Answer 4: The nurse would first assess the current consumption of food and drink, which are the usual sources of caffeine. Supplements and over-the-counter medications can also contain caffeine. The nurse may decide to use all of the questions.

Answer 3: If heavy users stop suddenly, withdrawal symptoms occur including craving, irritability, restlessness, impatience, hostility, anxiety, confusion, difficulty concentrating, disturbed sleep, increased appetite, and decreased heart rate.

Answer 4: Withdrawal signs and symptoms are not anticipated for abuse of hallucinogens.

Answer 1, 2, 5: Characteristics of amotivational cannabis syndrome are decreased goal-directed activities, abrupt mood swings, abnormal irritability and hostility, apathy, and decline of personal grooming. Depression, paranoia, and suicidal thoughts or attempts are possible.

Answer 1: The patient is developing a tolerance, which is expected when patients are prescribed opioids for acute pain; abstinence will resolve the problem. The nurse should not recommend medications; this is outside the scope of practice. For patients who have chronic pain, continued opioid prescriptions can result in addiction, but at this point, the patient is still having acute pain. The health care provider is unlikely to increase the dosage, because the fracture is healing; he/she will probably recommend NSAIDs. Answer 3: When friends and family begin to query use, this is a sign that a problem is developing and the nurse can help the friend evaluate behaviors of an alcohol problem.

Substance use becomes a problem when the user loses control and obtaining and using the substance begin to exert control over the individual. The form of alcohol is irrelevant. If the friend has talked to her boyfriend, it is likely that he would deny or minimize the problem.

Answer 4: The nurse paraphrases the mother’s underlying source of guilt. Denial is a normal and typical response for most family members. The other responses are also partially true and the nurse may decide to use them at the appropriate time.

Answer 2: While all of these factors are present in the middle stage, abuse of many dif-

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Answer Key 106

30.

31.

32.

33.

34.

35.

36.

37.

ferent types of substances is most likely to hasten progression to the late stage.

Answer 3: Many Asians, American Indians, and Inuit have deficiencies in the enzymes that metabolize alcohol. Alcoholism is higher in these ethnic groups than in the general public. Jews, Mormons, and Muslims have very low rates of alcoholism, whereas the French and the Irish have high rates.

Answer 4: All of these patients have serious problems; however, alcoholism is a national health problem surpassed only by heart disease and cancer. In addition, the increasing number of elderly patients who need complex health care services is a national issue.

Answer 1: All of these statements about alcohol are true, but vitamin B1, folic acid, and vitamin B12 deficiency are caused by the prolonged use of alcohol, which has a toxic effect on the intestinal mucosa that results in decreased absorption of these nutrients.

Answer 3: If the nurse suspects alcohol withdrawal, then the nurse gives the patient a matter-of-fact explanation about symptoms and directly asks the patient about alcohol use. Assessing for pain is a correct action, but recall that the symptoms could also be related to other conditions such as pulmonary emboli, anxiety, or hypoglycemia. The nurse would call the provider to report findings. A blood alcohol level is not useful if withdrawal is occurring. Making the medical diagnosis is out of the scope of nursing practice, but gathering data to give to the health care provider is a nursing responsibility.

Answer 1: Delirium tremens (DTs) is a complication of alcohol withdrawal. The risk of death from this complication is as high as 15%, even with treatment.

Answer 2: Denial is the most commonly used defense mechanism used by substance abusers.

Answer 1, 2, 3, 4, 6: Elevated liver enzymes, hypoglycemia, abnormal clotting times, and abnormal blood protein levels occur with alcoholism. Magnesium levels will be decreased in some cases. It is not uncommon to find anemia.

Answer 2: Respiratory depression is the most serious problem and the airway should be assessed and managed to prevent aspiration.

The other actions are also important.

Critical Thinking Activities 38. a. Possible contributing factors to alcohol abuse include genetics, deficiencies in hepatic enzymes, personality traits, or cultural/familial behaviors. b. The CAGE questionnaire has four questions that can be used to assess alcoholism. Two or more “yes” responses to any of the four questions suggests alcoholism.

(See Box 35-2, p. 1149.) c. The family can experience anger, frustration, guilt, or denial. Family can inadvertently contribute to alcohol abuse of affected member with codependent behavior, such as making excuses or overcompensating. Family members can be advised to seek help for themselves.

39. a. At this point, the nurse may decide to continue observing for other behaviors that the night-shift nurses display or to collect more data about the patients who were having the pain before drawing a conclusion. Or the nurse may decide to discuss the patients’ reports with a supervisor. b. Specific role-related signs of the chemically impaired nurse are requesting nighttime assignments, making frequent trips to the bathroom, being absent from the unit, being involved in inaccurate opioid counts or noting excessive wasting of opioids, charting illogically or carelessly, having patients who do not get relief from pain medication, and making mistakes in treatments. (See Box 35-10, p. 1160 for additional information.) c. The chemically impaired nurse is referred for a peer-assistance program for treatment and supervision in order to maintain licensure. d. The Healthcare Integrity and Protection Data Bank (HIPDB) is a national data bank wherein federal and state government agencies are required to report all final adverse actions that are taken against a health care provider, supplier, or practitioner. This is an incentive for impaired professionals to seek treatment. e. Nobody wants to be a tattletale, especially if the coworker is a friend. Also, when an incident happens, the morale of the unit is affected. Seeking advice and counseling is helpful during these dilemmas and if injury to a patient is prevented, then the

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Answer Key 107

outcome is positive, even for the impaired nurse who will have to participate in an assistance program and have extra supervision.

13.

CHAPTER 36—HOME HEALTH NURSING

14.

Fill-in-the-Blank Sentences 1. legislative; regulatory; health care 2.

60 3. physical strengths; functional abilities 4.

Medicare

15.

True or False 5.

False. Licensure by the state is only one type of home health agency. Other methods are certification by state or by need and accreditation by an outside agency.

6.

False. Medicare and Medicaid have specific requirements that must be met in order to qualify. People who do not have private insurance or those who cannot pay out-of-pocket expenses must often rely on self, family, or friends.

7.

True 8.

False. Medicaid is coverage for all ages. Medicare is for those over the age of 65.

9.

False. DRGs are used to set a pay rate according to diagnosis for hospitals to receive Medicare reimbursement.

10. True Multiple Choice 11. Answer 4: Occupational therapy will suggest assistive devices such as eating utensils that are easier to manipulate and exercises that that can build fine motor control and coordination. The health care provider would sign the plan of care that would include occupational therapy. Physical therapy assists with issues of mobility, strength, and balance. The home health aide assists with ADLs as needed.

12. Answer 2: “No Smoking” signs should be clearly visible to decrease risk of fire. Waterbased gel is recommended for lips. Disposable equipment should be examined frequently and changed as needed. Once a month is likely to be too long for some items; heat, humidity, hygiene, and maintenance of equipment are factors affecting the equipment. Wool blankets are likely to increase static.

16.

17.

18.

19.

Answer 3: Telehealth is best utilized for patients who need monitoring for standard measurements such as vital signs and blood glucose. The other patients will require a home health professional to go to the home and perform the skill or do the assessment.

Answer 4: For entry into the system, Medicare and Medicaid require an interdisciplinary treatment plan that outlines frequency and duration. The health care provider must have a face-to-face visit with the patient and the provider must sign the plan.

Answer 1: The patient who is able to eat without choking has returned his/her pre-stroke functional ability (restorative). The patient who stops smoking has improved and moved towards a higher level of health (improvement). The patient who is routinely exercising is maintaining current level of health (maintenance). The patient who is compliant with recommended diet is using health promotion information to minimize health disorder (promotion).

Answer 2, 3, 4, 5: The LPN/LVN can perform skills related to medication administration and the ongoing monitoring of parameters such as vital signs, blood glucose readings, and assessment of physical status. Reinforcing dietary information is also appropriate. The RN is responsible for the admission assessment and should review and evaluate the patient’s progress to determine if goals are met or if the plan must be recertified by the health care provider.

Answer 3: Medicare will not cover visits that only involve household chores. The patient must require some skilled nursing or physical therapy service and then a home health aide is able to provide personal care and physical assistance.

Answer 4: The aide should be given specific information about what to look for and what to report. All team members should foster independence rather than doing everything for the patient. The nurse should direct the aide as to type of bath procedure, because the patient may be used to taking a bath, but physical condition now makes getting in and out of the bathtub very dangerous. Instructions to “report problems” is too vague. This puts the aide in the position of having to determine what is or is not a problem.

Answer 3: The supervisor would first ask the nurse to describe a typical home visit to assess

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Answer Key 108

20.

what the nurse is doing and how the time is being spent. Based on the assessment of the nurse’s performance, the supervisor may also consider using the other options.

Answer 1, 3, 4, 5: Home health documentation is similar in purpose to any health care documentation. When quality of care is recorded, assessment and improvement of care can occur through review of documentation. All patient records are legal documents.

Reimbursement is even more closely tied to documentation in home health because of Medicare and Medicaid regulations. Documentation does not replace verbal communication. The family does not have free access to patient records. Rights to privacy continue in the home setting.

Critical Thinking Activities 21. a. The RN should do the initial assessment.

The LPN/LVN works under the supervision of the RN and observes wound healing and performs/teaches wound care, monitors blood pressure, and the patient’s self-care efficacy for management of diabetes. All care and observations are carefully documented to meet the standards of Medicare and third-party insurance companies. b. RN or LPN/LVN must ensure that appropriate instructions are given. Delegation of interventions to assistive personnel in the home can include provision of hygienic care and assistance with other activities of daily living, measurement of vital signs, glucose monitoring, and possibly medication supervision. c. i. Physical therapy—Services provided by a qualified and licensed physical therapist, with the goal of treatment being restorative. ii. Home health aide—A primary skilled or therapy service must be needed before HHA services can be provided.

22. Personal and professional attributes described for RNs also apply to the LPN/LVN. Independent practice is not allowed, but self-direction,

motivation, creativity, clinical proficiency, flexibility, compassion, empathy, and patience are all essential attributes. Good communication skills—both written and spoken—are necessary. The ability to work alone, follow directions, recognize important changes in condition, and assist in patient teaching are needed. It is important to understand and practice the concept of teamwork. Nurses who prefer the structure of the institutional setting and benefit from immediate direction and frequent peer support find the independence of home care practice difficult. (Note to student: Home health may not be the ideal first job for a new nurse because of the level of independence that is required. If you choose to do home health as your first job, make sure that your prospective employer offers a good preceptor program and ongoing clinical support.)

23. Admission to the home health care agency includes a complete patient evaluation, environmental assessment, identification of primary problems, family/support person assessment, determination of level of knowledge about care, involvement of the patient in the plan, notification of patient rights, costs, billing, and information on advance directives.

Differences between home care and acute care admission would be the explanation of costs and billing related to different funding sources. The home environment is considered in the overall discharge planning in an acute care facility, but the home environment assessment is more in-depth and detailed by the home health nurse. Also, the home health nurse is more likely to obtain a better assessment of family and community support.

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Answer Key 109

CHAPTER 37—LONG-TERM CARE Table Activity See Box 37-1, p. 1182.

Terminology 1.

Respite care

Definition of Services to Support Older Adults Scheduled stays for the older adult to give the caregiver a break from the responsibility of providing care.

2.

Daycare

Facilities are frequently used by family members and caregivers who work during the day.

3.

Home health care

Includes homemakers, shoppers, respite care workers, personal care attendants, home health aides, and nursing care staff.

4.

Nutrition programs

Senior centers serve meals or home delivery of one hot meal per day.

Senior centers

Centers that provide recreational activities, lunch, health screening, exercises classes, educational classes, and transportation to and from the site if needed.

5.

6.

Transportation services

12.

13.

14.

15.

Service for grocery shopping or medical appointments.

True or False 7.

False. The need for long-term care arises when an individual is not capable of meeting daily needs independently.

8.

True 9.

True 10. False. PACE has 88 sites in 29 states and requires only that the patient be 55 years of age or older, live in a “service area,” be screened by a group of health professionals, and sign and agree to enrollment terms.

Multiple Choice 11. Answer 1, 2, 4, 6: Activities of daily living (ADLs) include the routines of hygiene, dressing and grooming, toileting, eating, and

16.

17.

18.

ambulating. Shopping would be considered an instrumental ADL. Occasionally, CNAs will assist with shopping; for example, when the patient lives at home. In long-term care settings, this duty would be less common. Socialization is important and will occur as the CNA and nurse interact with the patient, but is not technically considered an ADL. Answer 2: The subacute unit offers the skilled nursing services that the patient will require and he needs these services for a limited time.

Answer 3: OBRA defines requirements for the quality of care given to residents and covers many aspects of institutional life, including nutrition, staffing, qualifications required of personnel, and many others. Use of restraints for confused patients would be a considered a violation of OBRA. The nurse could review, but does not update, the residents’ advance directives. Medicare and Medicaid place many stipulations on long-term care and the goals of these programs are intertwined with OBRA, but the nurse is not responsible to ensure that the residents are qualified for Medicare or Medicaid.

Answer 4: This couple mostly needs help with ADLs; an assisted-living facility would supply their needs, but would also allow them to live in relative independence as a couple with their own belongings in their own private space.

Answer 1, 2, 3, 4, 6: Ideally, everyone except the other residents can be involved in the meeting, because all have a contribution to make to the overall care plan. Including other residents would be a violation of privacy and confidentiality.

Answer 3: A primary concern for any patient population is safety, but for the nursing home residents safety is emphasized because the residents are likely to have physical and cognitive deficits or changes related to aging that increase the risk for injury. Communication, documentation, and assistance are also important.

Answer 1: The RAI is a comprehensive assessment that is done at admission. The intent is to look at all aspects of the residents’ status.

The information is used to develop an individualized plan of care for each resident.

Answer 3: It is typical for summaries to be done monthly. If there were any acute changes noted they would be documented as they occurred.

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Answer Key 110

19.

20.

Answer 3: First, the nurse would ask the family what they have been considering. It is likely that repeat episodes of wandering have triggered some preliminary thoughts or investigation of some options. The other questions could also be used after the family discloses initial ideas and concerns.

Answer 2: For the benefit of the resident, the CNA should be invited to attend. The resident is currently not adjusting to being in the facility, and the positive relationship with the CNA should be incorporated into the plan of care. Also the CNA may be doing something with or for the resident that others should also be doing.

Critical Thinking Activities 21. a. The usual patient or resident in a longterm care facility demonstrates cognitive impairment, incontinence, inability to perform ADLs, and an inability to be supported in a home environment. Residents usually experience cardiovascular disease (hypertension and stroke), mental and cognitive disorders (Alzheimer’s), and endocrine disorders (diabetes). If you see yourself as a good match for these patients, long-term care is an option for you. b. Medications in long-term care facilities may be administered by certified medication aides or technicians because of the large number of residents who require medications. There is also a 2-hour window of administration in this setting because of the volume of administration.

If you are about to graduate from nursing school, the idea of allowing medication aides to do this important duty may make you feel uncomfortable. Delegation, assignment, and supervision of personnel is a learned skill that will come with opportunity and practice. Work beside the medication aide to see how he/ she performs and discuss scope of practice. This will help you develop trust in other coworkers and leadership skills.

22. a. See Box 37-4, p. 1187. b. Funding long-term care is an important issue for most families and it is likely that your family is or will be concerned about this issue. If your grandmother has longterm care insurance, than you are lucky, because many people do not. If your grandmother has any assets, those will

have to be liquidated and used initially.

If that money runs out, she might be eligible for Medicaid. Medicare may cover some of the costs if your grandmother has a specific medical condition that needs treatment; for example, a broken hip. But if she just needs help with ADLs or the functional activities of living, you should not count on Medicare. Many families are paying out-of-pocket for long-term care for their elderly relatives.

23. All nurses need to have an awareness of how legal aspects affect their practice. In long-term care, the nurse will care for the residents for extended periods of time. The residents are more likely to be elderly, possibly confused, and to have given power of attorney to someone or to have a guardian. Elderly residents will frequently rely on health care staff to explain and interpret complex information. The nurse must know who to call and when to call if problems occur. The nurse must make the immediate interpretation of the advance directives when there is illness or injury and will have to make the decision whether to call 911 or to perform comfort measures or other interventions.

In an acute care facility, patients stay a very short time and the goal is to care for immediate needs and then discharge them back into the community. There are usually more resources in acute care facilities for decisionmaking. Decisions such as informed consent for major procedures are handled by the health care provider. While all patients are encouraged to complete advance directives, the directives are usually not needed for the majority of patients whom the nurse cares for on a daily basis. During acute care, the family is frequently at the bedside for a portion of the day and available to answer questions; whereas in long-term care, family is more likely to visit on weekends or holidays.

CHAPTER 38—REHABILITATION NURSING Matching 1. c 2. a 3. d 4. e 5. b

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Answer Key 111

Fill-in-the-Blank Sentences 6. chronic illnesses 7. functional; complications; environment 8. behavioral; image; dynamics 9. goal-oriented (outcome-oriented) 10. adapt 11. charge 12. educator; caregiver; counselor; care coordinator; case manager; patient advocate; consultant; researcher; administrator; manager 13. variants 14. developmental potential 15. early Multiple Choice 16. Answer 1: Level of injury is at thoracic spine T1-T12 and involves paralysis of lower extremities. Paralysis of bladder, bowel, and sphincters; pain in chest or back; abdominal distention; and loss of sexual function are other potential symptoms. Patient will have use of the upper extremities.

17. Answer 3: Level of injury is at cervical spine C2-C7 and involves paralysis of all extremities and trunk, respiratory failure, bladder and bowel disturbance, bradycardia, perspiration, elevated temperature, and headache. Immobility increases risk for respiratory infections.

Cognitive problems are not anticipated unless there is a concurrent head injury or if there are complications such as sepsis or hypoxia secondary to perfusion problems.

18. Answer 1: Patient has sustained a mild brain injury and headache and vertigo are expected findings. Difficulty with judgment and reasoning accompany moderate injury. Prolonged posttrauma amnesia and behavioral problems accompany severe injury and comatose or unresponsive states are characteristic of catastrophic injuries.

19. Answer 3: Autonomic dysreflexia is frequently caused by a distended bladder and removal of the source of irritation should resolve the problem. Sitting or high Fowler’s is the position of choice to decrease intracranial pressure. Giving an antihypertensive medication may result in hypotension once the source of irritation is located and removed. Calling the provider is appropriate if initial nursing measures do not resolve the problem.

20. Answer 2, 4, 5, 6: Passive and active range-ofmotion exercises, anticoagulants, and elastic stockings are preventive measures. Vigilant assessment is needed to identify development

21.

22.

23.

24.

25.

of DVT. Fluid restriction would contribute to the development of DVT. Application of heat could mask the symptoms.

Answer 4: Observation is the best method to determine the level of assistance required.

For example, if the patient can manipulate a spoon, he can probably manipulate a comb.

Asking the UAP to assist as needed is inappropriate delegation and this places the assessment of the patient’s abilities on the UAP. Patient may overestimate or underestimate abilities by self-report; however, asking the patient for input is part of the overall plan.

Reading the documentation is also appropriate, but the patient’s status may have changed and a baseline assessment for rehabilitation therapy is needed.

Answer 4: Sitting in a stable chair will allow the patient to independently manipulate the soap, water, and washcloth. She can wash and rinse herself. Getting in and out of a tub is difficult for many older people. In addition, patients with hip fractures are usually instructed to avoid hip flexion. The patient could lose balance and fall, even if the UAP is very close by. Using a bath basin may be appropriate in some circumstances, but generally patients are encouraged to get out of bed if they are able to, because ambulation prevents many complications.

Answer 3: Most people benefit if distractions are minimized during learning; however, the patient with traumatic brain injury is the most likely to have trouble concentrating and focusing on new information.

Answer 2: If the patient can independently stay at home and the spouse acknowledges this ability, then one person is unemployed rather than two. Continuously working toward an unrealistic goal will only increase the stress for patient and spouse. If the spouse quits her job, than her fears for her husband may subside, but it is likely that financial issues will eventually cause stress. The patient can acknowledge the spouse’s stress, but telling her to stop worrying is unlikely to be successful.

Answer 1, 2, 3, 4, 6: Air-filled cavities in the body (ears, lungs, and gastrointestinal tract) and organs enveloped by fluid-filled cavities (brain and spinal cord) are most susceptible to compression damage from high-explosive blasts. Airborne debris embedded in any body part comprises the secondary injury cat-

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Answer Key 112

egory. Injuries that occur from being thrown as the result of an explosive shockwave are considered tertiary. Inhalation and exposure to toxic chemicals, traumatic amputations of limbs, and burns are examples of quaternary injuries. Myocardial infarction is not part of the expected injury pattern; however, it could occur if the patient has a preexisting condition or secondary to injuries that cause blood loss or decreased oxygenation.

Critical Thinking Activities 26. a. In a rehabilitative assessment of a patient with a traumatic brain injury, the nurse may expect to see inconsistent performance of activities, anger, depression, and frustration. There may be multiple problems with cognition along with a lack of initiative. Egocentric behavior is normal. b. Most patients with traumatic brain injuries require physical, cognitive, and psychosocial intervention for many years, if not the remainder of their lives. Emphasis is on attainment of a maximum level of functioning, whether it is a return to an occupation or achievement of basic ADLs. c. Examples of possible outcomes for patients with traumatic brain injuries are: Will demonstrate ability to perform ADLs related to grooming by combing own hair.

Will remain injury-free.

Will demonstrate an awareness of safety hazards.

8.

9.

10.

11.

CHAPTER 39—HOSPICE CARE Fill-in-the-Blank Sentences 1. cancer 2.

Curative treatment 3. professional staff visits; medication; equipment; respite; acute 4.

Palliative care 5. in the last 6 months Table Activity 6.

See Table 39-1, p. 1213.

Multiple Choice 7.

Answer 3: The patient and the primary caregiver must desire and be willing to participate in planning care. Hospice care should be available without discrimination; however, there are criteria related to prognosis, certifi-

12.

cation by health care providers, and patient and caregiver’s willingness to participate.

Cancer is the most common diagnosis in hospice, but any terminal conditions could also be included. Informing family members is correct, but the patient and primary caregiver will generally be making the decisions and comfort is the goal, rather than life support.

Answer 1: Respite care is a period of relief from responsibilities of caring for a patient.

Palliative care consultant gives advice about relief of patient’s pain or symptoms. Bereavement counseling assists family/caregiver after the patient has died. The hospital ethics committee advises about ethical issues such as discontinuation of feeding.

Answer 1, 2, 4, 6: Anticholinergics help to manage excessive secretion. Anticonvulsants are prescribed for neuropathic pain. Antiemetics are for nausea and vomiting. Anxiolytics are for anxiety and reduced anxiety helps to decrease the subjective experience of pain.

Anticoagulants and antihypertensives could be ordered, but are less emphasized in hospice care.

Answer 4: The explanation of “managing the pain and keeping him alert” reassures the wife that specific and measurable goals are being met. The other responses are partially correct, but vague responses are less helpful to the wife.

Answer 3: Primary caregiver and patient are encouraged to live and enjoy life; thus going to an occasional movie or taking a break would be advisable. The patient and family may decide that a long-term care facility is a good choice, but this is just one of many options that should be presented to the whole family. Hoping for remission would not be a hospice goal; however, hope for realistic goals would be encouraged (e.g., hope to live for daughter’s wedding). The patient should be offered food and fluids, but the emphasis is not on healing and recovery. Emphasis is on helping the patient’s symptoms (e.g., taking some fluid will help relieve dry mouth and eating prevents hypoglycemia symptoms).

Answer 2: The nurse is first and foremost a patient advocate. Giving the patient the opportunity to continue or stop is way of showing respect and giving the patient control. The other options could also be considered once the nurse knows that the patient desires to have the rituals continue.

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Answer Key 113

13.

14.

15.

16.

17.

18.

19.

Answer 4: The volunteer coordinator’s responsibility is to assess the patient and family’s needs and to train the volunteers and match them with the patient and family; thus the situation needs to be reassessed, the volunteer needs to be retrained, and possibly a different volunteer should be assigned to this family.

Answer 2: The nurse will recognize that the aide spends a lot of time with the patient, so it is natural for them to develop a rapport. Frequent reports from the aide will be valuable to the entire team. The nurse may also decide to use the other options. Praising reinforces desirable behavior. Reminding about scope of practice may be appropriate if the aide starts giving the patient advice about personal or health problems. Having rapport and trust with a patient is always desirable.

Answer 4: The nurse coordinator coordinates the services of the hospice team, which includes the physical therapist, who would be the specialist to actually teach the wife how to do the transfer skills. It is likely that the nurse coordinator will have to assess and document the patient’s abilities for purposes of obtaining health care provider’s orders. The assessment data are also used for reimbursement.

Answer 2: ESAS addresses the areas of pain, tiredness (lack of energy), drowsiness, nausea, appetite, shortness of breath, depression (feeling sad), anxiety or nervousness, and the patient’s overall feeling of well-being.

Answer 2: The nurse would try a prescribed nonopioid medication and nonpharmaceutical options and observe for relief of pain. The nurse should not encourage a patient to take a medication after the patient reports ill effects.

The nurse should contact the provider and report the patient’s reluctance to take opioid medication and the response to the nonopioid medication. Changing to alternative routes or lowering the dose without a provider’s orders is practicing outside the scope of practice.

Answer 4: Metoclopramide (Reglan) is contraindicated for patients with suspected obstruction because it increases gastric motility. The other medications could be ordered for nausea.

Answer 1: Replace fluids first; very mild salt solutions may be better tolerated than sweet tastes; however, if the patient prefers sweet, clear liquids those are acceptable. Rice and pudding are okay if the patient is tolerating

20.

21.

22.

23.

24.

25.

liquids. Favorite foods should be held until patient feels well enough to enjoy them.

Answer 4: Assess discomfort and bowel function before offering any other interventions.

Answer 3: Stomatitis is an inflammation of the tissues in the mouth. It is uncomfortable to eat; therefore, hygiene and swabbing the mouth help relieve the discomfort. Antiemetics are given to decrease nausea and vomiting.

Weighing the patient is not recommended, because the patient will feel depressed about weight loss and weight gain is unlikely. Bring meals in, if cooking smells seem to be affecting the patient.

Answer 1: The patient and family need emotional support in understanding and experiencing this untreatable condition. The other options are possible, but rarely considered at this stage.

Answer 2: Applying oxygen will make the caregiver feel better while the nurse is on the way. The “death rattle” is often heard 24-48 hours before death, so the nurse should go to the house, support the caregiver, explain the death rattle, and help the caregiver prepare for imminent death. Bronchodilators can be used for dyspnea and air hunger when appropriate. Calling 911 is not appropriate. Pooling of mucus and fluids is the cause of the noise, and is somewhat expected; however, explaining this over the phone is insufficient. The caregiver needs support.

Answer 4: Transdermal scopolamine will help to control the excess secretions. Assess the patient’s ability to successfully use coughing and deep-breathing. This could be a useful intervention, but it is likely that weakness will prevent successful production of secretions.

Droperidol (Inapsine) is an antiemetic medication. Suctioning is usually not done because it is uncomfortable for the patient and the caregiver would have to wake frequently during the night.

Answer 2: This is serious and complex issue, so the nurse should go up the chain of command. While it is normal for the staff to grieve, the aide’s behavior is excessive and potentially burdensome to the caregiver. The nurse coordinator should investigate the aide’s behavior, the caregiver’s response, and the need for counseling. The outcomes could impact the caregiver’s grieving and the aide’s future participation as a team member.

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Answer Key 114

26.

Answer 4: The caregiver is apparently very stressed out, so the nurse would listen to the caregiver and assess the situation. Contacting the team is premature. The nurse coordinator would be contacted after the nurse assesses and determines that the plan needs revision. If the caregiver had demonstrated fear, anxiety, or had indicated that something was wrong with the patient, the nurse would check the patient’s status first. Anger and frustration suggest that the patient’s health status is not the problem; the caregiver’s feelings of helplessness are the issue.

Critical Thinking Activities 27. a. Refer to Box 39-2 on p. 1216. Pain assessment includes presence of pain, location, intensity (use of scale), variation in intensity, subjective description, treatments being used, rating of relief with current treatment, factors that precipitate or aggravate the pain, and its effect on ADLs. b. Nursing responsibilities in addition to pain assessment are monitoring the use and effectiveness of pain relief medications and treatments, having dosages of medications adjusted according to the patient’s needs, and educating family members/caregivers about pain relief measures. c. i. Mild to moderate pain is usually controlled by NSAIDs (nonsteroidal antiinflammatory drugs). ii. Severe pain is usually treated with opioids. iii. Long-lasting results are achieved with MS Contin, OxyContin, and Duragesic patches. d. Additional measures for pain relief include application of hot or cold packs, repositioning, music therapy, relaxation techniques, TENS devices, imagery, hypnosis, and biofeedback.

28.

In this case, the patient is not able to contribute to the decision-making process. This family, like all families, has strengths and weaknesses and everyone seems to have an opinion. The nurse coordinator should assess each the family member’s abilities and feelings. The social worker can help the family work through communication issues so that members understand each other. Nurse coordinator or social worker can help the family understand different options. For example, in long-term care, the staff is considered the primary caregiver. It is also possible that they could hire someone to assist as caregiver in the home setting. Family members could also be assisted in developing a plan to divide responsibilities and take turns in doing the actual caregiving. Discussing additional resources such as respite care, volunteer services, and spiritual and bereavement will help reassure the family that they are not alone in the process.

CHAPTER 40—INTRODUCTION TO ANATOMY AND PHYSIOLOGY Crossword Puzzle 1.

1

2

3

P H A G O C Y T O S I S O Y 4 5 C M MI T O S I S 6 D Y E E T 7 F I L T R A T I O N M E F O S B M 8 9 F P T O R G A N T U L A A I 10 11 S A S P I N O C Y T O S I S I S I E E S 12 O O S MO S I S L U 13 N N U C L E U S E

Fill-in-the-Blank Sentences 2. anterior 3. posterior 4. superior 5. superficial 6. inferior 7. medial 8. lateral 9. distal 10. proximal

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Answer Key 115

Table Activity 11. See Table 40-6, p. 1238 for additional information.

One Body Part of Major System

Major System

Function

Lungs

Respiratory

Exchange of carbon dioxide for oxygen; regulation of acid-base balance

Heart

Cardiovascular

Transportation of nutrition, water, oxygen, and wastes

Brain

Nervous

Coordination of body’s activities; communication

Stomach

Digestive

Mechanical and chemical breakdown of food; absorption of nutrients

Kidneys

Urinary

Clearing blood of waste products; water and electrolyte balance; acid-base balance

Bones

Skeletal

Support; movement; storage of minerals; blood cell formation

Voluntary muscles

Muscular

Movement; maintenance of posture; heat production

Skin

Integumentary

Protection; regulation of body temperature; synthesis of chemicals; sense organ

Thyroid gland

Endocrine

Production of hormones that affect metabolism

Lymph nodes

Lymphatic

Protection

Gonads

Reproductive

Production of sex cells

Figure Labeling: Planes of the Body 12. The sagittal plane runs lengthwise from the front to the back. A sagittal cut gives a right and a left portion of the body. A midsagittal cut gives two equal halves. The coronal (frontal) plane divides the body into a ventral (front) section and a dorsal (back) section. The transverse plane cuts the body horizontal to the sagittal and frontal planes, dividing the body into caudal and cranial portions. See Figure 40-2, p.

1228 for additional information.

Multiple Choice 13. Answer 3: The gallbladder is located just below the right ribs. The spleen is on the left side. The small intestine and cecum are located lower in the abdominopelvic cavity.

14. Answer 2: The urinary bladder is located in the hypogastric region. See Figure 40-4, p.

1229 for additional information.

15. Answer 1: The stomach is located in the epigastric region. See Figure 40-4, p. 1229 for additional information.

16. Answer 2: The appendix is located in the right lower quadrant. See Figure 40-5, p. 1230 for additional information.

17. Answer 4: Once diagnosed, patients are usually placed on “nothing by mouth” (NPO),

18.

19.

20.

but a patient who develops a small bowel obstruction at home will often seek health care because of vomiting and abdominal pain. A proximal obstruction is one that is closer to the beginning of the small intestine; therefore, the blockage is higher up in the system. Vomiting can occur whenever there is an intestinal obstruction; however, in a distal large intestinal obstruction, vomiting is less likely. If it develops, it usually occurs later and the emesis could have a fecal odor.

Answer 1: The epidermis or skin is composed of stratified squamous tissue. One of the main functions is to protect the body from infection.

Bones are for strength and structure. Simple columnar tissue participates in the secretion of mucus. Adipose tissue provides insulation.

Answer 3: The mucous membranes are designed to trap microorganisms and dryness decreases that function. Poor oral hygiene contributes to respiratory infection, especially for patients who are bedridden. Patients who are in a coma are not given solid food. Dignity and preservation of the teeth are desirable for all patients.

Answer 3: The bursae are small cushionlike sacs that are found between joints; therefore,

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Answer Key 116

the nurse would assess the movement and discomfort of the major joints.

Critical Thinking Activities Activity 1 21. Knowledge of how the body works helps the nurse to distinguish normal findings from abnormal findings. Knowledge of location and function of organs helps the nurse predict the involvement of underlying structures that are related to patients’ reports of pain and discomfort and design interventions that will enhance function or repair dysfunction.

Knowledge of physiology at the cellular level helps the nurse implement interventions that keep the body in homeostasis.

Activity 2 22. A 2-cm ecchymosis noted on distal tip of first digit of right foot.

Activity 3 23. Accuracy is an important part of documentation; thus using the patient’s words in direct quotes is acceptable. In addition, assessment data should reflect the nurse’s ability to make and record professional observations. When the nurse’s records are reviewed by other health care professionals or by legal or financial consultants, use of correct terminology and accuracy reflect the quality of care.

CHAPTER 41—CARE OF THE SURGICAL PATIENT

3.

4.

5.

6.

7.

8.

9.

f e b g c i h

True or False 10. True 11. True: Ablative surgery is an excision or removal of diseased body part.

12. False: Palliative surgery is surgery for relief or reduction of intensity of disease symptoms; will not produce cure. Breast biopsy is a diagnostic procedure.

13. True: Diagnostic surgery is surgical exploration that allows the health care provider to confirm diagnosis.

14. True: Same-day admit conditions are when the patient enters the hospital and undergoes surgery on the same day and remains for convalescence.

15. True: Transplant surgery is replacement of malfunctioning organs.

16. True: Constructive surgery is restoration of function lost or reduced as result of congenital anomalies.

17. True: Reconstructive surgery is restoration of function or appearance to traumatized or malfunctioning tissue.

18. True: Major surgery involves extensive reconstruction or alteration of body parts; poses great risks to well-being.

19. False: Cataract surgery is considered a minor ambulatory procedure.

Matching 1. d 2. a

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Answer Key 117

Table Activity 20.

Assessment

Normal Findings

Frequency

a.

Vital signs

Same as or close to preoperative

q 15 minutes x 4, q 30 minutes x 4, q 60 minutes x 4, q 4 hours x 4, until assessments are within normal range

b.

Incision

Dressing dry and intact; no drainage

Every time vital signs are assessed

c.

Ventilation

Respiration normal rate and volume

q 1-2 hours

d.

Pain

Relieved by analgesics

Pain is considered the fifth vital sign and should be assessed concurrently with vital signs

e.

Urinary function

Voids adequate amount

Within 6-8 hours of surgery

f.

Venous status

Extremities are warm, pulse present, and normal color

q 2 hours

g.

Activity

According to order and patient: muscle-strengthening exercises, sitting, dangling, and walking as ordered and tolerated

Per health care provider’s orders and patient’s ability

h.

Gastrointestinal function

Flat abdominal area; bowel sounds audible

q 2 hours

Multiple Choice 21. Answer 4: In the induction phase, the patient is awake and the administration of anesthetic agents begins. The stage is completed when the patient loses consciousness, and endotracheal intubation is established and placement verified.

22. Answer 2: Anesthesia may be maintained through a combination of inhalation and IV medications. Emergence from anesthesia occurs when the procedure is completed and reversal agents are given.

23. Answer 3: Spinal anesthesia is often used for lower abdominal, pelvic, and lower extremity procedures; urologic procedures; or surgical obstetrics.

24. Answer 2: Local anesthesia is commonly used for minor surgical procedures, such as a biopsy of a superficial skin lesion.

25. Answer 4: Combinations of sedatives, tranquilizers, anesthetics, or anesthetic gases are commonly used for conscious sedation. The health care provider is frequently focused on the procedure and relies on the nurse to monitor the patient. Monitoring vital signs is necessary to detect adverse effects of the medication or the procedure.

26.

27.

28.

29.

30.

Answer 3: Resuscitation equipment must be readily available in case the patient has respiratory depression or cardiac dysrhythmia.

Recovery is rapid and relatively less risky than other types of anesthesia. The patient is not routinely intubated. Nurses frequently give central nervous system depressants (e.g., morphine). In the case of conscious sedation, the provider will frequently administer the medication; however, policies vary by facility.

Answer 3: For Arab Americans, verbal consent often has more meaning than written consent because it is based on trust. Fully explain the need for written consent.

Answer 1: Teaching 1 or 2 days before surgery is ideal because the patient’s anxiety is not too high. Teaching too far in advance would affect retention of the information. The teaching cannot be delayed because of the nurse’s schedule.

Answer 3: Before bowel surgery, medication (neomycin, sulfonamides, erythromycin) may be given over a period of days to detoxify and sterilize the GI tract.

Answer 2, 3, 4: Antihypertensives interact with anesthetic agents to cause bradycardia, hypotension, and impaired circulation.

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Answer Key 118

31.

32.

33.

34.

35.

36.

37.

38.

Answer 1: NSAIDs inhibit platelet aggregation and may prolong bleeding, increasing susceptibility to postoperative bleeding.

Answer 2: In the immediate postoperative period, all patients are at risk for aspiration related to nausea and vomiting and will have impaired abilities to manage secretions. Elderly patients have additional problems related to age.

Answer 2, 4, 6: The UAP can assist the patient to remove any personal clothing and don hospital attire and can also apply the antiembolic stockings. The UAP can assist the patient to move from the bed to the stretcher.

Comparing data, checking IV sites and equipment, and ensuring that the postoperative list is completed are nursing responsibilities.

(Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 4: The patient may be feeling fear of the unknown or fear of cancer; long-term, she may be thinking about death, mutilation, or change of lifestyle. First address the feelings and then ask her to expand on her fears.

Based on assessment findings, the other options might be used.

Answer 2: While all of these patients have the potential for adverse reactions and drug-drug interactions, the elderly patient with polypharmacy and chronic health conditions is the most vulnerable.

Answer 2: Smoking increases the risk for respiratory complications, such as pneumonia and atelectasis. The patient’s reading on pulse oximeter is likely to be lower than normal or low-normal because of the smoking. Patientcontrolled analgesia pump and call bell are also important, but less related to the issue of smoking.

Answer 4: “What...?” is an open-ended question. This allows the patient to seek information and the nurse can determine areas where the patient needs clarification. The other questions are closed-ended and do less to encourage the patient to speak.

Answer 4: If consent is obtained while the patient is under the influence of consciousnessaltering substances (even if prescribed), the consent is not considered valid. The other information is also relevant and the provider should be advised.

39.

Answer 2: The UAP can assist with oral care; however, the patient and the UAP should be instructed that fluids should not be swallowed. During NPO status, patients usually are not given any fluid. The exception could be small sips of water to take certain medications. Some providers will allow the patient to have small hard candies, but sucking hard candies does stimulate peristalsis, so this is not standard practice for all patients who are NPO.

UAPs are not responsible for checking IV fluids.

40. Answer 3: Coughing increases intracranial pressure; therefore, coughing is contraindicated for patients with intracranial surgery.

41. Answer 2: The nurse would check for distention first and then consider the other options.

42. Answer 3: Slowing of the respiratory rate suggests that the level of anesthesia is causing respiratory paralysis; the patient may require resuscitation. A decrease in blood pressure is also serious because of possible vasodilation.

Loss of sensation and decreased movement of the lower extremities are expected.

43. Answer 3: The nurse would assess the extremity for the new report of discomfort. Based on assessment findings, the nurse could consider the other options. (Postoperatively, the patient could have an emboli or a deep vein thrombus. Positioning on the operating table could put pressure on tissues or nerves. Patient could also have a problem that is not directly related to surgery; for example, cardiac.)

44. Answer 1: The patient is instructed to get up and void before getting the medication because it causes most people to get drowsy.

Urinary retention is also a common complication after surgery. The surgeon should mark the site and obtain consent. Most preoperative checklists require noting that the site has been marked and that the consent form is signed.

Vital signs can be taken before or after medication.

45. Answer 1, 2, 4, 6: The UAP can obtain most of the equipment, but is not responsible for checking the function of pumps or suction equipment. The nurse should ensure that these items are functional, as they are likely to be needed when the patient arrives. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or del-

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Answer Key 119

46.

47.

48.

49.

50.

egated to a UAP. Remember that UAP need specific instructions.)

Answer 4: The patient must have stable vital signs before he/she is transferred to the nursing unit. If the order for transfer has been written, the PACU nurse would be responsible for informing the anesthesia provider about the unstable vital signs. Nausea, vomiting, a sore throat, and wound pain are expected.

Answer 1: First the nurse would check the patient. If there are no obvious signs or symptoms of shock, then the nurse would instruct the UAP to take and report BP and pulse to determine a trend. A lower-than-baseline blood pressure is not uncommon after surgery.

Answer 4: The scrub nurse performs actions that require sterile handling. The circulating nurse is considered nonsterile and can perform tasks that require asepsis. He/she helps the scrub nurse and surgeons maintain sterility.

Answer 3: The ambulatory surgery patient is released to home, so the patient must be alert and pain, nausea, and vomiting must be controlled. The patient is not allowed to drive himself home and family’s willingness to assume responsibility does not absolve the nurse from making decisions about the patient’s safety.

Answer 3: Any of these findings warrant further investigation; however, for diabetic patients, there is an increased susceptibility for infection and poor wound healing. Impaired communication can be a problem for patients who have had a cerebrovascular accident.

Bloody emesis could be related to esophageal varices. Hypoventilation is a problem for patients with preexisting respiratory disorders.

Critical Thinking Activities Activity 1 51. Types of latex reaction: Irritant reaction, types I and IV allergic reaction Factors influencing: The patient’s susceptibility and the route, duration, and frequency of latex exposure

Risk factors: History of anaphylactic reaction of unknown cause during a medical or surgical procedure, multiple surgical procedures, food allergies, a job with daily exposure to latex, history of reactions to latex;

allergy to poinsettia plant; history of allergies and asthma

Methods of prevention: Screen prior to admission, provide a latex-free environment, communication to all members of the health care team, clearly marking the chart Activity 2 52. See Box 41-3, p. 1244.

Activity 3 53. Older patients have higher morbidity and mortality rates than younger patients.

Older individuals often have other coexisting conditions that increase stress on the older patient. Recovery can be affected by the level of mental functioning, individual coping abilities, and the availability of support systems. These are often altered in the older adult.

Risks of aspiration, atelectasis, pneumonia, thrombus formation, infection, and altered tissue perfusion are increased in the older adult.

Disorientation or toxic reactions can occur in the older adult after the administration of anesthetics, sedatives, or analgesics. Older adults often have a slower metabolism of these substances. These reactions may linger days after administration.

CHAPTER 42—CARE OF THE PATIENT WITH AN INTEGUMENTARY DISORDER Matching 1. j 2. h 3. b 4. e 5. a 6. i 7. c 8. d 9. n 10. m 11. f 12. t 13. o 14. k 15. r 16. s 17. l 18. p

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Answer Key 120

19.

20.

21.

q g u

32.

Short Answer 22. Protection from infection Regulation of temperature Synthesis of vitamin D Prevention of dehydration Excretion of waste 23. P—Provocative and palliative factors (things that bring the condition on) Q—Quality/quantity (characteristics and size) of the skin problem R—Region (specific region of the body) S—Severity (of the signs and symptoms) T—Time (length of time the patient has had the disorder) 24. A—Is the mole Asymmetrical?

B—Are the Borders irregular?

C—Is the Color uneven or irregular?

D—Has the Diameter of the growth changed recently?

E—Has the surface area become Elevated?

Figure Labeling—Rule of Nines 25. See Figure 42-19, p. 1324.

26. a. 36% b. 54% c. 18% Multiple Choice 27. Answer 2: Alopecia is hair loss, which is a common side effect of chemotherapy. Use of scarves or wigs could help. Also teach the patient that the hair will grow back. Therapeutic baths and applying lotions after bathing help with pruritus. Shaving, tweezing, or pumice stones can be used for hirsutism.

28. Answer 1: Paronychia is an infection of the nail that spreads around the nail. Topical antibiotics and wet dressings are the usual treatment; sometimes a surgical incision and drainage of the infected area are performed.

29. Answer 4: Skin disease, endocrine problems, and malnutrition are associated factors for hypotrichosis.

30. Answer 3: The most likely diagnosis is cellulitis. The extremity should be immobilized and elevated and warm, moist dressings are applied to relieve discomfort. Therapeutic baths are usually used for dry or itchy skin.

31. Answer 3: Eczema is associated with allergies to chocolate, wheat, eggs, and orange juice.

33.

34.

35.

36.

37.

38.

39.

40.

Answer 1: Isotretinoin (Accutane) is teratogenic; thus pregnancy is an absolute contraindication and strict contraception is advised for 1 month before starting and 1 month after completing treatment. Avoiding sun exposure is also advised.

Answer 2: A raised, black nevus is considered one of the most threatening skin lesions, and removal is recommended to prevent it from becoming malignant. Any change in color, size, or texture or any bleeding or pruritus deserves investigation. The other comments reflect typical changes associated with aging.

Answer 1: Clubbing of the fingertips indicates chronic hypoxemia, which is associated with conditions such as emphysema.

Answer 2: The palm of the hand supplies more information about temperature and texture than the fingertips, and both sides should be compared. A cotton-tipped applicator can be used to test for sensation. Use of gloves is recommended if the skin is broken or if mucous membranes are being assessed.

Answer 3: The nurse may suspect selfmutilation, but must conduct further assessment. Based on the assessment, the nurse might consider using the other options.

Answer 4: The eschar provides protection, so at the this point it is left intact. The RN and LPN/LVN would collaborate to develop a comprehensive, long-term care plan, which may include the wound care specialist. The ulcer is currently unstageable because it can’t be fully assessed.

Answer 3: Health care staff who have received two doses of the varicella vaccine should be assessed for symptoms 8-21 days after exposure to the patient with shingles. Staff who develop symptoms consistent with herpes zoster should be removed from active duty.

Health care staff who have not received the two doses of varicella vaccine may be infective for 8-21 days and should be moved to another duty location away from patient care.

Answer 3: Dermatitis medicamentosa can cause patients to have respiratory distress.

Dermatitis venenata is caused by contact with plants and the area should be immediately washed. Pain, itching, and infection are possible complications for many skin disorders, but these problems have lower priority than respiratory distress.

Answer 4: Wheals and hives after exposure to foods, insect bites, drugs, and other allergens

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Answer Key 121

can lead to anaphylactic shock. Epinephrine would be given to this patient for respiratory symptoms or if rapid worsening occurs. Herpes simplex is accompanied by burning sensation and a dry, crusty lesions. Single pink, scaly patch that resembles a large ringworm occurs with pityriasis rosea. Skin maceration, fissures, and vesicles around the toes is typical of tinea pedis.

Critical Thinking Activities Activity 1 41. a. Emergent phase: Stop the burning by removing clothes and shoes. Open the airway, control bleeding, and remove all nonadherent clothing and jewelry. Cover the victim with clean sheet or cloth, assess ABCs, and look for life-threatening injuries. Assessment every 30 minutes to 1 hour. Initiate fluid therapy, insert Foley catheter, monitor intake and output every hour, insert NG tube to prevent aspiration, and administer analgesics in small, frequent doses. b. Acute phase: ABCs—assessment of respiratory pattern, vital signs, circulation, intake and output, ambulation, bowel sounds, inspection of wound, and mental status. Control of pain decreases anxiety, promotes sense of support. Initiate protective measures for skin by maintaining protective isolation. Dressing and treatment of burns as ordered. Monitor of eschar, débridement of wound, range of motion. Postoperative care after each surgery. Maintain and assess nutritional status. c. Rehabilitation phase: Return to productive life, address social and physical skills; may take years.

Activity 2 42. a. Oxygenation, pulmonary function, cardiac function, blood count, temperature b. Assess for pallor by looking at the mucous membranes, lips, nail beds, conjunctivae of lower eyelids c. Palpation for warmth and induration

CHAPTER 43—CARE OF THE PATIENT WITH A MUSCULOSKELETAL DISORDER Figure Labeling 1.

See Figure 43-2 A, p. 1338.

Short Answer 2. a. Support b. Movement c. Mineral storage d. Hemopoiesis e. Protection 3. a. Motion b. Maintenance of posture c. Production of heat 4.

Perform the 7 Ps of orthopedic assessment to establish a baseline and monitor changes in the patient’s muscular function, bone integrity, distal circulation, and sensation: Pain: Does it seem out of proportion to the patient’s injury? Does the pain increase on active or passive motion?

Pallor Paresthesia or numbness Paralysis Polar temperature: Is the extremity cold compared with the opposite extremity?

Puffiness from edema or a hematoma Pulselessness: A Doppler ultrasound device may be useful to determine the presence or absence of blood flow if unable to palpate distal pulses 5.

Treatment of sprains usually consists of rest, ice, compression, and elevation (RICE) of the affected area.

True or False 6.

False: The pillow is used to maintain leg abduction.

7.

False: Scoliosis is a lateral (or “S”) curvature of the spine. Kyphosis is a rounding of the thoracic spine (hump-backed appearance).

8.

True 9.

True 10. True Multiple Choice 11. Answer 1: Diarrhea, nausea, and vomiting are potential side effects of colchicine. Fluid retention and sodium retention are side effects of adrenocorticosteroids. Seizures and dysrhythmias are side effects of meloxicam (Mo-

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Answer Key 122

12.

13.

14.

15.

16.

bic), which is an NSAID. Hypercalcemia and orthostatic hypotension are side effects of teriparatide (Forteo) which is used for postmenopausal women who are at increased risk for osteoporosis fractures or who cannot use other treatments.

Answer 1, 2, 4: Foods that are good sources of calcium include whole and skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardines with bones, spinach, many green vegetables, calcium-fortified orange juice, and soymilk.

Answer 2: The health care provider is most likely to order an x-ray examination of the ankle to rule out fracture. The radiation exposure is minimal; however, female patients of childbearing age should always be asked about pregnancy. Assessment of allergies and medications and past treatments are good general questions for all patients, but in this case are less relevant to the diagnostic test that will most likely be ordered.

Answer 3: Loss of sensation and movement are unexpected complications that should be reported. Headache is the most common symptom, but if correct positioning and ordered analgesics do not relieve the pain, this should also be reported. Patients are encouraged to take fluids flush the dye from the body. Patients are usually in a flat or semiFowler’s position for 8-12 hours; the nurse would explain the purpose of the position and initiate diversion interventions (e.g., television, reading, listening to music).

Answer 2: AKS can affect the cardiovascular and respiratory systems. Inflammatory bowel disease occurs in about 3-10% of patients.

Back pain and stiffness, weight loss, vision change, and fatigue are common. The 7 Ps could be used, but apply more to assessment of extremities. Mental status and urination should not be directly affected.

Answer 3: The patient is describing the symptoms of gout; thus, the nurse would do a dietary history to include specific questions about alcohol, organ meats, anchovies, yeast, herring, mackerel, or scallops, because foods high in purines worsen gout. Patients with ankylosing spondylitis should be asked about bowel changes. All patients should be asked about exercise routines. Jaw tension, excessive fatigue, or anxiety would be more typical for patients with fibromyalgia.

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Answer 1: Osteomyelitis is an infection of the bone. Drainage precautions are initiated, because the wounds frequently require débridement, irrigation, and sterile dressing changes.

Ambulating may be restricted because the affected part is usually rested. Patients with arthritis or fibromyalgia are more likely to have trouble moving in the early morning. Ice packs are more appropriate for patients with sprains or strains; sometimes for patients with arthritis.

Answer 1, 2, 4, 5: Coughing and deepbreathing, clear liquids with transition to a regular diet, assessing ability to use assistive devices, and monitoring IV fluids and antibiotics would be included in the care of the patient who had unicompartmental knee surgery. The patient would not have a cast and intraarticular injections of corticosteroids would be given by the health care provider for rheumatoid arthritis.

Answer 2: The nurse’s first action would be to assess for signs/symptoms of hypovolemic shock. An increase in pulse is an early sign.

A decrease in blood pressure comes later. The nurse could also look at the urinary output, but the most useful piece of data is to know output per hour. Reassurance and visitors are appropriate if the patient is physically stable, and needs additional emotional support.

Answer 2: Pain is a primary symptom of compartment syndrome or infection. In addition, pain is a subjective symptom that the child will have to report to parents. Capillary refill and other assessments, cast care and maintenance are important, but the parents can be given written information about these topics. Fiberglass casts do not degrade if they get wet, but drying them out can be timeconsuming.

Answer 4: The head of the bed should not be elevated past 45 degrees to a avoid acute flexion on the device. The other actions are part of the postoperative care.

Answer 1: Bedrest is typically for the first 24 hours. The other comments are correct.

Answer 2: When a person falls, the natural instinct is to extend the arms out to break the fall. This results in a Colles’ fracture, which is a fracture of the distal portion of the radius within 1 inch of the wrist joint. A head-to-toe assessment always gives good information, but the obvious injuries should be addressed

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Answer Key 123

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first in this “field” situation. Mental status examination would be the priority if the patient could not relate details of the fall (e.g., loss of consciousness because of a cardiac, neurologic, or metabolic event). Based on the patient’s current status, the environmental assessment should be performed after other potential injuries are assessed.

Answer 1: The patient has signs and symptoms of a pelvic fracture and hemorrhage is the most life-threatening complication.

Hemoglobin and hematocrit are laboratory indicators of blood loss. Blood type and Rh are important if the patient needs emergency surgery. Urinalysis and stool for occult blood are performed because of the position of the bladder and the colon in the pelvic area.

Answer 4: The nurse performs the assessment first. Based on the assessment findings, the nurse may decide to use the other options.

Answer 2: Volkmann’s contracture is a permanent contracture that can result from undetected and untreated compartment syndrome.

The result is clawhand with flexion of the wrist and hand and atrophy of the forearm.

The nurse would assess the patient’s abilities to perform ADLs. The other options are actions that should have been performed during the patient’s initial injury and treatment.

Answer 2: The arterial blood gases are within normal limits. The patient with a long bone fracture is at risk for fat embolism, but the occurrence is relatively rare. However, respiratory failure is the most common cause of death associated with fat embolism, so the nurse would continue to monitor the patient.

Answer 2: Frequent position changes and stretching hands are preventive measures for carpal tunnel syndrome. Warm packs will worsen the inflammation and edema.

Suggesting use of medication, even over-thecounter medications, is not advised, especially because the health care provider has not evaluated the medical condition. Wrapping the wrist may help a bit, but the health care provider is likely to recommend the use of a commercial splint.

Answer 3: Patients who have had a laminectomy are at risk for a paralytic ileus; therefore, the nurse would first assess for possible bowel obstruction.

Answer 4: An elevated serum alkaline phosphatase signals osteogenic sarcoma or other bone disorders (liver disease is also associated

with elevated alkaline phosphatase). Phantom limb pain occurs after amputation for some individuals. Fibromyalgia has a variety of symptoms, but the pain tends to be in the muscles and in the low back. Compartment syndrome is the result of excessive pressure within the fascial compartments, usually caused by a cast or dressing, but can also be caused by a crushing injury.

Critical Thinking Activities Activity 1 31. Genetic and environmental factors, such as small bone structure and lack of exercise, can contribute to the rate of bone loss. Individuals most at risk for developing osteoporosis are small-framed, white (European descent) or Asian race, smoking, and alcoholism. Medical conditions associated with an increased development of the disease include hyperthyroidism, chronic lung disease, cancer, inflammatory bowel disease, alcoholism, and Vitamin D deficiency. Medications that are linked to the development of osteoporosis include steroids, anticonvulsants, immunosuppressant therapies, and heparin. Diets low in calcium or high in caffeine and protein are also implicated.

Nursing interventions are aimed at preventing further bone loss and fractures. Teach the patient to include milk and dairy products in the diet. Use vitamin D supplements as prescribed. Food and beverages that contain caffeine also contain phosphorus, which contributes to bone loss. Encourage smoking cessation. Safety measures, such as side rails, handrails, bedside commodes with seat elevators, and rubber mats in showers can help prevent falls in older adults. Efforts are made to keep patients with osteoporosis ambulatory to prevent further loss of bone substance as a result of immobility. Encourage weightbearing exercise to increase bone density.

Activity 2 32. FMS is not life-threatening, but 50% of patients report that they have trouble completing ADLs. There is a wide range of symptoms, such as aches, fatigue, cognitive difficulties, problems sleeping, anxiety, depression, and tingling sensations. Symptoms can overlap with chronic fatigue syndrome. There are no specific diagnostic tests; thus, an exclusion

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Answer Key 124

approach is used and the diagnosis could take years. FMS is hard to treat and many will have trouble achieving remission.

Activity 3 33. Women are at greater risk for hip fracture due to their increased occurrence of osteoporosis and longer life expectancy compared with men. This woman is thin and therefore has inadequate local tissue to absorb shock.

Climbing stairs to the second floor requires coordination and balance that change with age. The loose rugs and clutter are hazardous and low light impairs vision. Bending to pet the dog or having him jump on her can put her off balance; the physiologic changes of aging result in decreased joint flexibility and muscular strength. The cane, walker, and eyeglasses appear to have low value for this woman, even though they could help prevent falls.

Activity 4 34. Rheumatoid arthritis (RA) is a progressive, inflammatory, systemic disease believed to be autoimmune in nature. Osteoarthritis (OA) is a disease resulting from the deterioration of joints. It is nonsystemic and noninflammatory. RA may affect any area of the body and is characterized by periods of remission and exacerbation. OA involves joints. Both disorders include signs and symptoms of muscle weakness, pain, and stiffness. RA patients also report malaise and loss of appetite.

Management of RA includes administration of antiinflammatory medications to control the progression of the disease, pain relief, and measures to prolong joint function. Management of OA includes physical therapy, heat applications, drug therapy, and joint replacement. The prognosis for each is variable.

CHAPTER 44—CARE OF THE PATIENT WITH A GASTROINTESTINAL DISORDER Figure Labeling 1.

See Figure 44-1, p. 1403.

Fill-in-the-Blank Sentences 2.

Peristalsis 3. infections; decay 4. reflux 5. proteins; fats; simple sugars

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water; feces; expulsion blood clotting fats proteins; fats; carbohydrates hypothalamus

Multiple Choice 11. Answer 2, 3, 4, 5: Injury, trauma, or disruption of the anal sphincter can result in fecal incontinence. Spinal cord lesions can result in loss of conscious control of defecation. Normal changes that occur with aging are usually not significant enough to cause incontinence. Voluntary inhibition of defecation is learned in childhood as a means to control emptying of the rectum.

12. Answer 2: Musculature of the bowel contains its own nerve centers that respond to distention through peristalsis. Therefore, even when the patient has motor paralysis, reflex defecation often persists or can be stimulated. Bowel training is a better long-term option; the other options could be considered as interim measures until bowel control is achieved.

13. Answer 1: Biofeedback training has been proven effective with alert, motivated patients who have motility disorders or sphincter damage that causes fecal incontinence. The patient learns to tighten the external sphincter in response to manometric measurement of responses to rectal distention.

14. Answer 3: High-fiber foods facilitate defecation. Fluids should also be encouraged.

15. Answer 2: Sucralfate (Carafate) acts by coating the gastric mucosa. Misoprostol (Cytotec) is contraindicated during pregnancy. Cimetidine (Tagamet) increases the serum levels of oral anticoagulants, theophylline, phenytoin, some benzodiazepines, and propranolol.

Diphenoxylate with atropine (Lomotil), dimenhydrinate (Dramamine), atropine, scopolamine, hyoscyamine, dicyclomine, and clidinium (Donnatal, Bentyl) are just a few of the drugs that can cause sedation.

16. Answer 1: Intrinsic factor (a substance secreted by the gastric mucosa) is produced to allow absorption of vitamin B12. Pernicious anemia can develop because of vitamin B12 deficiency. Patients with a partial gastrectomy should have a blood serum vitamin B12 level measured every 1 to 2 years so that replacement therapy of vitamin B12 via a monthly injection or via nasal route weekly can be instituted before anemia appears. Hemoglobin

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Answer Key 125

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and hematocrit would be monitored when blood loss is suspected. Iron dextran can be given for anemia associated with blood loss in Crohn’s disease. Increasing fruits and vegetables and decreasing red meat and fat is good general advice, but is inadequate to address the patient’s risk for pernicious anemia.

Answer 2, 3, 4, 5: Stomach carcinogenesis probably begins with a nonspecific mucosal injury as a result of aging; autoimmune disease; or repeated exposure to irritants such as bile, antiinflammatory agents, or smoking.

Other factors include history of polyps, pernicious anemia, hypochlorhydria (deficiency of hydrochloride in the stomach’s gastric juice), chronic atrophic gastritis, and gastric ulcer.

Because the stomach has prolonged contact with food, cancer in this part of the body is associated with diets that are high in salt, smoked and preserved foods (which contain nitrites and nitrates), and low in fresh fruits and vegetables.

Answer 2, 4, 5: The onset of Crohn’s disease is usually insidious, with nonspecific complaints such as diarrhea, fatigue, abdominal pain, and fever. As the disease progresses, the patient experiences weight loss, malnutrition, dehydration, electrolyte imbalance, anemia, and increased peristalsis.

Answer 2, 4, 5: The patient should be kept on bedrest and kept NPO. Vital signs should be monitored because there is a risk for peritonitis. Antibiotics can be given if perforation is suspected or may be given as a preoperative medication. Enemas and heating pads should not be used because of increased risk for peritonitis. Antacids are unlikely to offer relief to this patient.

Answer 3: The nurse would assess the abdominal pain, check the vital signs, and assess for other symptoms of hypovolemic shock.

Other symptoms of perforation would include melena, oral bleeding, and guarding.

Answer 1: The patient returns in 8 hours to have the monitoring device removed. The pill camera passes through the gastrointestinal system in 2-3 days. There is no need to retrieve the camera and problems with passing the device or change in stool are not expected.

Answer 4: During the procedure, mild hydrochloric acid is administered through the NG tube. If pain increases, then the test is considered positive. Relief of pain by nitrates is more associated with anginal pain. Antacids

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could provide some relief and are used in the treatment of reflux and gastritis. Decompression of the stomach can provide relief; for example, in the case of obstruction or pancreatitis.

Answer 1: Barium is a contrast medium that can interfere with visualization during a colonoscopy or in the interpretation of the flat plate and ova and parasite examinations.

Answer 2: Removing the plaques can cause pain and bleeding. The other actions are correct in the care of oral candidiasis.

Answer 3: For lesions that do not heal within 2-3 weeks, the neighbor should seek medical attention. Diluted hydrogen peroxide can be used for candidiasis or halitosis. Lipstick or lip balm that includes sunscreen and consuming fruit and vegetables are good preventive measures, but inadequate to address the existing lip lesion.

Answer 2: The conservative approach mostly includes modification of lifestyle, which includes avoiding foods and beverages that contribute to discomfort, smoking and alcohol cessation, losing weight, sleeping with head elevated, and not lying down immediately after eating. Medications are also used in a stepup fashion. Nissen fundoplication is a surgical procedure that would be used if medical therapies are not successful. Barrett’s esophagus is considered precancerous and requires endoscopy and biopsy every 1-3 years. Discussion of this information is premature, unless the provider or nurse suspects that the patient is likely to be noncompliant and needs to hear the worst-case scenario in order to comply.

Answer 3: Perforation is the most lethal complication of peptic ulcer disease (PUD) because of peritonitis. An elevated white blood cell count will accompany this potentially lethal infection. Fecal assay antigen and occult blood are used to diagnosis PUD. Pain during the hydrochloric test is used to diagnose gastroesophageal reflux disease.

Answer 2: The patient is describing symptoms of dumping syndrome which occurs in approximately one-third to one-half of patients who have surgery for peptic ulcer disease.

Symptoms are usually triggered by a bolus of hypertonic food. The other questions could be used to gather additional information.

Answer 3: The use of antidiarrheals is not recommended because the body is trying to rid itself of the E. coli pathogen. The health

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Answer Key 126

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care provider could order antidiarrheals if the fluid loss is relentless. Oral fluids are the first choice, but IV fluids can be ordered if the patient is having trouble with oral fluids or to replace initial fluid loss. Contact isolation would be appropriate to prevent the spread to others.

Answer 4: C. difficile is not destroyed by antiseptic hand rub, so soap and water are required for adequate hand hygiene. The other options are not part of contact isolation or needed for the care of this patient.

Answer 4: Patients with celiac sprue must avoid wheat, rye, and barley.

Answer 3: First the nurse acknowledges feelings and then assesses what the patient understands about the disease and the diagnostic process. Based on the assessment, the nurse may decide to use the other options.

(Note to student: Recall principles of therapeutic communication by starting where the patient is emotionally; acknowledge feelings and encouraging expression of feelings.)

Answer 1: With severe diarrhea, the body loses sodium, potassium, calcium, and bicarbonate. Hematocrit levels are likely to be elevated because of fluid loss. A fecal sample is likely to show blood because of irritation to the mucosa. Liver function tests should not be relevant to this condition.

Answer 2: First the nurse tries to help the patient express feelings about the procedure and other concerns. Based on the assessment of concerns, the nurse may decide to use the other options. (Note to student: Recall principles of therapeutic communication by starting where the patient is emotionally; acknowledge feelings and encouraging expression of feelings.)

Answer 1: Crohn’s disease causes ulceration with fistula formation that can connect the colon with the urinary tract. The urine of patients with suspected appendicitis will be tested to rule out urinary infection as a source of the pain. Patients with ulcerative colitis could develop urinary tract infections related to improper hygiene of the perineal area; thus staff and patients should be aware to clean and wipe from front to back. Peptic ulcer disease should not contribute directly to urinary tract infections.

Answer 4: The side-lying with knees flexed (fetal position) is preferred because this decreases the strain on the abdominal wall.

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Answer 2: For acute diverticulitis, the patient is likely to be NPO. The other actions are correct.

Answer 1: The nurse recognizes the potential for peritonitis; however, additional assessment with vital signs should be performed before sitting the patient in semi-Fowler’s position (BP could be low and pulse elevated because of shock) or notifying the health care provider who will ask about the last set of vital signs. PRN pain medication is not appropriate if peritonitis is suspected. (Remember to apply the nursing process; the first step is assessment.)

Answer 1, 2, 4, 6: Monitoring vital signs, pain, bowel sounds, fluid balance, and drainage and bleeding are appropriate care. The patient should turn, cough, deep-breathe, and be encouraged to ambulate. The Foley should be removed as soon as possible to prevent infection and to allow adequate time to assess the patient’s ability to void. Suction should be temporarily discontinued during ambulation.

Answer 3: Increasing fluid intake and a highfiber diet decrease the likelihood of constipation; straining at stool can cause hemorrhoids.

Suggesting use of hydrocortisone creams or rubber-band ligation is the responsibility of the health care provider.

Critical Thinking Activities Activity 1 41. a. Assessment: Includes noting difficulty swallowing and painful swallowing. Observe for regurgitation, vomiting, hoarseness, chronic cough, and iron-deficiency anemia. b. Nursing diagnoses and planning: Ineffective breathing pattern related to incisional pain and proximity to the diaphragm; Imbalanced nutrition, less than body requirements related to dysphagia; Decreased stomach capacity related to gastrostomy tube c. Implementation: Monitor respirations carefully because of proximity of incision to diaphragm and patient’s difficulty carrying out breathing exercises. Monitor intake and output and daily weights to determine adequate nutritional intake.

Assess to determine which foods patient can and cannot swallow, and to select and prepare edible foods.

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Answer Key 127

d. Evaluation: Evaluation should reflect the patient’s response to interventions and the resolution, partial resolution, or failure to resolve the problems identified by nursing diagnoses.

Activity 2 42. a. Preoperative i. Preparation: Encourage improved nutritional status; offer a highprotein, high-calorie diet if oral diet is possible. Total parenteral nutrition may be necessary for severe dysphagia or obstruction.

Gastrostomy tube feedings may be indicated. Give prescribed antibiotics. ii. Knowledge: Discuss what to expect during entire procedure, review activities that will be done during recovery process. b. Postoperative i. Knowledge: Discuss availability of pain medications. ii. Pain: Review nonpharmacologic methods to relieve pain. iii. Noncompliance: Discuss the implications for recovery and the development of complications with noncompliance. iv. Nutrition: Start clear fluids at frequent intervals when oral intake is permitted; introduce soft foods gradually, increasing to several small meals of bland food; have patient maintain semi-Fowler’s position for 2 hours after eating and while sleeping if heartburn (pyrosis) occurs.

Activity 3 43. a. Presence of distention, visibility of peristaltic waves, vomiting, tenderness, guarding behaviors, presence and characteristics of bowel sounds b. Abdominal x-rays, CT scans, sigmoidoscopy or colonoscopy may be used to confirm the presence of an intestinal obstruction. Hematologic studies may be used to assess the degree of impact of the obstruction. These blood studies include electrolyte levels and hemoglobin and hematocrit readings. c. Removal of gas and fluid, correction of electrolyte imbalances, relief or removal of the obstruction

d. The manifestations of mechanical and intestinal obstructions are similar. Regardless of the cause of the obstruction, the result is an inability of gastric contents to pass through the GI tract. The primary difference between the types is the underlying cause. Nonmechanical intestinal obstructions result from a neuromuscular or vascular disorder. Mechanical obstructions are caused by a physical occlusion in the intestinal tract.

CHAPTER 45—CARE OF THE PATIENT WITH A GALLBLADDER, LIVER, BILIARY TRACT, OR EXOCRINE PANCREATIC DISORDER Matching 1. i 2. a 3. f 4. b 5. j 6. h 7. m 8. g 9. k 10. e 11. d 12. l 13. n 14. c Fill-in-the-Blank Sentences 15. discoloration; 2.5 mg/dL 16. two to three; three to four 17. liver 18. 16,000 19. gallstones 20. cigarette smoking Multiple Choice 21. Answer 4: Patient should exhale and not breathe while needle is being inserted. This allows the health care provider to insert the needle between the sixth and seventh or eighth and ninth intercostal spaces and into the liver.

22. Answer 1: The purpose of the T-tube is to allow the bile to drain out. Initially, up to 500 mL of drainage would be considered an expected outcome. The flow should decrease over time. Inflammation, pain, and bleeding are not expected findings.

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Answer Key 128

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Answer 4: The pain is expected because of diaphragmatic irritation secondary to abdominal stretching and to residual carbon dioxide.

The appropriate intervention is to give an analgesic.

Answer 2: The level of lipase is more specific for diagnosing acute pancreatitis. Low albumin, increased glucose, and elevated amylase are likely to accompany the diagnosis of pancreatitis; however, changes in albumin, glucose, and amylase can be associated with many other disorders.

Answer 1: Hepatitis E is most often seen in southeastern and central Asia, the Middle East, Africa, and Mexico. Drinking water from questionable sources and eating raw shellfish increase the risk for hepatitis E. High-risk sexual behaviors and sharing needles are sources of hepatitis B and C. Hepatitis G has shown up in Europe, Asia, and Australia.

Answer 2: The number of tablets or ingestion of fatty food just before the test could alter the outcome. Also, vomiting and diarrhea can alter the absorption of the dye. Laxatives and enemas are usually not required. Amount of fluid should not affect examination; however, fat in the fluids (i.e., whole milk) could be a factor.

Answer 1: For a pregnant woman, ultrasound offers an option that is safe. Oral cholecystography and intravenous cholangiography and computed tomography require exposure to x-rays.

Answer 3: There are no special instructions that the UAP needs to care for a patient after a HIDA scan; verbally reassuring the UAP is a good idea, because he/she may not be familiar with what happens during diagnostic procedure. The amount of radioisotope is very minimal, so use of the dosimeter is not required. (Note to student: Certain units or jobs may require that all personnel wear dosimeters all the time.) The isotope is given intravenously, but bleeding is not an expected side effect of the procedure. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 2: The needle liver biopsy is an invasive test that creates a potential for hemorrhage, shock, peritonitis, and pneumothorax; thus, frequent assessment of vital signs is

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required. The serum ammonia test is accomplished by drawing a blood sample. Oral cholecystography and radioisotope liver scan do not require any care beyond routine assessment after returning from the procedure.

Answer 3: The purpose of a soft toothbrush with gentle brushing action is a precaution initiated when patients are at risk for bleeding. In this case, the cirrhotic liver cannot absorb vitamin K or produce the clotting factors VII, IX, and X. These factors result in the patient with cirrhosis to develop bleeding tendencies.

Answer 1, 2, 4: Preoperative patients need to learn about coughing and deep-breathing and would be ideal candidates for the student.

The patient with chronic hepatitis is also a good choice. The patient with esophageal varices should not be encouraged to cough because of the potential for rupture. The patient with acute pancreatitis needs to cough and deep-breathe, but this patient is less than ideal for a first-semester student, because acute pancreatitis causes severe pain and the patient may have little tolerance for the novice.

Answer 3: Hepatic encephalopathy is a type of brain damage caused by liver disease and consequent ammonia intoxication. The other tests are also included in the general diagnosis of liver disease.

Answer: 1.4 mL 155 lbs ÷ 2.2 = 70.45, rounded to 70 kg 70 kg × 0.02 mL/kg = 1.4 mL Answer 4: If the patient knows that the procedure will provide relief for noxious symptoms, he/she is more likely to cooperate.

Nasogastric tube insertion is extremely uncomfortable, but giving pain medication does not alleviate the sensations of tearing or gagging. An antianxiety medication may be more effective in this case. Having the most experienced nurse insert the tube is a good strategy for an anxious patient, but he/she must still agree to cooperate. Calling the health care provider is also appropriate if the patient is determined to leave the hospital.

Critical Thinking Activities Activity 1 35. a. Infection and rejection of the organ b. Respiratory complications (pneumonia, atelectasis, pleural effusions), hemorrhage, infection, electrolyte imbalances

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Answer Key 129

c.

The patient will be closely observed for signs of rejection. There will be medications to reduce the likelihood of rejection.

Cyclosporine is an effective immunosuppressant drug. Other immunosuppressants used include azathioprine (Imuran), corticosteroids, tacrolimus (Prograf), mycophenolate mofetil (Cellcept), and new agents including the interleukin-2 receptor antagonists basiliximab (Simulect) and daclizumab (Zenapax). d. Coughing and deep-breathing exercises, monitoring neurologic status, signs of hemorrhage, input and output, assessment of drainage from Jackson-Pratt drains, NG tubes, and T-tubes. Protective isolation is likely to be needed and the nurse should monitor for signs and symptoms of infection and rejection.

Activity 2 36. a. Cholelithiasis b. Increased heart and respiratory rates, diaphoresis, elevated temperature, elevated leukocyte count, mild jaundice, steatorrhea c. Fecal studies, serum bilirubin tests, ultrasound of the gallbladder and biliary system, HIDA scan, or operative cholangiography (OCG) may be done. Ultrasound of the gallbladder is highly accurate in diagnosing cholelithiasis.

Activity 3 37. a. Smoking, obesity, red meat, pork, fat, and coffee contribute to risk for pancreatic cancer. Symptoms can be vague and insidious; therefore, cancer is usually wellestablished before it is diagnosed and life expectancy can be 4 to 6 months after diagnosis. The patient may have to undergo many diagnostic tests and will then be told that tumors are inoperable. The pain is likely to be significant.

The patient may express regret because of failure to modify lifestyle, fear related to death, frustration related to intensive diagnostic testing, and treatments that provide little hope for cure. The patient will be dealing with severe pain while having to face loss of social, work, family, and community roles. b. The nurse is aware that the patient faces many challenges. Active listening encour-

ages expression of fears and concerns.

Give information as needed to decrease anxiety. Expert care and anticipating needs also helps to decrease the patient’s anxiety. Refer to social services and support groups as appropriate.

CHAPTER 46—CARE OF THE PATIENT WITH A BLOOD OR LYMPHATIC DISORDER Short Answer 1.

The blood performs three critical functions.

First, it transports oxygen and nutrition to the cells and waste products away from the cells, and it transports hormones from endocrine glands to tissues and cells. Second, it regulates the acid-base balance (pH) with buffers, helps regulate body temperature because of its water content, and controls the water content of its cells as a result of dissolved sodium ions.

Third, it protects the body against infection by transporting leukocytes and antibodies to the site of infection and prevents blood loss with special clotting mechanisms.

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The lymphatic system has three basic functions: (1) maintenance of fluid balance, (2) production of lymphocytes, and (3) absorption and transportation of lipids from the intestine to the bloodstream.

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Lymph nodes (glands) have two functions: (1) to filter impurities from the lymph and (2) to produce lymphocytes (WBCs).

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The spleen: (1) has a major role in homeostasis by destroying worn-out or defective RBCs; (2) is a reservoir for blood; (3) forms lymphocytes, monocytes, and plasma cells; (4) houses white blood cells in the lining of the hollow cavities within the spleen; (5) produces RBCs before birth (the spleen is believed to produce RBCs after birth only in cases of extreme hemolytic anemia).

True or False 5.

False: Blood is slightly alkaline, with a pH range of 7.35 to 7.45.

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False: White blood cells defend the body against bacteria and viruses. The primary function of the red cells is the transportation of oxygen.

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False: There is a greater risk of penetrating underlying structures if the sternum is selected as the site. The posterior superior iliac crest is considered the preferred site for children.

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Answer Key 130

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True True True

Table Activity 11. See Table 46-1, p. 1491 for additional information.

Blood Test

Normal Values

Red blood cells (RBCs)

Males: 4.7-6.1 million/mm3 Females: 4.2-5.4 million/mm3

Hemoglobin

Males: 14-18 g/dL Females: 12-16 g/dL

Hematocrit

Males: 42%-52% Females: 37%-47%

Platelet count

150,000-400,000/mm3

White blood cells (WBC) actual cell count

5000-10,000/mm3

Prothrombin time (PT)

11-12.5 seconds

International Normalized Ratio (INR)

0.7-1.8

Partial thromboplastin time (PTT)

60-70 seconds

Multiple Choice 12. Answer 1: When patients are dehydrated, the hemoglobin and hematocrit appear higher than normal. Restoring fluid balance will yield normal results for hemoglobin and hematocrit. Platelet counts and prothrombin time should not be affected.

13. Answer 3: Bandemia is seen in patients who have serious bacterial infections, so the nurse is aware of the need to monitor for development of sepsis, which could lead to septic shock. Conditions such as dehydration or polycythemia vera increase the risk for deep vein thrombosis. Thrombocytopenia is a reduction of platelets. The basophils are involved in allergic response.

14. Answer 3: If the father is Rh-positive and the mother is Rh-negative, anti-D antibodies can exist from a previous pregnancy, miscarriage, ectopic pregnancy, or transfusion. In subsequent pregnancies, if the baby is Rh-positive, hemolytic disease (in the newborn) could be triggered by the presence of the mother’s antiD antibodies.

15. Answer 1: Some Jehovah’s Witnesses will accept volume expanders (colloids) and autologous blood. The health care team can administer blood to children without the consent of parents according to the US Supreme

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Court. It is however within the rights of a responsible and coherent adult to refuse treatment.

Answer 4: The UAP can assist the patient with self-care activities and toileting, but the nurse must assess the patient’s limitations and give the UAP specific instructions. The UAP might apply oxygen if there was a true emergency, but generally the patient’s shortness of breath should be reported to and assessed by the nurse. Teaching the visitors and patients about limitations and designing an appropriate visit schedule should be done by the nurse with consideration of the patient’s wishes and his/her limitations. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 3: Subtle changes in behavior such as restlessness or anxiety are considered early signs. Orthostatic blood pressure is manifest after patient loses 1000-1500 mL of blood. Decreased red cell count may not be evident in the early stages. Decreased urine output is a compensatory mechanism that indicates that blood is being shunted away from the kidneys in order to preserve the brain and heart.

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Answer Key 131

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Answer 3: The patient has a risk for internal bleeding (risk for hypovolemic shock) and peritonitis (risk for septic shock). If the pain is worse, the nurse would reassess the pain and then call the health care provider to report findings. Using SBAR (situation, background, assessment, recommendations), the nurse could ask for orders for diagnostic testing or for a change in pain medication.

Answer 1: While waiting for the health care provider to call back, the nurse should enlist the UAP to take and report vital signs. The other actions are correct, but the nurse is responsible for those tasks. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 3: Blood thinners, aspirin, antiinflammatory medications and vitamin E are likely to be discontinued before surgery.

Answer 4: Pain is likely to be severe due to tissue ischemia. The other symptoms could also occur.

Answer 1, 3, 5: Patients with sickle cell disease should avoid high altitudes, flying in unpressurized planes, dehydration, extreme temperatures, iced liquids, alcohol, and vigorous exercise. Patients should not smoke and should protect extremities from injury because of impaired circulation. Patients with sickle cell disease have frequent problems with infections. It is important for the patient to remain current with vaccinations and take prophylactic antibiotics to protect against these infections.

Answer 2: In polycythemia, the blood is very viscous and there is an increased risk of deep vein thrombosis. There is a potential for lifethreatening pulmonary emboli if the clot breaks off and travels to the lungs. The nurse would perform all of the other assessments as part of total patient care.

Answer 2: For the patient’s safety and protection from infection, the nurse would initiate protective isolation, wash hands, and don appropriate apparel (e.g., mask, gown, gloves), then check the patient for signs of infection.

Hand hygiene is important to stress to the patient, but it’s more important to inform visitors and all caregivers. The medication list should be reviewed because adverse reactions to medication is the primary cause of agranu-

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locytosis (severe reduction of white cell components).

Answer 1: Drawing pictures and storytelling will help the child express fears and worries.

The child is likely to need protection against infection and be in protective isolation.

Treatments include chemotherapy and bone marrow transplant. In addition, the usual processes that combat infection are altered. Exposure to animals, plants, or other people should be avoided during neutropenic episodes.

Answer 1, 2, 3, 4: Ecchymoses and petechiae suggest that the patient bruises very easily.

This could be the result of a coagulation disorder or a medication such as prednisone. The nurse asks questions to determine if the patient has noticed bleeding from other sources.

Asking the patient about the cause of bruises is also appropriate to identify specific trauma or injury to the bruised areas. Hydrocortisone cream is not useful in this case. Dietary assessment is always useful, but in this case is more related to the patient’s general health than to the specific finding of ecchymoses and petechiae.

Answer 2: With a low platelet count, the nurse initiates bleeding precaution measures.

Placing pressure on the arms or legs during movement can cause bruising. A mask is not necessary, but good hand hygiene is always appropriate. Patients with sickle cell disease would be encouraged to drink fluids to prevent dehydration. Patients with red blood cell disorders are more prone to fatigue; however, the nurse would assess all patients for ability to achieve ADLs and instruct the UAPs accordingly.

Answer 4: Non-contact sports such as golf would be recommended because of the potential for injury in other sports.

Answer 1: In the early stages, the patient may report a painless enlargement of a cervical, axillary, or inguinal lymph node. Night sweats, weight loss, and fever are “B” symptoms associated with a poor prognosis. Alcoholinduced pain is a feature associated with Hodgkin’s, but does not consistently manifest in every patient.

Answer 2, 3, 4: By the time non-Hodgkin’s is detected and diagnosed, the disease is usually widespread. Involvement of the digestive organs is likely, but the lymph system could spread the disease and cause pressure in any area. Pleural effusion, bone fractures, and

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Answer Key 132

paralysis are possible complications. Chemotherapy is the mainstay of treatment for nonlocalized disease. The prognosis is worse than Hodgkin’s and the diagnostic testing and treatment are rigorous, so it is likely that the patient and family will need support. Localized pain in the spine that increases with movement is more associated with multiple myeloma. Total assistance for ADLs is not anticipated until the end stage of the disease.

Critical Thinking Activities Activity 1 31. a. Pernicious anemia b. The Schilling test for pernicious anemia is being replaced by a serum test called megaloblastic anemia profile c. Vitamin B12 injections, folic acid supplements, iron supplements, possible transfusions d. The treatment must be lifelong. Failure to maintain treatment will result in death.

Activity 2 32. a. Iron deficiency anemia b. Female, due to the occurrence of menses, recent pregnancy, history of stomach surgery c. Tachycardia, spoon-shaped fingernails, headache, burning tongue; desire to eat clay, starch, and ice d. Iron supplements may be contraindicated in peptic ulcer disease.

Side effects include gastrointestinal (GI) upset (nausea, vomiting), constipation or diarrhea, and green to black stools.

Iron is absorbed best from the duodenum and proximal jejunum. Therefore enteric-coated or sustained-release capsules, which release iron farther down in the GI tract, are counterproductive; they are also more expensive.

If side effects develop, the dose and type of iron supplement may be adjusted.

Some people cannot tolerate ferrous sulfate because of the effects of the sulfate base. Ferrous gluconate may be an acceptable substitute.

Iron is best absorbed in an acidic environment. To avoid binding the iron with

food, iron should be taken about an hour before meals, when the duodenal mucosa is most acidic. Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also enhances iron absorption.

Do not administer with an antacid because it reduces the absorption of iron.

If a dose is missed, continue with schedule; do not double a dose.

Iron may interfere with absorption of oral tetracycline antibiotics and quinolones (Cipro, Levaquin, Noroxin). Do not take within 2 hours of each other.

Dilute liquid iron preparations in juice or water, and administer with a straw to avoid staining teeth. Provide oral hygiene after taking.

Check for constipation or diarrhea.

Record color (iron turns stools green to black) and amount of stool.

Iron is toxic, and caution must be taken to store iron preparations out of a child’s reach.

Activity 3 33. a. Ambulation helps counter hypercalcemia because weight-bearing helps the bones reabsorb some calcium. Calcium reabsorption in the bones decreases the risk of pathologic fractures. Fluids prevent dehydration and dilute calcium and prevent protein precipitates that can cause renal tubular obstruction. b. First, the nurse would assess the pattern of pain and plan activities for when pain is lower and energy is higher. Medicate the patient 30-40 minutes before ambulation and explain the benefits of ambulation. Obtain assistive devices as needed; for example, a wheelchair can be nearby if the patient wants to stop and rest. To increase sense of control, encourage the patient to take an active role in the design of the ambulation program. Enlist the family as appropriate. Setting small goals—for example, walking to the end of the hall— is also helpful.

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Answer Key 133

Activity 4 34.

Assessment

Malaise, fatigue, and weakness. Patient may relate history of illness, easy bruising, bleeding tendencies with petechiae and ecchymoses. Nonhealing cuts and bruises, draining lesions, jaundice, and palpable subcutaneous nodules. Edema and tenderness in lymph nodes. Gastrointestinal symptoms, cardiovascular and respiratory changes. Neurologic symptoms such as headache, numbness, tingling, paresthesia, and behavioral alteration. System-by-system approach to confirm patient’s report of symptoms.

Nursing diagnoses

Risk for infection; Risk for injury (bleeding, falls); Fatigue; Deficient knowledge; Pain, acute; Pain, chronic; Ineffective tissue perfusion; Impaired gas exchange; Activity intolerance; Ineffective coping; Impaired skin integrity.

Planning

Determine the priority for nursing interventions from the list of nursing diagnoses according to Maslow’s hierarchy of needs and set goals accordingly.

Implementation

Place patient in private room. Avoid contact with visitors or staff members who have an infection. Stress careful handwashing to the patient and other caregivers.

Assist in planning daily activities to include rest periods to decrease fatigue and weakness. Oxygen is given for dyspnea or excessive fatigue with exertion. Patient teaching stresses the disease process and continued medical follow-up.

Evaluation

Patient shows no signs of infections; temperature and WBC count are within normal limits. Patient has not fallen. Patient shows no signs of bleeding, or bleeding is controlled quickly. Patient is able to bathe self in 30 minutes without fatigue. Patient is able to explain measures to prevent infection and measures to prevent hemorrhage. Patient states no shortness of breath.

CHAPTER 47—CARE OF THE PATIENT WITH A CARDIOVASCULAR OR A PERIPHERAL VASCULAR DISORDER Tracing a Drop of Blood 1.

Superior or inferior vena cava → right atrium → tricuspid valve → right ventricle → pulmonary semilunar valve → pulmonary artery → capillaries in the lungs → pulmonary veins → left atrium → bicuspid valve → left ventricle → aortic semilunar valve → aorta Impulse Pattern 2.

SA node → AV node → bundle of His → right and left bundle branches of AV bundle → Purkinje fibers Figure Labeling 3.

See Figure 47-6, p. 1537. a. Anterior right atrial branch of right coronary artery b. Right coronary artery c. Marginal branch of right coronary artery d. Anterior interventricular branch of left coronary artery e. Marginal branch

f. Circumflex branch of left coronary artery g. Left coronary artery Matching 4. f 5. e 6. d 7. q 8. b 9. a 10. k 11. m 12. j 13. i 14. g 15. r 16. h 17. t 18. u 19. v 20. c 21. l 22. w 23. n 24. o

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Answer Key 134

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Fill-in-the-Blank Sentence 27. Troponins 1 and 2 28. B6; B12; folate 29. 5 30. Yoga; walking 31. Intermittent claudication 32. smoking cessation Multiple Choice 33. Answer 1: Prothrombin time, International Normalized Ratio, and partial thromboplastin time reflect blood clotting, so these laboratory values are the most important to follow up for patients who are on anticoagulant therapy. The electrolytes are important for heart muscle contraction. Enzyme creatine kinase, creatine phosphokinase, and myoglobin can be used to assist with the diagnosis of myocardial infarction, but troponin levels are now more commonly used. B-type natriuretic peptide is used in the diagnosis of heart failure.

34. Answer 4: Low hemoglobin indicates decreased ability to carry oxygen to the body cells and anemia, so the first action is to make sure that the patient is getting supplemental oxygen. (Oxygen is likely to have been previously ordered for a diagnosis of MI; if not, the nurse should start oxygen and then obtain an order.) The other options could also be included to correct low hemoglobin.

35. Answer 1: During cardiac catheterization, the catheter is inserted into a peripheral vessel (usually the arm or the groin). There is a potential for bleeding or injury to nerves, so pulses and sensation distal to the site of insertion must be checked. Electrocardiograms and positron emission tomography are considered noninvasive.

36. Answer 2: Smoking cessation or at least reducing the number of cigarettes is a modifiable factor. Heredity plays a role, but is considered nonmodifiable. Prophylactic drugs would not be the first line of therapy for this healthy patient. Discussions of diet and exercise would be more appropriate. Body mass index of 30 is too high because this indicates obesity.

37. Answer 2: Elevation of blood glucose is thought to contribute to damage to the arterial intima and contribute to atherosclerosis.

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Answer 4: Recent studies indicate that type D personality has the highest risk for cardiovascular problems because of increased anxiety and depression. The type A personality who is in a hurry and often angry or irritated was formerly believed to have the highest risk.

Answer 2: The monitor is showing a normal sinus rhythm. (Note to student: If there is ever any doubt about the monitor function or display or if you doubt your interpretation of the ECG tracing, just check on the patient.)

Answer 4: Recall that bearing down is one way to cause vagal stimulation. The other options can also cause sinus bradycardia, but are less likely to have such a rapid recovery to a regular rate.

Answer 3: In third-degree heart block, the impulses to stimulate heart muscle contraction are not being transmitted through the AV junction. The rate is very slow and symptoms of hypotension and angina are likely.

Answer 1: For this patient, there is an increased risk for ventricular fibrillation. The patient may or may not have symptoms during the episodes, but aggressive treatment is likely in order to prevent ventricular fibrillation, which is a lethal dysrhythmia. Betaadrenergic blockers are used in the ongoing suppression of ventricular tachycardia.

Answer 2: Ventricular fibrillation can be reversed if an electrical countershock is applied using the defibrillator. If defibrillation fails to convert the dysrhythmia, a bag-valve-mask with supplemental oxygen and a crash cart will be needed. A temporary pacemaker is not typically used for ventricular fibrillation.

Answer 4: The arm on the pacemaker side should be immobilized for the first several hours; then for 6-8 weeks, the patient must refrain from lifting the arm over the head.

Climbing stairs and participation in active sports are more related to recovery during cardiac rehabilitation. Electrical sources may interfere with the pacemaker’s fixed mode.

Answer 4: Stents are thrombogenic; thus, the patient is likely to be prescribed an anticoagulant.

Answer 2: Applying patches in the morning and removing them at bedtime prevents the development of tolerance. Nitroglycerin tablets should always be carried in a pocket or purse for immediate availability. A burning sensation under the tongue is expected dur-

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Answer Key 135

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ing activation of the tablet. Up to three tablets should be taken to determine if pain relief is adequate.

Answer 3: Pain is the foremost symptom and is the target of immediate therapy, because pain is a signal of ischemia. Diaphoresis is secondary to pain or possibly hypotension.

Palpitations could occur, but are not a typical complaint. Shortness of breath is related to the body’s attempt to increase oxygen to the tissues.

Answer 4: Fortunately, rheumatic fever now occurs less frequently in the United States, because treatment for group A β-hemolytic streptococci infections has improved. For older patients or for patients who have emigrated from undeveloped countries, the possibility for rheumatic heart disease still exists.

Answer 3: First, the nurse would determine if the correct dose and form of the nitroglycerin were taken. If the nitroglycerin was taken correctly, than the nurse may opt to quickly assess for other symptoms that suggest cardiac or digestive problems. Based on the assessment, the nurse may decide to call 911 or the health care provider. The neighbor should not drive himself to the hospital.

Answer 2: Thrombolytics are not used for patients with active internal bleeding, suspected aortic dissecting aneurysm, recent head trauma, history of hemorrhagic stroke within the past year, or surgery within the past 10 days.

Answer 4: For 24-48 hours, the patient is usually limited to getting up to the bedside commode; thereafter, the activity is gradually increased, but the nurse should carefully assess the patient before and after exertion and then give the UAP additional instructions about how to assist the patient.

Answer 4: Teaching him how to read the labels gives him a practical skill that he can use at the grocery store. The other options are incorrect. Healthy fats that do not exceed 30% of the total calories are part of good nutrition.

Fiber intake should be 20-30 grams.

Answer: 2.27 rounded to 2.3 liters.

One liter of fluid equals 1 kg (2.2 pounds); a weight gain of 2.2 pounds signifies a gain of 1 liter of body fluid.

2.2 pounds : 5 pounds = 2.272 1 liter x Answer 1: The patient is describing a corrective action that he uses to deal with orthop-

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nea. Worsening heart failure is accompanied by fluid retention and it is likely that sleeping in a chair is causing the fluid to collect in the lower extremities. As the edema worsens, the abdominal girth will increase and the breathing will become more labored as the fluid progresses upwards. The nurse is also likely to assess compliance with diet and medications.

The home health nurse has an additional advantage of being able to look at the environment. Climbing stairs or navigating distances between rooms may be an issue as the patient becomes progressively more fatigued.

Answer 3: Digoxin should be held for a pulse under 60/min. The other actions are correct.

Answer 2: Remember the priorities of airway and breathing and give the patient oxygen.

Next establish a peripheral IV for morphine and diuretics. Arterial blood gases and auscultating lung sounds will assist in the diagnosis, but the patient is in severe distress and the symptoms are attended to first.

Answer 3: The UAP can weigh the patient. The other tasks are nursing responsibilities. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 1: In pericarditis, the membranous sac that surrounds the heart becomes inflamed. Fluid collects in the sac and the heart becomes compressed by the pressure of the fluid. The effusion restricts the movement of the heart (cardiac tamponade).

Answer 3: Endocarditis puts the patient at risk for emboli that can travel to any organ.

Sudden shortness of breath suggest that a large embolus or numerous small emboli have lodged in the lungs. The other signs/symptoms are part of the presenting clinical manifestations.

Answer 2: The grandmother is historically correct in thinking that patients die within a year, so she may be thinking about something that happened in the past. Giving her accurate and up-to-date information can help her reevaluate her granddaughter’s chances for recovery.

Talking about surgical procedures is premature at this point. Telling her about heart rest and staff taking care of the child are okay, but these are generalized statements that do little to explain the therapeutic advantages of current treatment.

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Answer Key 136

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Answer 3: Cardiomyopathy caused by cocaine abuse is seen more frequently now than ever before. Cocaine causes intense vasoconstriction of the coronary arteries and peripheral vasoconstriction, resulting in hypertension.

Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The prognosis is poor. Excessive alcohol intake over a prolonged period of time also increases the risk.

Answer 1: Transplant patients need immunosuppressive therapy and protective isolation.

Pericardiocentesis is performed for cardiac tamponade. Percutaneous transluminal angioplasty is diagnostic and reparative for coronary artery disease or embolism.

Answer 4: The prehypertensive category was created to help people recognize that small increases in blood pressure can have large consequences on health. Patients would be advised about controlling modifiable risk factors and encouraged to participate in routine health appointments.

Answer 3: For arterial insufficiency, the leg should be dependent, because this will increase the blood flow to the tissues and help decrease the pain. The other options are likely to increase pain. Elevation and ice will decrease the blood flow. Exercise must be balanced with rest.

Answer 1: Dark-green vegetables contain vitamin K which counteracts the effect of the anticoagulant drug.

Answer 2: The patient is showing signs and symptoms of a ruptured aneurysm and hypovolemic shock. The nurse would place the patient in a shock position and immediately call for help. (Note to student: See Chapter 46 nursing interventions for hypovolemic shock for additional information. Rapid response team, code team, or hospitalist may be available in different facilities.) The patient does need a patent IV. Giving pain medication is not a priority, although oxygen should be started.

Answer 3: Early ambulation and encouraging mobility, which includes change of position and range-of-motion exercises are the most important preventive measures. Compression stockings and calf measurements are part of prevention and detection. Elevating the legs may be ordered as a comfort measure if DVT occurs.

Critical Thinking Activities Activity 1 68. a. Myocardial infarction b. A myocardial infarction results from the occlusion of a major coronary artery or one of its branches. This leads to ischemia. c. 12-lead ECG, chest radiograph, cardiac fluoroscopy, myocardial imaging, echocardiogram, PET scan, or multigated acquisition scanning (MUGA). Blood workup may include electrolytes, CBC, ESR, serum cardiac markers: CK-MB, myoglobin, troponin-I d. Prevention of further tissue damage, interventions to promote tissue perfusion e. Monitor vital signs, administer oxygen, monitor pain, administer medications as ordered Activity 2 69. a. Native American, history of hypertension b. Nitroglycerin, aspirin, beta-adrenergic blocking agents such as propranolol, metoprolol (Lopressor), nadolol (Corgard), atenolol (Tenormin), and timolol (Blocadren); and calcium channel blockers such as nifedipine (Procardia), verapamil, diltiazem, and nicardipine (Cardene)

For patients unable to tolerate aspirin, ticlopidine (Ticlid) or clopidogrel (Plavix) may be given. c. Angina pain is caused by the temporary lack of oxygen and blood supply to the heart.

Activity 3 70. a. Changes in the cardiac musculature lead to reduced efficiency and strength, resulting in decreased cardiac output.

Disorientation, syncope, and decreased tissue perfusion to organs and other body tissues can occur as a result of decreased cardiac output. Arterial disease resulting from the aging process causes hypertension because of the increased cardiac effort needed to pump blood through the circulatory system. Edema, secondary to heart failure, may cause tissue impairment in the immobile older adult. Immobility leads to venous stasis, venous ulcers, and poor wound healing. It also increases the risk of venous thrombosis and embolus formation. Older adults

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Answer Key 137

with cardiac disease often receive several medications. Even with lower doses of medications, the older adult may suffer toxicity, since the rate of drug metabolism and excretion decreases with age. Independent older adults with cardiac conditions should receive adequate teaching regarding medication, diet, and warning signs of complications. Encourage them to maintain regular contact with the health care provider and to seek care at the first sign. b. Signs and symptoms of heart failure include: Decreased cardiac output • Fatigue • Anginal pain • Anxiety • Oliguria • Decreased gastrointestinal motility • Pale, cool skin • Weight gain • Restlessness Left ventricular failure • Dyspnea • Paroxysmal nocturnal dyspnea • Cough • Frothy, blood-tinged sputum • Orthopnea • Pulmonary crackles (moist popping and crackling sounds heard most often at the end of inspiration) • Radiographic evidence of pulmonary vascular congestion with pleural effusion Right ventricular failure • Distended jugular veins • Anorexia, nausea, and abdominal distention • Liver enlargement with right upper quadrant pain • Ascites • Edema in feet, ankles, sacrum; may progress up the legs into thighs, external genitalia, and lower trunk c. Heart failure is managed with digoxin, vasodilators, ACE inhibitors, beta blockers, and angiotensin II receptor blockers.

Nesiritide is the first of the drug class called human BNPs. It reduces pulmonary capillary pressure, improves breathing, and causes vasodilation with increase in stroke volume and cardiac output.

d. Teach the patient to monitor for signs and symptoms of recurring problems such as shortness of breath; swelling of ankles, feet, or abdomen; and frequent nighttime urination. Plan activity to provide for rest periods; take medications as prescribed; report signs of nausea, pain, lightheadedness, and syncope to the doctor. Eat foods high in potassium and low in sodium if taking diuretics. Avoid alcohol when taking vasodilators.

Activity 4 71. a. Venous stasis ulcers result from vein insufficiency causing stasis of blood. People who are homeless spend a lot of time with their legs in a dependent position. This puts greater strain on vessels. The corrective measure is to lie down and elevate legs, but this is not always possible for homeless persons. Poor nutrition, exposure to the elements, and lack of access to hygienic facilities impairs healing of ulcers. b. P for pulses: Assess the patient’s affected extremity first. Compare the findings with previous ones or correlate them with the patient’s signs and symptoms. Pulses should be present in venous disorders, but edema may interfere with palpation.

Use a Doppler as needed.

A for appearance: Note whether the extremity is pale; mottled; cyanotic; or discolored red, black, or brown.

T for temperature: If the problem is venous, the extremity will feel normal or abnormally warm.

C for capillary refill: Capillary refill is normally less than 2 seconds, but it may be extended when the patient has PVD.

H for hardness: Palpate the extremity to determine whether the tissues are supple or hard and inelastic. Hardness may indicate long-standing PVD, chronic venous insufficiency, lymphedema, or chronic edema. Hardened subcutaneous skin also increases the risk of stasis ulcers.

E for edema: Pitting edema frequently indicates an acute process, and nonpitting edema may be seen with chronic conditions, such as venous insufficiency. Assess both extremities for edema and compare and document the findings.

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Answer Key 138

S for sensation: In addition to asking the patient about pain, ask if he or she has other abnormal sensations, such as numbness or tingling, or heat or cold. c. Visibly ulcerated skin having dark pigmentation, dryness, scaling, and edema may occur. Dull aching pain relived by elevation of the extremity. Peripheral pulses are usually present with venous insufficiency. Pain, aching, and cramping associated with venous disorders are usually relieved by activity and/or elevating the extremity. d. The focus is on promotion of wound healing and preventing infection. Dietary management including adequate protein intake with supplements of vitamin A and C, and mineral zinc. Débridement of necrotic tissue, antibiotic therapy, and protection of ulcerated areas. Homeless patients may need assistance in obtaining medication or nutritious foods. The nurse should suggest ways to adapt wound care and instruct about elevating legs whenever possible.

Activity 5 72. Recall the patient teaching points when you are doing the food product calculations.

• Recommended daily intake is 2 g sodium, 1500 calories, low cholesterol, and fluid restrictions.

• Limit total fat intake to 25% to 35% of total calories each day. Limit intake of saturated fats to less than 7% of total fat intake. Teach the patient that saturated fats (e.g., shortening, lard, or butter) are solid at room temperature; better sources of fat include vegetable, olive, and fish oils.

• Teach the patient to avoid foods high in sodium, saturated fats, and triglycerides.

Review alternative ways of seasoning foods to avoid cooking with salt. Explain the need to limit intake of eggs, cream, butter, and foods high in animal fat. Teach the patient and family how to read labels on foods.

• Teach the patient to eat 20-30 g of soluble fiber every day. Foods such as bran, beans, and peas help lower bad cholesterol (low-density lipoprotein).

Recommendations will be based on what you found on the shelf. Typically, canned foods are higher in sodium than fresh foods

and frozen premade meals are higher in fat.

For elderly housebound people, canned or frozen food is likely to be more convenient, but some product lines are better than others. One suggestion for single elders (or busy nursing students) is to make a batch of healthy homemade soups, beans, casseroles, etc., and freeze in single-serving portions.

CHAPTER 48—CARE OF THE PATIENT WITH A RESPIRATORY DISORDER Matching 1. d 2. e 3. f 4. b 5. g 6. h 7 a 8. c 9. j 10. i Fill-in-the-Blank Sentences 11. capillaries 12. 2; 3 13. carbon dioxide; oxygen 14. increased; decreased 15. Nasal polyps True or False 16. False: The right mainstem bronchus is larger and more vertical; therefore, foreign bodies are more likely to go to the right.

17. False: Lung cancer is the leading cause of death from cancer for men and women.

18. True 19. True Table Activity 20. pH

7.35-7.45

Paco2

35-45 mm Hg

Pao2

80-100 mm Hg

HCO Sao2

– 3

21-28 mEq/L 95%

Multiple Choice 21. Answer 3: Air cannot pass over the vocal cords, so normal speech is impossible. The

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Answer Key 139

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patient can breathe through the tracheostomy opening. Secretions will be produced, but interventions relate to keeping the skin around the opening clean and dry. The esophagus and trachea do not communicate, so choking is not anticipated.

Answer 1, 2, 3, 5, 6: The nurse would ask the patient to describe symptoms, onset, alleviating factors, and changes in ability to perform activities of daily living (ADLs). Patients with chronic lung disorders are likely to have had abnormal blood gas results (some may keep track of these results), but these findings are not relevant to the current status.

Answer 4: Flaring of the nostrils is usually considered a late sign. Increased respiratory rate is associated with many conditions. Some are serious (e.g., pulmonary edema), and others are benign (aerobic exercise). Adventitious breath sounds can be present and the patient may not be aware that there is a problem (e.g., immobile patients can have crackles). The orthopneic position does signal respiratory distress, but is also used by many patients who have chronic respiratory disorders.

Answer 2: Trauma combined with uneven chest expansion are associated with pneumothorax (collapsed lung).

Answer 1: The advantage of the helical computed tomography scan is that the entire study can be performed in less than 30 seconds. The disoriented patient may have difficulty cooperating for a V-Q scan or pulmonary angiography, as both are much longer procedures. A flat plate of the abdomen is the best exam for ingested foreign bodies. A mediastinoscopy will be performed to obtain lymph tissue. A chest x-ray will be performed for the patient exposed to tuberculosis.

Answer 2: The UAP can assist the patient to move and make position changes. The other tasks are nursing responsibilities. (Note to student: The UAP could ordinarily be expected to watch for and report seeing blood in specimens; however, some blood is an expected finding after biopsy and the nurse should do the assessment to determine if bleeding is excessive.) (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 1: The goal of thoracentesis for therapeutic reasons is to remove fluid from the

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thoracic cavity. Positioning the patient upright will facilitate the drainage.

Answer 3: Usually no more than 1300 mL of fluid is removed at one time because there is a risk of intravascular fluid shifting that will result in pulmonary edema. Because of the risk for pulmonary edema, the nurse is likely to increase the frequency of assessment. Giving the patient extra fluid could worsen fluid shifting. If the purpose was therapeutic, the fluid may or may not have been sent to the laboratory for analysis.

Answer 4: Warfarin is an anticoagulant, so the nurse would hold pressure on the puncture wound for 20 minutes to prevent a hematoma.

Answer 2: The student remembers that the automatic blood pressure cuff occludes blood flow to the distal portions of the extremity, so the first pulse oximeter reading is likely to be falsely low.

Answer 3: With epistaxis, frequent swallowing suggests that the blood is running down the back of the throat. This could either be rebleeding or posterior bleeding. Posterior bleeding is not always resolved with anterior packing.

Answer 1, 2, 3, 6: The goal is to keep the nasal mucous membranes moist, so a vaporizer, saline nose drops and lubricants are recommended. Nose picking and putting other objects into the nose should be avoided; this point is emphasized with pediatric patients.

Aspirin is considered an anticoagulant. Blowing vigorously can restart bleeding. (Note to student: The health care provider may have had the patient blow vigorously just prior to examination, so the patient may assume that the action is okay.)

Answer 1: The nurse can administer the allergens and should mark the sites. The localized reaction should be measured and documented. The health care provider is responsible for evaluating the outcomes of the test, discussing allergens to avoid, and instructing the patient about ambiguous results. The nurse can reinforce what the health care provider tells the patient, but should not initiate discussion of findings. Allergy testing and interpretation of results is not an exact science.

Answer 3: The universal sign for choking is hand over the throat. People who are vigorously coughing should be encouraged to continue coughing. While running out of the room is not an obvious signal, people have

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Answer Key 140

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been known to leave out of embarrassment.

Waving hands frantically is a signal, but cause would have to be assessed.

Answer 3: Resting the voice is the most important measure to reduce the inflammation of the vocal cords. The other measures help to promote comfort. Antibiotics are not prescribed for a diagnosis of viral laryngitis.

Answer 2: A rapid strep test is performed to detect the presence of β-hemolytic streptococci, which is a severe form of acute pharyngitis.

If those results are negative, then the second swab is used to culture a medium and is allowed to grow so the infecting organism can be identified.

Answer 3: The patient has symptoms of sinusitis. Transillumination involves shining a light in the mouth with the lips closed around it; infected sinuses will look dark, whereas normal sinuses will transilluminate.

Answer 4: Dairy products thicken secretions, so they become more tenacious and harder to expectorate.

Answer 4: The symptoms will mimic other respiratory disorders; thus, diagnosis is delayed because more common causes will be investigated first. During this delay, the infection will become more entrenched. Legionnaires’ and SARS can be transmitted via droplets in air, so many people could be exposed before the diagnosis is made. Anthrax has been identified as a possible bioterrorism agent. Morbidity is high for all three disorders. For Legionnaires’ disease, 15-20% have died in localized epidemics. For SARS, 10-20% require intubation and risk for death is high.

Anthrax responds to antibiotics once diagnosis is made.

Answer 4: The drug regimen is prolonged and for various reasons, many will fail to complete the therapy. This has contributed to multidrug-resistant TB strains. Family and friends are generally not at high risk for contracting TB. Hand hygiene and covering the mouth while coughing are encouraged as the main infection control measures. Mortality rates of 72-89% are noted among HIV-infected people with multidrug-resistant TB strains.

Answer 2: Severe pain in peripheral lung cancer is likely to be caused by a pleural effusion.

The treatment for this is a thoracentesis.

Answer 3: A pleural friction rub is considered diagnostic for pleurisy. The nurse should hear a dry, creaking, grating, low-pitched

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sound with a machinelike quality during both inspiration and expiration. Crackles are interrupted crackling or bubbling sounds more common on inspiration. Sonorous wheezes are deep, loud, low, coarse sounds (like a snore) during inspiration or expiration.

Sibilant wheezes are high-pitched, musical, whistlelike sounds during inspiration or expiration.

Answer 4: Acetylcysteine (Mucomyst) is used to reduce the viscosity of secretions. This makes expectoration easier and more effective.

Answer 1: The UAP can help the patient ambulate, but the nurse must give specific instructions about holding the container below the chest and ensure that the UAP and patient do not place undue pressure on the tubes.

(Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 3: IV fluids are usually withheld to prevent adding fluids to the overloaded patient. (An IV saline lock would be the expected order.) The other orders are appropriate for patients with pulmonary edema.

Answer 2: The nurse would first check vital signs and a pulse oximeter reading and assess for other signs of respiratory distress or decreased cardiac output. Notifying the RN and health care provider would be the next step.

A blood gas is likely to be ordered. Assessing the leg is not helpful once the thrombus becomes an embolus.

Answer 1: Sepsis is the most common precursor of ARDS. The window is 5-10 days after onset of sepsis. ARDS due to injury usually manifests in 12-24 hours. COPD or asthma can be factors as underlying respiratory diseases, but many patients who have COPD or asthma never develop ARDS. Answer 1: Care should be divided into short sessions with intermittent periods of rest. Hygienic care should not be completely deferred; the nurse should determine how the care can be abbreviated or adapted and inform the UAP accordingly. The nurse must assess the patient’s response to ambulation and patient’s ability to participate in range-of-motion exercises and then inform the UAP. Answer 4: An increased number of red blood cells (polycythemia) occurs as the body at-

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Answer Key 141

50.

tempts to increase the oxygen to tissue. Dehydration could contribute to an elevated red cell count, but is not directly related to chronic bronchitis.

Answer 3: For newly diagnosed asthma patients, identification of allergens in the home environment will help them to control/avoid exposure and will decrease episodes of acute attacks. These patients should be able to resume normal activities after treatment for an acute episode.

Critical Thinking Activities Activity 1 51. a. Obstructive sleep apnea b. Risk factors include obesity and male gender. Personal history factors include recent motor vehicle accident caused by falling asleep and reports of loud snoring at night. c. Mild sleep apnea can be corrected by avoiding sedatives and alcohol for 3-4 hours before sleep. Other corrective measures include weight loss, use of oral appliances to bring the mandible and tongue forward to enlarge the airway space, and support groups. In severe cases, nasal continuous positive airway pressure (nCPAP) may be used.

Activity 2 52. a. Symptoms are generally mild. They may include cold symptoms, headache, anorexia, myalgia, and irritating cough that produces mucopurulent or bloody sputum. b. Blood and sputum cultures, chest radiographic studies, complete blood cell count, pulmonary function tests, ABGs, and pulse oximetry c. There is no definitive treatment for viral pneumonia. Medications that may be prescribed include analgesics, antipyretics, expectorants, and bronchodilators. d. Assessments should include vital signs, breath sounds, assess characteristics of sputum, and tolerance of activities.

begin to forget to take medication once the symptoms are resolved. There is also a higher incidence of TB among older people, urban poor, minority groups, immigrants, and the homeless. The barriers to care include financial concerns, access to facilities, problems understanding the provider’s instructions, difficulty with follow-up care, and differences in health values and beliefs.

First the nurse should seek the patient’s opinion on what would help increase compliance and the major stumbling blocks in meeting that goal. Compliance can be increased for some by including family members in the teaching sessions. For others, directly observed therapy allows a health worker to observe while the person takes the medication. Education regarding the dangers of multidrug-resistant strains will encourage some. Others may need help from social services to locate financial resources. Helping the patient link the medication to a routine activity (i.e., brushing teeth) could help. An electronic reminder could be used.

Activity 4 54. a. Assessment should include: • Breath sounds, vital sounds • Note the amount and characteristics of the drainage • Monitor laboratory results— specifically ABGs, WBC count • Observe for bubbling or fluctuations in the drainage bottle b. Keep tubing as straight as possible. Keep all connections tight and taped at connections. Never elevate the drainage collection receptacles above the level of the chest. c. The absence of bubbling in the water seal chamber indicates possible occlusion of the system. d. Bubbling should be intermittent. Constant bubbling indicates a leak in the system.

Activity 3 53. Drug therapy for tuberculosis (TB) lasts between 6 and 9 months and many people will

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Answer Key 142

CHAPTER 49—CARE OF THE PATIENT WITH A URINARY DISORDER Word Scramble 1. anuria

d.

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azotemia

a.

3.

4.

bacteriuria hemodialysis

i. f.

5.

dysuria

e.

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hematuria nocturia

b. c.

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oliguria

h.

9.

prostatodynia

j.

10.

urolithiasis

g.

urinary output of less than 100 mL/day retention of excessive amounts of nitrogenous compounds in the blood bacteria in urine requires access to the circulatory system to route blood through the artificial kidney painful or difficult urination blood in the urine excessive urination at night decreased urinary output , less than 500 mL in 24 hours. pain in the prostate gland formation of urinary calculi

Short Answers 11. a. Controlling body fluid levels by selectively removing or retaining water b. Assisting with the regulation of pH c. Removing toxic waste from the blood 12. a. Filtration of water and blood products occurs in the glomerulus of Bowman’s capsule. b. Reabsorption of water, glucose, and necessary ions back into the blood occurs

13.

primarily in the proximal convoluted tubules, Henle’s loop, and the distal convoluted tubules. This process reclaims important substances needed by the body. c. Secretion of certain ions, nitrogenous waste products, and drugs occurs primarily in the distal convoluted tubule. This process is the reverse of reabsorption; the substances move from the blood to the filtrate.

Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging.

These occur because of weakened musculature in the bladder and urethra, diminished neurologic sensation combined with decreased bladder capacity, and the effects of medications such as diuretics.

• Urinary incontinence can lead to a loss of self-esteem and result in decreased participation in social activities.

• Older women are at risk for stress incontinence because of hormonal changes and weakened pelvic musculature.

• Older men are at risk for urinary retention because of prostatic hypertrophy.

• Urinary tract infections in older adults are often associated with invasive procedures such as catheterization, diabetes mellitus, and neurologic disorders.

• Inadequate fluid intake, immobility, and conditions that lead to urinary stasis increase the risk of infection in the older adult.

• Frequent toileting and meticulous skin care can reduce the risk of skin impairment secondary to urinary incontinence.

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Answer Key 143

Table Activity 14. Urinalysis Color

Constituent

Normal Range Pale yellow to amber

Turbidity Odor pH

Clear to slightly cloudy Mildly aromatic 4.6-8

Specific gravity Glucose Protein Bilirubin Hemoglobin Ketones Red blood cells White blood cells Casts Bacteria

1.003-1.030 Negative Negative Negative Negative Negative Up to 2 LPF 0-4 LPF Rare Negative

Influencing Factors Diabetes insipidus, biliary obstruction, medications, diet Phosphates, white blood cells, bacteria Medication, bacteria, diet Stale specimen, food intake, infection, homeostatic imbalance State of hydration, medications Diabetes mellitus, medications, diet Renal disease, muscle exertion, dehydration Liver disease with obstruction or damage, medications Trauma, renal disease Diabetes mellitus, diet, medications Renal or bladder disease, trauma, medications Renal disease, urinary tract infection Renal disease Urinary tract infection

Figure Labeling 15. See Figure 49-13, p. 1720.

Multiple Choice 16. Answer 2: Phenazopyridine (Pyridium) causes the urine to turn a bright-orange color. The goal is to increase the acidity of the urine, so if the patient is following the recommended diet, the pH should actually decrease. The leukocytes should decrease because of the Bactrim.

Ketones should not be present.

17. Answer 1: Ketones appear in the urine as the body converts fats into energy, because glucose is not available to use as an energy source.

18. Answer 3: WBC casts in the urine indicate involvement of the renal parenchyma in renal disorders, such as acute pyelonephritis or acute glomerulonephritis.

19. Answer 3: The normal range of specific gravity is 1.003-1.030; thus, excessive body water decreases specific gravity. Water intoxication occurs when the patient drinks an excessive amount of water. The other three conditions will cause dehydration and the specific gravity will increase.

20. Answer 2, 3, 4, 5: The serum creatinine test is used to diagnose impaired kidney function.

With normal renal excretory function, the serum creatinine level should remain constant

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and normal. Prostatitis could cause an obstruction to flow, but the kidneys continue to produce urine normally.

Answer 1, 2, 3, 4: The normal range is less than 4 ng/mL. Elevated levels may result from prostate cancer, inflammation or infection, urinary tract infection, or recent cystoscopy or prostatic biopsy.

Answer 3: For renal angiography, the nurse must assess circulatory status of the involved extremity every 15 minutes for 1 hour, then every 2 hours for 24 hours. A kidney-ureterbladder radiography and ultrasonography do not require any special postprocedural care. For the intravenous pyelogram, the patient needs to be encouraged to drink water to flush the dye from the system, and the venipuncture site should be routinely observed.

Answer 3: Cholinergic and anticholinergic medications may be administered during urodynamic studies to determine their effects on bladder function.

Answer 4: Bedrest is instituted for 24 hours after the procedure. Mobility is restricted to bathroom privileges for the next 24 hours, and gradual resumption of activities is allowed after 48-72 hours.

Answer 4: Osmotic diuretics are used for acute renal failure to prevent irreversible failure, but they are contraindicated in advanced

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Answer Key 144

end-stage renal failure. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

26. Answer 2: The patient with urge and functional incontinence will benefit the most from having an external condom, because he is unable to get to the bathroom in time. The patient with Alzheimer’s is likely to pull the external catheter off. If the patient with a urinary tract infection has problems with incontinence, antibiotic therapy should resolve the problem. An enlarged prostate prevents flow, so the external catheter does not address the underlying problem.

27. Answer 4: The nurse would first check to make sure that the tube and catheter are not kinked or obstructed and that the collection bag is below the level of the bladder. Once function of drainage system is checked and low urinary output is verified, the nurse would assess for signs and symptoms of decreased cardiac output, which will eventually contribute to renal failure. The RN and health care provider would then be notified of findings.

28. Answer 2: Spironolactone (Aldactone) is a potassium-sparing diuretic, so it is contraindicated for patients who have hyperkalemia.

29. Answer 2: The nurse would advise the patient that diphenhydramine (Benadryl) can cause urinary retention. This could add problems with passing urine, because BPH can cause an obstruction of urine flow. In addition, the nurse would remind the patient that all OTC medications should be reviewed with the health care provider and on file with the local pharmacist.

30. Answer 1: Kegel exercises are recommended in prevention and treatment of stress incontinence, which is loss of urine during coughing, laughing, sneezing, or straining.

Kegel exercises are recommended for all patients who are able to practice conscious motor control over the pelvic musculature to reduce present or future episodes of incontinence. Some patients who have Parkinson’s or Alzheimer’s may be able to learn Kegel exercises, depending on cognition and motor control.

31. Answer 3: The Foley catheter is inserted to splint and support the suture line after re-

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construction of the urethra; thus, tension on the catheter could result in disruption of the surgical site. The other patients have catheters primarily for drainage purposes.

Answer 1: In nephrotic syndrome, excess fluid in the body is the most common sign. Patients who develop acute glomerulonephritis may report a preceding episode of sore throat or skin infection with fever and malaise. Burning with urination, low-back pain, hematuria, and fever are more associated with cystitis. Dysuria, weak stream, and increasing pain with bladder distention are seen in patients with urethral strictures.

Answer 4: Excess fluid causes edema and hypertension, so the patient is placed on bedrest until those symptoms resolve. The patient is also likely to have orthopnea, so the head of the bed should be elevated.

Answer 2: Albumin and blood in the urine are early indicators of renal failure. Residual urine is a bladder outflow problem that is not related to actual kidney function. Retained urine in the bladder is suspected to contribute to bladder cancer. Ketones in the urine are usually associated with diabetes mellitus, although diet and medication could be factors.

Prostate-specific antigen is a screening test for prostate cancer.

Answer 2: The nurse would auscultate the arteriovenous fistula for bruit (adventitious sound of venous or arterial origin heard on auscultation) and palpate arteriovenous fistula for thrill (abnormal tremor). A nurse should never access the fistula to draw blood, to give fluids or to check patency, unless he/she has had special training in dialysis procedures.

Checking the distal pulses and sensation and asking about pain are routinely done for all patients, but circulation problems to distal tissues and pain are not anticipated.

Critical Thinking Activities Activity 1 36. a. Signs and symptoms include pain in the costovertebral angle, elevated temperature, chills, and pus in the urine. b. Urinalysis: pus, bacteria, and leukocytosis present

IVP: presence of an obstruction or degenerative changes

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Answer Key 145

Activity 2 37. a. Urolithiasis b. Ideally, the stone will be passed without intervention. Fluid intake should be increased and monitored. The urine will be strained to check for the stone or “graveling.” Cystoscopy, surgical incision, or chemolytic medications to dissolve the stone may be ordered. Extracorporeal shock wave lithotripsy is an alternative to surgery. c. Dietary modifications to reduce the level of calcium phosphorus and purinecontaining foods may be indicated. These foods include cheese, greens, whole grains, carbonated drinks, nuts, chocolate, shellfish, and organ meat. Fluid intake of at least 2000 mL/day is also recommended.

Drugs may be ordered to prevent absorption of minerals associated with stone formation.

Activity 3 38. a. The patient may experience anorexia, nausea, vomiting, and edema. Special attention should be paid to signs of hydration, including mucous membranes, skin turgor, and urine output. There may also be signs of drowsiness, muscle twitching, and seizures. b. In the oliguric phase, BUN and serum creatinine levels rise while urinary output decreases to less than 20 mL/hr (less than 400 mL/24 hr). The oliguric phase may last from several days to weeks to months. Some patients may experience the nonoliguric form, usually caused by nephrotoxic antibiotics, in which urinary output may exceed 2 L/24 hr. In the diuretic phase, blood chemistry levels begin to return to normal and urinary output increases to 1-2 L/24 hr. The diuretic phase usually lasts 1-3 weeks. Return to normal or near-normal function occurs in the recovery phase. Recovery begins as the glomerular filtration rate rises. Recovery can take up to 1 year. c. The wife should be advised this would not be the best option. The diet should be low in protein, potassium, and sodium.

Carbohydrates should be high. The items she is proposing to bring in are high in protein and sodium.

Activity 4 39. a. Women are more susceptible to UTIs than men because the urethra is short and proximal to the vagina and rectum. b. Complaints may also include frequency, urgency, and nocturia. Abdominal palpation may also cause discomfort over the bladder. c. Antibiotics and urinary antiseptics d. Teach the woman to cleanse the perineal area from front to back to prevent contamination of pathogens (especially E. coli) from the rectum to the short urethra.

• Encourage drinking 2000 mL of liquids per day unless contraindicated.

• Instruct the patient to take all the prescribed medications, even though symptoms may subside quickly.

• Empty bladder as soon after intercourse as possible. If UTIs are associated with intercourse, recommend cleansing of genitalia with soap and water prior to having sexual relations.

• Shower instead of tub baths.

• Limit use of bubble baths.

• Instruct the patient about early detection and testing with Chemstrip LN. CHAPTER 50—CARE OF THE PATIENT WITH AN ENDOCRINE DISORDER Matching 1. b 2. a 3. d 4. c 5. g 6. h 7. e 8. f 9. k 10. l 11. i 12. j Figure Labeling 13. See Figure 50-1, p. 1726.

Fill-in-the-Blank Sentences 14. antidiuretic hormone (ADH)

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Answer Key 146

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30; 2 to 3 insulin 60-99 mg/dL; 5-6% hypertension, obesity, dyslipidemia Diabetes 45% Table activity (See Table 50-5, p. 1758 for additional information.)

Type of Insulin

Injection Time (Before Meal)

Risk Time for Hypoglycemic Reaction

Peak Action

Duration

Lispro (Humalog)

5-15 min

No meal within 30 min

15-30 min

1-2 hr

Regular Humulin R Novolin R

30 min

Delayed meal or 3-4 hr after injection

30-60 min

2-4 hr

NPH/Regular Mix 70/30 Humulin Mix 70/30

30-60 min

Delayed meal or 3-4 hr after injection

30-60 min

6-12 hr

Lente

30 min

3-6 hr after injection

1-3 hr

6-12 hr

Glargine (Lantus)

Usually take at 9 pm, once daily

Starting dose should be 20% less 1-2 hr than total daily dose of NPH

No pronounced peak

Ultralente

30 min

6 hr after injection

18 hr

Multiple Choice 22. Answer 3: First, the nurse acknowledges the underlying feelings of change and loss.

Option 1 is false reassurance. Option 2 is a platitude. Option 4 may be a possibility after assessment, treatment, and discussion.

23. Answer 2: A school nurse would notify the parents, so the child could be evaluated by a health care provider (for diagnostic testing to rule out giantism). A nurse who works with/ for the health care provider would perform the other options. The health care provider might also contact the school nurse and ask for regular height and weight reports.

24. Answer 1, 2, 4: Nursing assessment and intervention for patients with diabetes insipidus is focused on fluid loss and dehydration. Fluids should not be restricted. Patients should be assisted to ambulate because they may be tired. It is likely that they are frequently walking to the bathroom during the day and at night; thus, encouraging additional ambulation is not necessary.

25. Answer 1: For any of these patients, the nurse would be aware of the possibility of developing SIADH; however, malignancies are the most common cause of SIADH; cancerous cells are capable of producing, storing, and releasing ADH.

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27.

28.

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4-6 hr

Answer 4: Brain edema will result in a change in mental status, progressive lethargy, or changes in personality. These symptoms are followed by seizures and loss of deep tendon reflexes.

Answer 3: All of the findings are positive; however, a gradual increase of serum sodium is the purpose of the therapy.

Answer 3: In the postsurgical period, patients who have had thyroidectomy surgery are encouraged to deep-breathe, but the nurse would check with the health care provider about coughing, because of potential strain on the suture line.

Answer 1: Graves’ disease is hyperthyroidism, so the symptoms that manifest reflect an increased metabolism. Intolerance to cold, constipation, and lethargy are symptoms of hypothyroidism. Skeletal pain, pain on weight-bearing, and paranoia are seen in hyperparathyroidism. Polyphagia, polydipsia, and polyuria are characteristics of diabetes mellitus.

Answer 4: Levothyroxine (Synthroid) is a replacement therapy for patients with hypothyroidism; thus, normalization of TSH levels indicates that the therapy is working.

Normalization of urine specific gravity would be a therapeutic goal for diabetes insipidus.

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Answer Key 147

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Gradual improvement of serum sodium is the treatment goal for SIADH. A blood glucose of 250 mg/dL is used as a target to initiate intravenous dextrose solutions for patients who are being treated for diabetic ketoacidosis.

Answer 2: The patient is displaying symptoms of thyroid crisis. The risk is greatest in the first 12 hours after surgery.

Answer 3: Upon finding a palpable nodule, the health care provider would order diagnostic testing to rule out thyroid cancer. Severe hypothyroidism in adults is called myxedema.

It is characterized by edema of the hands, the face, the feet, and periorbital tissues. Congenital hypothyroidism is called cretinism.

Colloid goiter could manifest as an unsightly enlargement of the thyroid gland or with dysphagia, hoarseness, or dyspnea.

Answer 1: Although the nurse may see that the patient would benefit from a MyPlate review, the dietary restriction related to the hyperparathyroidism is dairy products.

Answer 3: Hyperparathyroidism causes an increase in serum calcium and the goal is to rid the body of the excess. Thiazide diuretics are not used because they decrease renal excretion of calcium and thus increase the hypercalcemic state. Diuretics can be used in acute renal failure to preserve kidney function or in disorders that cause fluid retention, such as congestive heart failure. Diuretics are usually included in the regimen for hypertension.

Answer 2: In this emergency situation, the LPN/LVN recognizes that IV calcium can precipitate hypotension, serious cardiac dysrhythmias, or cardiac arrest. Thus electrocardiographic monitoring is indicated when administering calcium. Assessing for allergies, verifying medication orders, and checking patency of the site are responsibilities of the nurse who is administering the drug. (Note to student: When patients become unstable or critical, the LPN/LVN should notify the health care provider and RN and the RN should assume care and responsibility for the patient. The LVN/LPN uses knowledge and skills during a crisis to contribute to care of patients under the supervision of the RN.) Answer 2: Foods that are low in phosphorus are encouraged because calcium and phosphorus levels are reciprocal. In other words, if the serum phosphorus level is lower, the calcium level will increase, which is desirable for these patients.

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Answer 2: Diabetes insipidus causes production of urine with a very low (dilute) specific gravity.

Answer 3: Simple goiter is usually caused by a dietary insufficiency of iodine.

Answer 3: Cortisol is a glucocorticoid that provides extra reserve energy in times of stress. Aldosterone, the principal mineralocorticoid, regulates sodium and potassium levels by affecting the renal tubules. Glucagon is a pancreatic hormone, which responds to decreased levels of glucose in the blood.

Answer 4: Regular insulin is given via the intravenous route for hyperglycemia.

Answer 2: Corticosteroids should never be abruptly discontinued because of the risk inducing adrenal insufficiency. The other options could be done under the supervision of the health care provider.

Answer 1: The skin is very thin and fragile and easily torn; thus, gentle handling is necessary. The nurse must assess the skin; this cannot be delegated. Frequent washing or shaving could contribute to skin damage.

Answer 3: These are signs of impending addisonian crisis, which is potentially lifethreatening and the health care provider should be notified immediately. The frequency of assessment will increase because of acuity. Documentation is always appropriate, but the patient’s condition must be addressed first.

Answer 2: Recall that epinephrine and norepinephrine are involved in the fight or flight response. Lethargy, constipation, and depression could be evident in many disorders; however, hypothyroidism could cause these symptoms. Kussmaul’s respiration, hypotension, and drowsiness are seen in patients with diabetic ketoacidosis. Excessive thirst, increased urine output, and lethargy are seen in diabetes insipidus.

Answer 4: The glycosylated hemoglobin (HbA1c) blood test measures the amount of glucose that has become incorporated into the hemoglobin within an erythrocyte; these levels are reported as a percentage of the total hemoglobin. Because glycosylation occurs constantly during the 120-day life span of the erythrocyte, this test reveals the effectiveness of diabetes therapy for the preceding 8-12 weeks. The other tests give limited results related to current status.

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Answer Key 148

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Answer 3: Type 1 diabetics have the greatest risk for diabetic ketoacidosis, which can be brought on by minor illness. Presence of ketones should be reported to health care provider.

Answer: 15 mL/hour 100 units : 3 units = 15 mL/hour 500mL x mL Answer 2: This patient is NPO for a procedure, so the nurse decides not to feed this conscious patient, but to use the emergency protocol to administer 50% dextrose. Once the patient has received the bolus, the nurse should recheck the blood glucose and call the health care provider. The nurse cannot make the decision to cancel the procedure.

Critical Thinking Activities Activity 1 49. a. Type 1 diabetes mellitus b. In addition to polyuria, polydipsia, and polyphagia, she may be thin with a sudden onset of symptoms including blurred vision, appearance of halos around lights, and headaches. As the condition progresses, there may be changes in electrolyte balances. c. Insulin injection are given between the fat and muscle layers.

Gently pinch up at least a 2-inch fold of tissue (not just the skin). And quickly insert the needle into the top of the fold, entering the subcutaneous tissue. The needle should be inserted at a 90-degree angle. Inject the insulin slowly. Place the alcohol swab against the needle hub at the injection site, and pull the syringe unit straight out in one swift motion. Do not massage the site. Teach the patient how to rotate sites for injection.

Store insulin and other supplies properly. Patients can be reminded that aspiration does not need to be done before injection and the injection site does not need to be cleansed with alcohol. The open bottle may be stored at room temperature once opened. It is acceptable to store unused bottles in the refrigerator. d. Acute complications include: • Diabetic coma • Hyperglycemic hyperosmolar nonketotic coma • Hypoglycemic reaction

• Increased risk for acute infections

Long-term complications may include blindness, cardiovascular problems, renal failure, and increased risk of chronic infection (that could lead to amputation).

These complications may be avoided or lessened in severity with the appropriate care and attention to the prescribed medication and dietary regimen.

Activity 2 50. a. Radiographic examinations to determine bone age and a skull series to rule out tumors. Serum growth hormone levels will also be evaluated. b. Underdevelopment of the jaw may cause problems with teeth eruption. Sexual development may be delayed. c. The overall prognosis is favorable. Most people with dwarfism are able to reproduce normally. d. Injection of growth hormone replacement Activity 3 51. Diabetes mellitus is more prevalent in older adults. A major reason for this is that the process of aging involves insulin resistance and glucose intolerance, which are believed to be precursors to type 2 diabetes. The classic signs and symptoms of diabetes may not be obvious in older adults. Older adult diabetic patients are at increased risk for infection and should be counseled to receive proper immunizations and seek regular medical attention for even minor symptoms. The older adult often has difficulty managing diabetes. Dietary management may be complicated by a variety of functional, social, economic, and financial factors.

Some symptoms of hypothyroidism in the older adult are similar to those in a younger person but are more likely to be overlooked because the symptoms—fatigue, mental impairment, sluggishness, and constipation—are often attributed solely to aging. The older person with hypothyroidism has more disturbances of the central nervous system, such as syncope, convulsions, dementia, and coma.

There is often pitting edema and deafness.

The older patient with hyperthyroidism frequently has manifestations related only to the cardiovascular system, such as palpitations, angina, atrial fibrillation, and breathlessness. Signs and symptoms often attributed

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Answer Key 149

to “aging” may actually indicate an endocrine problem.

Activity 4 52. Endocrine disorders can mimic other disorders. For example, palpitations can occur in hyperthyroidism, but can also occur in cardiac disorders. Older patients especially can have endocrine disorders that cause disorientation, confusion, or lethargy. These symptoms can be mistaken for other conditions, such as dementia, delirium, drug side effects, or electrolyte imbalances. Patients may not be able to answer questions about history or symptoms because of confusion or coma. Symptom development can be subtle or vague and patients themselves may not be aware that changes are occurring. In addition, many health care professionals are less familiar with endocrine disorders, so cardiac, respiratory, renal, or nervous system disorders may be suspected before endocrine disorders are considered.

CHAPTER 51—CARE OF THE PATIENT WITH A REPRODUCTIVE DISORDER Figure Labeling 1.

See Figure 51-3, p. 1778.

Matching 2. g 3. a 4. e 5. h 6. b 7. i 8. c 9. j 10. f 11. d 12. m 13. l 14. n 15. k

True or False 21. False: Rigorous exercise or the insertion of a tampon may tear the hymen. If the hymen does remain intact, it is ruptured by coitus (intercourse).

22. False: The goal of patient education is to provide information without influencing patient choices, regardless of the nurse’s personal beliefs.

23. False: CA-125 has been touted as a way to detect primary ovarian cancer, but unfortunately it does not do so. CA-125 is useful mainly to signal a recurrence of ovarian cancer and to follow the response to chemotherapy treatment.

24. True Short Answer 25. (a) Producing and storing sperm, (b) depositing sperm for fertilization, and (c) developing the male secondary sex characteristics 26. (a) Educating patient groups likely to have sexual concerns, (b) providing anticipatory guidance throughout the life cycle, (c) promoting a milieu conducive to sexual health, and (d) validating normalcy about sexual concerns 27. (a) Amenorrhea: absence of menstrual flow (b) Dysmenorrhea: painful menstruation (c) Dysfunctional uterine bleeding (DUB), abnormal uterine bleeding (d) Menorrhagia: excessive bleeding in amount and duration (e) Metrorrhagia: bleeding between menstrual periods 28. (a) Cure the infection, (b) prevent reinfection, (c) prevent complications, and (d) prevent infection of the sexual partner(s) 29. (a) Unprotected sex, (b) antibiotic resistance, (c) treatment delay, and (d) sexual behavior patterns and permissiveness Figure Labeling 30. See Figure 51-12 A, p. 1817.

Fill-in-the-Blank Sentences 16. 40 17. 3 18. 9 19. human chorionic gonadotropin (hCG) 20. 55; 70

Multiple Choice 31. Answer 1, 2, 4, 5: Many illnesses—such as diabetes mellitus, end-stage renal disease, hypertension, cancer, certain types of prostate surgery, spinal cord injuries, organ transplants, chronic obstructive pulmonary disease, and heart disease or heart surgery—may cause patients concern or may result in actual inabilities with sexual function. In primary

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Answer Key 150

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syphilis, there may be a rash or painless chancre, but sexual function is not impaired; thus, the risk to infect others continues.

Answer 1: The American Cancer Society recommends that every woman begin annual Pap tests within 3 years after becoming sexually active or no later than 21 years of age. Women age 30 years or older who have had three normal Pap tests in a row may be screened every 2 to 3 years instead of annually. Women who have had a hysterectomy may stop having cervical cancer screenings (unless their surgery was done as a treatment for cervical cancer or precancerous cells).

Answer 3: In testicular biopsy, a sample is obtained by aspiration or through an incision into the testes. For semen analysis, the semen can be obtained by manual stimulation, or by using a condom. The prostatic smear is obtained by massaging the prostate via the rectum. The prostate-specific antigen is a blood test.

Answer 3: Pink-tinged urination, urinary frequency, and burning with urination are considered normal because of the mechanical irritation caused the scope. The other findings are not expected and could signal infection or other complications.

Answer 2: The pain of “menstrual cramps” that are characteristic of dysmenorrhea can be relieved with local heat applications or warm showers. In the other conditions, abdominal pain is not anticipated; in addition for excessive bleeding or irregular bleeding, heat applications could worsen the bleeding.

Answer 1, 2, 3, 4, 5: The nurse is assessing for menorrhagia or abnormally excessive bleeding. Comparing flow and pad/tampon use to regular periods is one way to determine amount of blood loss. Aspirin and anticoagulants could potentiate blood loss. Rigorous exercise is more likely to be associated with amenorrhea.

Answer 1: Premenstrual dysphoric disorder is a severe mood disorder that may be treated with antidepressants.

Answer 3: This patient should be referred to the provider, because the bleeding could be a signal of cancer.

Answer 2: The hormonal changes that accompany menopause lead to decreased bone density. Calcium and vitamin D should be encouraged throughout life to support bone

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health. (See Chapter 43, Medical Management of Osteoporosis for additional information.)

Answer 3: Dyspareunia is pain with sexual intercourse. For postmenopausal women, this could be related to dryness in the vaginal vault. Pruritus is itching. Procidentia is another term for uterine prolapse. Phimosis is a condition in which the prepuce (foreskin) is too small to allow it to be retracted over the glans.

Answer 1: If the patient doesn’t experience any pain, it means that the tubes are occluded, so the gas is not passing through.

Answer 3: First the nurse tries to help the patient identify what things, events, or factors are making him experience this sense of losing power. After initial assessment, the nurse may decide to discuss with the patient feelings about aging, review past accomplishments, or talk about coping strategies.

Answer 1: Sildenafil citrate (Viagra) can potentiate the hypotensive effects of nitrates (nitroglycerin tablets). The nurse would alert the health care provider so the patient can be properly advised. Vitamin B6 supplement and ibuprofen (Motrin) could be prescribed for dysmenorrhea. Cefoxitin (Mefoxin) and corticosteroids are prescribed to treat PID. Danazol (Danocrine) and vitamin E supplement could be prescribed to treat fibrocystic breast disease.

Answer 3: For patients with PID, the Fowler’s position facilitates the flow of vaginal drainage.

Answer 2: Flulike symptoms often occur in the first 24 hours. The other symptoms will occur later.

Answer 4: Tampons and pads should be alternated. The use of super-absorbent tampons is not recommended. Tampons should be changed every 4 hours. The hands should be washed after insertion, but washing them before is the key to preventing toxic shock.

Answer 3: Radiation therapy is usually started 2-3 weeks after surgery, when the wound is completely healed and the patient can comfortably raise her arm over her head.

Answer 2: The technique uses a balloon catheter to insert radioactive seeds into the breast after the tumor is removed (at the time of the lumpectomy or shortly thereafter into the tumor resection cavity). In brachytherapy, an internal radiation therapy, the patient is hospitalized for 48 hours. For external radiation,

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Answer Key 151

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the treatments are usually done 5 days a week for 5-6 weeks Answer 1: Epoetin alfa (Procrit) is helpful in raising erythrocyte counts to help correct anemia. The other drugs could be ordered to control the nausea and vomiting associated with chemotherapy.

Answer 1, 2, 3, 4: Tamoxifen is not used for women who desire continued fertility. The other statements apply to tamoxifen.

Answer 2: Autologous indicates originating within self; thus, the patient donates the bone marrow. Chemotherapy is performed prior to the transplant. Radiation and plasmapheresis are not used.

Answer 2: A cone-shaped section will be cut from the cervix; thus, it is important to monitor for bleeding after the procedure. Schiller’s iodine test is used for the early detection of cancer cells and to guide the health care provider in doing a biopsy. Encouraging fluids is done prior to ultrasound. Refraining from powders, deodorants, or ointments is an instruction given for mammography.

Answer 3: Oral contraceptives may be used to suppress ovulation by inhibiting prostaglandin levels. A recent theory proposes that dysmenorrhea may be caused by hypercontractility of the uterus resulting from higherthan-normal levels of prostaglandins.

Answer 1: Parenteral benzylpenicillin (penicillin G) remains the treatment of choice for all stages of syphilis. In patients who have an allergy to penicillin, tetracycline, erythromycin and ceftriaxone are prescribed.

Answer 4: In the male signs and symptoms of gonorrhea are mild to severe transient urethritis, dysuria, frequent urination, pruritus, and purulent exudate. Genital herpes is characterized by recurrent episodes of acute, painful, erythematous, vesicular eruptions (blisters) on or in the genitalia or rectum. The first sign of primary syphilis is a painless erosion or papule that ulcerates superficially with a scooped-out appearance. In men, signs and symptoms of chlamydia may include a scanty white or clear exudate, burning or pruritus around the urethral meatus, urinary frequency, and mild dysuria.

Answer 3: Pessaries are placed for uterine support. They should be removed and cleaned every 3-4 months. Unattended pessaries can cause erosion, fistula, and carcinoma.

Critical Thinking Activities Activity 1 57. a. Genital herpes b. There is no cure for herpes. The disease can be treated and possibly controlled by lifestyle changes and medications. This initial outbreak may last from 3-10 days. c. Keep the lesions clean and dry. Sitz baths may be helpful. Local anesthetics or systemic analgesics may be administered.

Antiviral therapy may be initiated with acyclovir, valacyclovir, or famciclovir. d. Patient education should include hygiene methods to prevent secondary infections and disease transmission, drug therapy, safe sex practices, and future implications of the disease.

Activity 2 58. a. Menarche begins on average at age 12. b. 1-2 ounces (30-60 mL) c. Estrogen, follicle-stimulating hormone (FSH), luteinizing hormone (LH), progesterone d. Personal hygiene • Wear pads during early period of heavy flow.

• Change tampons frequently to decrease risk of toxic shock syndrome.

• Consult health care provider if tampon use frequently causes discomfort.

• Take a daily shower for comfort; warm baths may relieve slight pelvic discomfort.

• Keep perineal area clean and dry; cleanse from anterior to posterior.

• Wear cotton underwear; remember that nylon pantyhose and tight-fitting jeans retain moisture and should not be worn for extended periods.

• Feminine hygiene products such as vaginal sprays and suppositories may contribute to a feeling of cleanliness.

• A daily douche is not recommended because it changes the protective bacterial flora of the vagina and predisposes the woman to infection.

Activity 3 59. a. Young, single, urban, poor, male, or homosexual, frequent sexual contact with multiple partners, and unprotected sexual

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Answer Key 152

activity are risk factors for STIs. Poor hygiene and poor nutrition are more likely to occur for the homeless and both contribute to infection. Poor nutrition also contributes to problems with menstruation. b. Until personal values are challenged, it is difficult to know exactly how one will react or cope. Having as much information about the new job, the patient population, and self is one way to prepare. Having support systems in place (family, friends, colleagues) is another way to prepare for new experiences.

With regard to gender identity differences, the nurse is likely to encounter gender issues in a large city that she never saw in her small hometown. In the beginning, the nurse may wonder, “Should I use Mr. or Ms. when I am addressing this androgynous person?” “Should I direct this person to the women’s restroom or the men’s restroom?” The nurse will learn to deal with these questions by relying on the principles of therapeutic communication. “How would you like me to address you?” “The restrooms are over there to the right and the left.”

One of the more difficult aspects of being a nurse is trying to be nonjudgmental towards patients who contribute to their own health problems by repeatedly participating in risky behaviors; thus, if the nurse sees the same young woman repeatedly return to the clinic to be treated for STIs, the nurse may think, “What’s the use?” In order to continue in this job, the nurse will have to examine her own beliefs and value system to determine if she can sustain commitment to the patient’s right of self-determination and continue to offer accurate information and compassionate care. The nurse could also decide that for her own sake and for the sake of the patients, she should seek a different type of job in a different environment.

Activity 4 60. The decision to have a child is possibly the most important decision that people make and inability to conceive creates self-doubt.

Diagnostic testing can produce a great deal of anxiety and stress. This testing may continue for fairly long periods with or without favor-

able results. Infertility testing can be expensive and may not be covered by some insurance carriers. Feelings of anger, frustration, sadness, and helplessness between partners and between the couple and health care providers may increase as more tests are performed.

There are many factors that can possibly contribute to infertility. Some of these relate to lifestyle, such as smoking, excessive alcohol use, athletic training, obesity, being underweight, or deciding to delay childbearing.

These factors can produce guilt and contribute to anxiety.

CHAPTER 52—CARE OF THE PATIENT WITH SENSORY DISORDERS 1.

See Figure 52-1, p. 1848.

2.

Crossword puzzle 1

H Y P 2 S E 3 C A T A R A C T R O 4 M A P 5 K E R A T I T I S B I S I A 6 A S T I G M A T I S M 7 O M C I U O 8 9 10 H O R D E O L U M S N 11 M T I Y J Y O T D U O S I R N 12 13 14 P R E S B Y C U S I S M I O T I C S N I L A T Y 15 16 A V E R T I G O T I N N I T U S R I V T 17 P R E S B Y O P I A C I A S T G 18 L A B Y R I N T H I T I S I M S S U S

True or False 3.

False: Most cataracts are age-related.

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True 5.

False: Central vision damaged by macular degeneration cannot be restored. Photocoagulation is preventive, not curative.

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False: There is no apparent relationship between vascular hypertension and ocular hypertension.

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True

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Answer Key 153

Fill-in-the-Blank Sentences 8.

180 9.

10 to 22 10. miotics 11. sweet; salt; sour; bitter Short Answer 12. a. Refraction: light rays are bent as they pass through the colorless structures of the eye, enabling light from the environment to focus on the retina. b. Accommodation: the eye is able to focus on objects at various distances. It focuses the image of an object on the retina by changing the curvature of the lens. c. Constriction: the size of the pupil, which is controlled by the dilator and constrictor muscles of the iris, regulates the amount of light entering the eye. d. Convergence: medial movement of both eyes allows light rays from an object to hit the same point on both retinas.

13. a. Total blindness is defined as no light perception and no usable vision. b. Functional blindness is present when the patient has some light perception but no usable vision. It may be congenital or acquired. c. Legal blindness refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced to 20 degrees.

14. (a) Increased intraocular pressure (IOP) because of obstruction of the outflow of aqueous humor, (b) optic nerve atrophy, and (c) progressive loss of peripheral vision 15. a. In conductive hearing loss, sound is inadequately conducted through the external or middle ear to the sensorineural apparatus of the inner ear. b. In sensorineural hearing loss, sound is conducted through the external and middle ear in a normal way, but a defect in the inner ear results in distortion, making discrimination difficult. c. Mixed hearing loss is a combined conductive and sensorineural hearing loss. d. Congenital hearing loss is present from birth or early infancy. e. Functional hearing loss may be caused by an emotional or a psychological factor. f. Central hearing loss occurs when the brain’s auditory pathways are damaged, as in a stroke or a tumor.

Figure Labeling 16. See Figure 52-13, p. 1875.

Multiple Choice 17. Answer 2: The automated perimetry test is a test for peripheral vision. Loss in the outer fields would make driving very dangerous.

The other tasks require a more focused view of what is straight ahead.

18. Answer 3: During fluorescein angiography, a dye is injected into a vein. The dye could cause a similar allergic reaction for those who react to seafood or iodine.

19. Answer 2: Diplopia is double vision, so reading is going to be very difficult, if not impossible. The patient should be instructed to steady self by grasping the bed rail or the arm of the chair when sitting upright. Foods that can be eaten with the fingers will be easier for this patient. Listening to the radio would be a better distraction than watching television.

20. Answer 2, 4, 5: The purpose of the cane is to determine the boundaries of the walking path and the tip of the cane is used to seek anything obstructing the path. The helper should walk in front of the patient; patient can hold the elbow for security and to detect directionality of helper’s movements. Walking slowly is advised so that objects can be detected.

Descriptions of surroundings help to create a mental picture for the patient.

21. Answer 4: In hyperopia, the patient can see distant objects, but close objects such as fine print are blurry; using over-the-counter eyewear that magnifies fine print may work initially.

22. Answer 2: Contact lenses change the shape of the cornea, so for a week or two prior to the initial evaluation, the health care provider will ask the patient not to wear them. Usually one day is sufficient for rest after surgery. Possibly, anticoagulant medications would be held, but systemic complications related to refractory surgery are unlikely.

23. Answer 3: People who wear contact lenses know they are not supposed to use saliva to clean the lenses; however, many users forget to carry sterile solution or a spare contact case. The nurse should help contact lens users plan ahead. Borrowing solution or lens cases from others is not recommended because of risk for infection. Adolescents generally prefer not to wear glasses, but possibly for active sports they are preferable.

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Answer Key 154

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Answer 3: Use of fresh makeup, individual applicators, and supervising the activity is the best option. This may seem a little costly, but the alternative would be to ban the activity with an explanation about eye infections.

Answer 4: Eye pads are contraindicated because they facilitate bacterial growth. The other actions are correct.

Answer 2: Severe eye pain is associated with this disorder.

Answer 1: Sjögren syndrome is an immunologic disorder characterized by deficient fluid production by the lacrimal, salivary, and other glands, resulting in abnormal dryness of the mouth, eyes, and other mucous membranes.

Answer 4: The eyes feel gritty because of the deficient fluid production in glands of the mouth, eyes, and other mucous membranes.

Answer 1, 2, 4, 5: Ectropion and entropion are characterized by abnormal direction of the eyelid with tearing and corneal dryness. Redness of the sclera may also be present.

Answer 3: The health care provider will use visual inspection and an ophthalmoscopic examination. Amsler’s grid assesses for disturbances in central vision. Snellen’s test assesses visual acuity. Pneumatic retinopexy is a procedure used to correct retinal detachment.

Answer 2: In diabetic retinopathy, microhemorrhages will cause floaters.

Answer 1: This older patient is reporting symptoms of macular degeneration.

Answer 3: Tonometry is most commonly done using puffs of air forced into the open eye. An increased ocular pressure suggests glaucoma.

Answer 1: Photophobia, dryness, burning, or tearing should be reported to the health care provider. The other statements are correct.

Answer 2: Lifting, bending, coughing, or stooping would increase intraocular pressure, which is not desirable in the postoperative period. The surgery should improve the glare that would occur while watching a movie.

Sunglasses are recommended. Sexual activity may be unadvisable for a period of time.

Sleeping with a spouse would be okay unless he/she tended to thrash around during sleep.

Answer 1: High-dose nutritional supplements of zinc, beta-carotene, and vitamins C and E have been shown to reduce the risk of progression to advanced ARMD by 25% (NEI, NIH, 2008). A diet rich in fruits and darkgreen leafy vegetables is also recommended (NEI, NIH, 2008).

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Answer 2: Progressive enlargement of the darkened area means the detachment is worsening and if the retina is not repaired, irreversible blindness will result. Pain is not an expected symptom of detachment. Type 1 diabetics are at risk for diabetic retinopathy and there is an increased risk for cataracts.

Retinal detachment can be related to injury, but is mostly related to aging, not heredity.

Answer 3: Cotton is not used because of potential to scratch the cornea. The other methods are acceptable.

Answer 2: The eye and stick are covered with a cup to prevent dislodgment (cup should be sufficiently large to cover the stick without touching it). Then the camper is taken to the hospital if 911 is not available to respond to the camping site.

Answer 4: If the Romberg test is abnormal, the patient lost his balance when standing erect, feet together, with eyes closed.

Answer 2: A warm compress over the affected ear will help relieve the pain. Swallowing can relieve the pressure, but sobbing and swallowing increase the chance for vomiting. The acetaminophen will work, but recall that pain medication is not as effective if given during the peak of pain. A prescription for a sedative is possible if the pain and sleeplessness are excessive.

Answer 2: Antivert is a medication used in the treatment of vertigo, which causes dizziness and a sensation of spinning.

Answer 1: Keep the patient flat with the operative side facing upward to maintain the position of the prosthesis and graft; make certain that the patient is not turned.

Critical Thinking Activities Activity 1 44. a. Monitor pressure dressing over eye. The dressing should be inspected at least every hour.

Assess for pain on the affected side or any headache. Monitor vital signs. b. Excess bleeding from site, headache, signs of excess blood loss c. Encourage verbalization of specific concerns. Provide support. When appropriate, advise patient that with healing, he can be fitted with a prosthetic device in 4-6 weeks.

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Answer Key 155

Activity 2 45. a. Mastoiditis b. It is the result of a spreading middle ear infection. The patient’s risk was enhanced after not completing the prescribed antibiotic therapy. c. If caught early, treatment will include IV antibiotic therapy and a myringotomy. If the infection has progressed, treatment will include IV antibiotic treatment and a simple mastoidectomy.

Activity 3 46. Nursing interventions for the patient having a vitrectomy include: • The patient is required to maintain a position on the abdomen or sitting forward resting the nonoperative side of the head on a table to allow air that is in the eye to float against the retina. This position is maintained for 4 to 5 days.

• Dark glasses are prescribed postoperatively to decrease the discomfort of photophobia.

• Assessing the eye patch • Applying ice packs • Monitoring vital signs • Assessing the dressing for bleeding Activity 4 47. It is likely that you have a grandparent, parent, or older aunt or uncle who has demonstrated some of the behaviors associated with hearing loss. The symptoms may have been gradual or only a few may have occurred so far. There may be circumstances where the behaviors are more pronounced. Most people adapt to gradual losses and loss of hearing may be more noticeable to those around who are trying to communicate with that person.

Activity 5 48. A sudden loss of any of the senses would be devastating to anyone. Since you are currently in nursing school, the loss would impact your ability to complete your studies. Moreover, imagine how difficult it would be to conduct an assessment of a patient if you couldn’t see or hear. Would you be able to perform patient care if you couldn’t see? How would you administer medication if you couldn’t read the label?

Perhaps you have small children and they rely on you for everything. How would you

adapt and cope so that the impact of your loss did not adversely affect them?

CHAPTER 53—CARE OF THE PATIENT WITH A NEUROLOGIC DISORDER Figure Labeling 1.

See Figure 53-2, p. 1899.

Matching 2. e 3. f 4. a 5. c 6. i 7. g 8. b 9. h 10. j 11. d 12. k Fill-in-the-Blank Sentences 13. central; peripheral 14. motor; sensory; visual; speech; auditory 15. Global cognitive dysfunction 16. Huntington’s 17. 100 True or False 18. True 19. True 20. False: Seventy to eighty percent of people who become infected with the West Nile virus do not have any type of illness.

21. False: Approximately 80% of patients with advanced HIV disease (AIDS) have neurologic symptoms that result from infection from HIV itself or from associated complications of the disease.

22. False: Dementia is not a normal consequence of aging, but may be a result of many reversible conditions, including anemia, fluid and electrolyte imbalance, malnutrition, hypothyroidism, metabolic disturbances, drug toxicity, a drug reaction or idiosyncrasy, and hypotension.

Figure Labeling 23. See Figure 53-7, p. 1915.

Word Scramble 24. Alert e

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Answer Key 156

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Disorientation d Stupor a Semicomatose b Comatose c

Multiple Choice 29. Answer 1, 2, 3, 4, 6: Changes related to aging include slowed reaction time, slowed learning, slight tremors when fatigued, increased difficulty with fine motor movement, and short-term memory loss. Nonpurposeful action like shuffling items is associated with dementia. Ability to locate misplaced items demonstrates a retention of problem-solving ability, despite some forgetfulness.

30. Answer 4: Fund of knowledge is an assessment of the patient’s retention of general knowledge that the average adult should know. The other components are orientation to time, person, and place; assessment of short-term memory; and ability to calculate.

31. Answer 4: The patient is demonstrating the maximum possible score which is 15 total points.

32. Answer 3: The FOUR Score coma scale includes eye response, brainstem reflexes, motor response, and respiration.

33. Answer 3: In motor aphasia, the patient can understand the nurse, but is unable to use the symbols of speech; thus, pointing at pictures or objects and developing a language of gestures will help the patient.

34. Answer 4: The glossopharyngeal nerve is involved in the gag reflex and swallowing movements. The trochlear and abducens nerves are involved in eye movement and the trigeminal is involved in jaw strength, facial sensation, and corneal reflex.

35. Answer 1: In unilateral neglect, the patient is unaware or inattentive to one side of the body; thus, she is unlikely to be able to accomplish any task that requires two hands. It is possible that she would struggle to put on one sleeve.

36. Answer 4: UAP is not expected to assess for numbness or tingling, but should be instructed to report any patient complaints of numbness, tingling, or pain. The patient should be flat in bed and fluids are usually encouraged.

Both measures are to prevent headaches.

37. Answer 3: If the access is at the carotid, hematoma or swelling could cause an airway obstruction. Respiratory effort is the priority assessment. Infection is always a concern, but

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there are no signs immediately after the procedure. Delayed reaction to contrast medium is possible, but usually the chief concern for contrast media is immediately after administration. Nausea and vomiting might occur, but usually nausea will occur in response to the contrast medium and that sensation is generally mild and transient.

Answer 1: The health care provider is likely to suggest acetaminophen, phenacetin, ibuprofen, and aspirin. Narcotics are avoided because these drugs are often subject to abuse; it is much better to counsel patients to develop other ways to relieve headaches. The nurse should suggest nonpharmaceutical measures such as relaxation techniques, regular exercise, adequate sleep, and avoidance of alcohol.

Answer 4: Many foods may contribute to migraines: such as aged cheeses (cheddar and Swiss), cured meats, fermented cabbage (sauerkraut), and soy and fish sauces. Nitrites are present in curing substances used in the preparation of meats such as bologna, ham, hotdogs, and bacon. Other substances that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, and caffeine.

Answer 2: The patient is likely to be more comfortable in a quiet, dark room. The patient can turn self. Warm compresses are not needed. Patient may refuse foods and liquids during the peak of nausea, but does not need to be kept on NPO status.

Answer 3: Gabapentin (Neurontin) is a medication that is prescribed for neuropathic pain.

Diabetics frequently have this type of pain in the lower part of the legs.

Answer 1: Change in level of consciousness is an early sign. The others are late signs.

Answer 2: The fixed and dilated pupil is the most ominous sign, which warrants immediate notification of the health care provider.

None of these reactions are considered normal and all should be pointed out to the health care provider.

Answer 1, 3, 5: Fluid is restricted to avoid adding fluid volume to the system. Flexion of the hips increases intraabdominal and intrathoracic pressure. Oxygen is given to support impaired brain tissue. Head should be in a neutral position. Enemas are not recommended.

Answer 4: In hemiplegia, the upper arm will tend to fall forward, so the counter-position

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Answer Key 157

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is abduction. It is unlikely that the patient can walk safely to the bathroom, even with assistance. The affected arm should be put through ROM exercises. The prone position would be good for the patient, but the nurse should make the determination if the patient can tolerate it, rather than expecting the UAP to make that decision.

Answer 1, 2, 3, 4: Multiple sclerosis is a disease that more frequently develops in young women. The onset is insidious, the symptoms are vague, and there are bouts of exacerbation and remission, but with progressive deterioration. The patient will be discouraged, because many treatments will have been tried, some will give partial symptom relief, but there is no cure and the patient sees herself getting progressively worse to the point of being totally helpless.

Answer 1: The classic triad of Parkinson’s includes tremors, rigidity, and bradykinesia.

Bradykinesia affects the gait and he may be propelled forward until an obstacle stops him.

Stiffness in bending or moving the arms is a sign of rigidity. Tremors affect fine motor control.

Answer 2: Eyelid drooping and double vision are considered early signs. The other signs will come later as the disease progresses.

Answer 3: Stroke risk can be reduced by up to 42% with appropriate treatment of hypertension. Controlling the other factors will also reduce risk.

Answer 4: The nurse would check for unintentional pouching of food on the affected side of the mouth. The other options are incorrect, except use of covered cups is okay.

Answer 1: For thrombolytic therapy, the timing is critical to the outcome. The clinic staff should work towards immediate transfer to a stroke center. If the patient were to suddenly become unresponsive, the clinic staff would stop to intervene; otherwise no action should delay transfer to a stroke center.

Answer 3: The patient may prefer to do his own care, because the face is very painful and he may fear that the UAP will cause pain just by touching. Shaving, combing hair, and hygiene in general can be deferred until the pain is better controlled. Warm puréed foods are best. Cold liquids are likely to increase pain.

Answer 2: Bell’s palsy is an inflammation of the facial nerve and the muscles of the face of the affected side become flaccid. This includes

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the eyelid. The purpose of the eye shield at night is to prevent corneal damage because the eyelid will not close.

Answer 2: The weakness and paralysis will start in the legs and move upwards. The primary concern is that rapid progression upwards will cause paralysis of the respiratory muscles.

Answer 3: For this patient, the reduction of stimuli decreases the risk for seizures, which are a complication of meningitis. The other options are correct rationales for different patient conditions.

Answer 2: Headaches are the most prominent early sign. Patients often report that the headache is more severe in the morning.

Answer 1: Redirection is the best first action, because it is possible that the nurse can get him to focus on something else. Medicating him is possible, but is not the first action to try, because it would be considered a chemical restraint. Allowing him to wander is a possibility, but his agitation could increase. Assigning a UAP is also possible if the nurse believes that the resident is a danger to himself.

Answer 4: Putting the patient in a sitting position decreases the blood pressure, especially the pressure in the head. Bladder distention and fecal impaction are the most common causes, so the nurse would check these and try to resolve the issue. The nurse can direct the UAP to recheck the blood pressure. This is a medical emergency and if the pressure does not come down, the health care provider must be notified so that drug therapy can be started.

Critical Thinking Activities Activity 1 59. a. The nurse protects from aspiration and injury and observes the seizure activity.

The nurse stays with the child and the area is cleared of dangerous objects if possible. The child’s head is supported and protected and if possible, turned to the side to maintain the airway. Restrictive clothing around the neck is loosened. The child is not restrained and no objects are placed in the mouth. b. The nurse would note, record, and report events that preceded the seizure, presence of aura, when the seizure occurred, length

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Answer Key 158

of ictal phase and postictal phase, and what occurred during each phase.

Activity 2 60. a. Transient ischemic attack (TIA) b. Yes, TIAs are significant because at least one in three people who experience them will experience a cerebrovascular accident within 2-5 years. c. Aspirin Activity 3 61. a. See Box 53-2, p. 1934 for the Warning Signs of Alzheimer’s Disease. b. Currently no effective treatment is available to stop the progression of AD, which occurs at a variable rate. The course of the disease can span 5-20 years. The economic costs of AD in the United States is on average $56,800 annually. While portions of this cost are absorbed by insurance coverage, large costs are borne by the family (Ramnarace, 2010). Ultimately, most patients die from complications such as pneumonia, malnutrition, and dehydration. The burden on the individual, the family, caregivers, and society as a whole is staggering. c. Engage in activities that require information processing (e.g., reading, learning a new language, doing crossword puzzles).

Participate in regular physical activity, leisure activities, and educational achievements throughout the lifespan. Antioxidant-containing foods such citrus fruits, dark-green vegetables, tomatoes, brown rice, and foods high in beta-carotene (sweet potatoes and carrots) are considered to lower the risk of the development of Alzheimer’s disease.

CHAPTER 54—CARE OF THE PATIENT WITH AN IMMUNE DISORDER Figure Labeling 1.

See Figure 54-2, p. 1965.

Matching 2. c 3. d 4. b 5. a 6. f

7.

8.

9.

10.

11.

e h i j g

Short Answer 12. (a) To protect the body’s internal environment by destroying foreign antigens and pathogens, (b) to maintain homeostasis by removing damaged cells from the circulation, and (c) to serve as a surveillance network for recognizing and guarding against the development and growth of abnormal cells.

13. a. Recognize self from nonself b. Respond to nonself invaders c. Remember the invader d. Regulate its action

See Box 54-2, p. 1966 for additional information.

14. a. Host response to allergen: The more sensitive the individual, the greater the allergic response is. b. Exposure amount: Generally, the more allergen the individual is exposed to, the greater the chance of severe reaction. c. Nature of the allergen: Most allergic reactions are precipitated by complex, highmolecular–weight protein substances. d. Route of allergen entry: Most allergens enter the body via gastrointestinal and respiratory routes. Injections of venoms and medications hold a more severe threat of allergic response. e. Repeated exposure: Generally, the more often the individual is exposed, the greater the response is.

15. In addition to gloves, latex-containing products used in health care may include blood pressure cuffs, stethoscopes, tourniquets, IV tubing, syringes, electrode pads, oxygen masks, tracheal tubes, colostomy and ileostomy pouches, urinary catheters, anesthetic masks, and adhesive tape.

Multiple Choice 16. Answer 1, 2, 3, 5, 6: Older adults are prone to urinary tract infections and urinary stasis will contribute. Fluids are offered to thin secretions because older adults have trouble coughing up secretions. Skin becomes fragile and dry. Hand hygiene is always appropriate; older adults have increased risk for infection. Oral hygiene is important because saliva

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Answer Key 159

17.

18.

19.

20.

21.

22.

23.

24.

(which fights bacteria) is decreased. High temperatures are not always seen in older adults, even if a serious infection occurs.

Answer 2: Progressively increasing the dose of allergens over time allows the individual to build up a tolerance, but not have the symptoms, because the initial dose is very dilute.

Leukotriene inhibitors such as montelukast (Singulair) are agents that significantly reduce symptoms of an allergic reaction caused by the release of leukotrienes from mast cells and basophils. Antihistamines compete with histamine by attaching to the cell surface receptors and blocking histamine release. Epinephrine produces bronchodilation and vasoconstriction and inhibits further release of chemical mediators of hypersensitivity reactions from mast cells.

Answer 3: Intravenous administration of medication is most likely to produce a rapid reaction if the patient has allergies to the medication, because the circulatory system will rapidly distribute the drug throughout the body. In the other routes, the absorption will be delayed compared to the IV route.

Answer 2: With friends, the nurse may be tempted to joke, but apparently this individual does not understand the physiology of allergic response. Every exposure to oysters has the potential to create a more rapid and rigorous response. Taking Benadryl may seem like a preventive measure to the friend, but abstinence is a better solution.

Answer 4: The nurse could try any of these strategies, but the patient is not able to clearly communicate or report on the complex factors in the home setting. The home health nurse will have better success assessing the situation and helping make immediate recommendations for the patient’s needs. (Note to student: Use critical thinking to determine the best interventions for patients; in this case, making a referral.)

Answer 1: A urine specimen is obtained to assess for hemolysis.

Answer 4: Immunoglobulin levels decrease with age and therefore lead to a suppressed humoral immune response in older adults.

Answer 1, 2, 3, 5: The plasma is generally replaced with normal saline, lactated Ringer’s solution, fresh frozen plasma, plasma protein fractions, or albumin.

Answer 2: Immediate aggressive treatment is the goal in anaphylaxis. At the first sign,

25.

26.

27.

0.2-0.5 mL of epinephrine 1:1000 is given subcutaneously for mild symptoms. The other actions may also be needed if the symptoms progress.

Answer 1, 2, 3: Breastfeeding provides natural passive immunity for the baby. Antivenom after a snakebite and postexposure immunoglobulin provide artificial passive immunity.

Having a disease like measles provides natural active immunity and getting vaccinated provides artificial active immunity.

Answer 2: The patient can have visitors, but ideally the nurse should screen all visitors for potential minor infections, remind them about handwashing, and check to make sure that no potentially infectious items or gifts are brought to the patient. Seven to 10 days is the time for tissue rejection; the UAP is not responsible for knowing how to respond or check for this. An instruction, such as to report pain, could be given. The patient’s medications should not harm a pregnant UAP. Health care staff with a cough or skin infection should not enter the room, even with mask and gown, if there are alternative team members who could be assigned. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)

Answer 2: Hypotension and citrate toxicity, which may cause hypocalcemia (headache, paresthesias and dizziness), are the most common complications.

Critical Thinking Activities Activity 1 28. a. The patient should be monitored after the allergy shot. This monitoring should include observation for adverse reactions and take place for at least 20 minutes. b. The patient should be taught signs and symptoms to look for regarding hypersensitivity reactions. The patient should have an EpiPen on hand at home. c. The health care provider should be notified. Interrupted doses put the patient at risk for hypersensitive reactions.

Activity 2 29. a. As a normal part of aging, a person’s immune system will often weaken. The risk

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Answer Key 160

of inflammation and infection increases with age. Skin becomes more fragile and may allow pathogens to enter. Infection in most body systems also increases due to a reduction of activity and secretion mobility and production. Aging often brings on diseases and disorders of several body systems. These may further complicate the patient’s health status. b. Since the patient has demonstrated an increase in illness, preventive measures should be discussed. The importance of handwashing, avoiding potentially harmful situations, and the need for yearly flu shots should be addressed. The signs of early illness may be subtle. To best counteract illness, early intervention is key. Patients are advised to contact their health care providers when illness occurs.

Activity 3 30. When did you first notice the rash?

Can you describe what the rash first looked like?

Where did it start?

Did it progress? If so, how?

Have you had this type of rash before? If so, how does it compare to this episode?

What makes the rash worse?

Is there anything that seems to make it better?

Are you having any other symptoms; for example, fever, coughing, congestion?

Have you used home remedies or over-thecounter medications to treat the rash? If so, what were they and did they help?

Have you recently used any new lotions, soaps, or other personal care products?

Have you worn new clothes or brought any new textiles or furniture into the house?

Have you eaten any new foods?

Is anyone in the same household having the same kind of rash?

Do you have any pets? Do they go indoors and outdoors?

What do you do for work?

Are you exposed to chemicals or pollutants at work? If so, what are they?

Have you recently taken any trips, especially outside the United States?

CHAPTER 55—CARE OF THE PATIENT WITH HIV/AIDS Matching 1. c (See Table 55-7, p. 2005 for additional information about dietary therapies.)

2. e 3. d 4. a 5. b 6. h 7. g 8. f True or False 9.

True 10. False: HIV can be transmitted via contaminated equipment used to inject steroids, vitamins, and insulin, in addition to illicit injectable drugs.

11. False: Currently, a person’s risk for acquiring HIV through a blood transfusion is estimated to be about one in 1.5 million. There is an 11day window where HIV could still go undetected by the most current tests.

12. True 13. False: Intravenous therapy, blood transfusions, and antibiotic usage may be considered palliative in the end stage of HIV disease because these interventions keep the patient comfortable and help maintain quality of life.

14. True Table Activity 15. See Figure 55-3, p. 1988.

Multiple Choice 16. Answer 2: Receptive anal intercourse is considered the most risky. The primary or late stages of the disease are periods of the highest viral load and this also increases the risk.

However, patients should be educated that transmission can occur at any time and any transfer of semen or genital secretions offers potential risk.

17. Answer 1, 2, 3, 4, 6: Injection drug users could reduce risk by not sharing needles, but the lifestyle factors and addiction to substances often result in sharing needles and other risky behaviors. Ease of access to safe sterile equipment would reduce risk of HIV.

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Answer Key 161

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

Answer 1: While all of these incidents should be reported, the deep puncture wound with a hollow-bore needle full of blood creates the greatest exposure.

Answer 3: Unfortunately, the antiviral prophylaxis can cause hepatitis, which may lead to a liver transplant.

Answer 2: In developed countries, antiretroviral therapy, formula feeding, and cesarean section have decreased the numbers from 25% (without interventions) to approximately 1%.

Answer 3: For a CD4+ lymphocyte level of 200 cells/mm3 or less, opportunistic infections begin to emerge because the body can no longer mount an adequate defense.

Answer 3: Typical progressors develop signs and symptoms several years after seroconverting. Long-term nonprogressors may not develop signs and symptoms even 30 years after seroconverting. Rapid progressors move from being infected with HIV to an AIDS diagnosis within 3 years.

Answer 4: Although currently somewhat theoretical, a low viral set point appears to be associated with longer survival times.

Answer 3: Alternative and complementary therapies can provide hope and relief from symptoms. The health care team should be open to hearing about the patient’s interests and advise according to how they could fit in the treatment plan.

Answer 1: As long as the phlebotomist is following Standard Precautions, there is no need to intervene. The nurse makes this decision based on knowledge of Standard Precautions.

(Note to the student: In the early days of HIV, the other options were being used because there was fear and uncertainty surrounding HIV/AIDS.) Answer 1, 2, 3, 4: For the patient with HIV, medications, infection, damage, and malabsorption contribute to diarrhea. Hygiene and diet could be factors if the patient is noncompliant with basic health promotion instructions.

Answer 3: The HIV-associated cognitive motor complex will first produce mild memory deficits, similar to early dementia. Physical impairments such as poor balance and coordination usually follow the cognitive impairments and safety becomes the priority.

Level of consciousness is usually not affected.

Numbness or tingling in hands or feet or pain

28.

29.

in feet with walking are associated with peripheral neuropathy.

Answer 1: Adolescents frequently believe in their invulnerability. Denial of risk would be typical.

Answer 2: Mutual masturbation would be the safest because there is no exchange of body fluids on mucous membrane surfaces. Vaginal sex with consistent condom use is considered reasonably safe. Mutual monogamy is only safe if both partners are mutually exclusive.

Serial monogamy is considered risky, especially depending on types of sexual activities/ behaviors.

Critical Thinking Activities Activity 1 30. a. The nursing student should be counseled about treatment options. The discussion should include recommended medications, testing, testing intervals, home care, and follow-up. b. The risk of exposure is highest if the exposure is to known HIV-positive blood by a blood-filled hollow-bore needle through a deep injury. If the infected patient is critically ill at the time of exposure, this also increases the risk. c. Higher success will occur with rapid onset of preventive drug therapy. An exposed individual may have up to 36 hours, but recommendations are to begin antiretroviral therapy within 1-4 hours of exposure. d. The pros include minimized chance of development of resistant virus, reduce HIV transmission risk, and improve quality of life. Cons include drugs often have unpleasant side effects and cause liver damage, therapy is expensive, and drug therapy is complex. e. Living with family members will not put them at risk for HIV infection. Hugging, handholding, and sleeping with family members will be safe. She should avoid unprotected sexual contact with her partner.

Activity 2 31. The staff recognized that the worker had risks and attempted to offer her HIV testing. Only in rare circumstances, such as the inability

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Answer Key 162

to give consent, can HIV antibody testing be completed without the patient’s informed consent. Many ethical and legal issues surround HIV antibody testing; knowledge of applicable state laws is essential. In many states, charges of assault and battery can be brought against health care workers who perform HIV testing against a patient’s will.

If the patient had agreed to HIV testing and been found positive, the clinic staff would have faced another dilemma because of the worker’s occupation and the potential exposure to others. From the patient’s point of view, she “tried to get her customers to use condoms” and she may have considered this the limit of her liability towards infecting others. From the staff’s point of view, prostitution is illegal and her behavior did increase risk for self and others; however, traditionally health care professionals do not refuse to treat prostitutes or notify the police. Unfortunately, there is no method to inform her customers, unless she agrees to disclose their names.

Activity 3 32. HIV is now considered a chronic disease and Standard Precautions are the norm. As a contemporary nurse, you may not feel any different about caring for an HIV/AIDS patient than you would about caring for any other patient. However, health care workers have contracted HIV by work exposure, so all workers should be mindful of the risk.

Compared to the early days of HIV, there is more information, more treatment options, and less stigma (although it still exists).

Health care workers and patients are likely to feel more empowered by safety measures such as needleless systems and heightened awareness of handling sharps. There are protocols for exposure that guide workers in the event of an accidental needlestick. In addition, there have been no new confirmed reports of work-related exposure to health care workers since 1999.

CHAPTER 56—CARE OF THE PATIENT WITH CANCER Matching 1. c 2. e 3. g

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

d b h a i f k m j o l q p n

Short Answer 18. social, psychological, physical, and spiritual 19. Any five of the following: (1) fear of recurrence, (2) chronic or acute pain, (3) sexual problems, (4) fatigue, (5) guilt for delaying screening or treatment, (6) behavior that may have increased the risk for cancer, (7) changes in physical appearance, (8) depression, (9) sleep problems, (10) change in role performance, and (11) being a financial burden on loved ones 20. prostate; lung; colon; rectum 21. breast; lung; colon; rectum 22. a. Changes in bowel or bladder habits b. A sore that does not heal c. Unusual bleeding or discharge d. Thickening or lump in breast or elsewhere e. Indigestion or difficulty swallowing f. Obvious change in warts or moles g. Nagging cough or hoarseness True or False 23. True 24. True 25. False: If a female has genes BRCA1 or BRCA2, she has a 60% risk of having breast cancer during her lifetime.

26. True Figure Labeling 27. See Figure 56-3, p. 2024.

Clinical Application of Math 28. a. Answer 30 minutes 150 minutes ÷ 5 = 30 minutes b. Answer 25 minutes 150 minutes ÷ 6 = 25 minutes c. Answer 25 minutes 75 minutes ÷ 3 = 25 minutes

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Answer Key 163

29.

d. Answer 11 minutes 75 minutes ÷ 7 = 10.71 rounded to 11 Answer 7 pounds 140 pounds × 0.05 = 7 pounds

Table Activity 30.

Male

39.

40.

Female

Erythrocytes (RBCs)

4.7-6.1 million/ 4.2-5.4 million/ mm3 mm3

Hemoglobin

14-18 g/dL

12-16 g/dL

Hematocrit

42-52%

37-47%

Multiple Choice 31. Answer 2: According to the American Cancer Society, smoking is the most preventable cause of death from lung cancer. Many other cancers are associated with smoking. The other lifestyle modifications are also important as contributing factors to select cancers.

32. Answer 4: Fruit and vegetable consumption is currently low in the United States. Fruits and vegetables are particularly important in preventing GI cancers, but also contain nutrients that decrease overall risk.

33. Answer 3: The nurse could suggest trying strawberries, peppers, tomatoes, or cantaloupe. Fresh food sources are better than supplements. The patient might accept juice, but compliance is unlikely since she dislikes citrus fruits. Carrots and cauliflower are good anticancer vegetables, but offer less vitamin C. 34. Answer 4: The best time is to perform BSE 2-3 days after the end of the menses. The first day of every month would be recommended to postmenopausal women. Women should not wait to see obvious symptoms. The purpose of BSE is to detect subtle changes before obvious symptoms occur.

35. Answer 2: African Americans have a higher risk for prostate cancer and should be advised that age 40 is the time to start.

36. Answer 4: Stage IV indicates metastasis.

37. Answer 1: T0; N0; M0 indicates no evidence of primary tumor, no regional lymph node metastasis, no (known) distant metastasis. See Box 56-2, p. 2023 for additional information.

38. Answer 1: The radioisotope will concentrate in the tumor areas. Isotope that is not picked up by the bone can be flushed out by the kidneys.

41.

42.

43.

44.

45.

46.

47.

48.

49.

Answer 3: The history of hip fracture should be investigated prior to the MRI. If the patient has some type of metal prosthesis in the hip, that would be a contraindication for MRI. Answer 2: Alkaline phosphatase is elevated if there is liver disease or metastasis to the bone or liver. Serum calcitonin is elevated in cancer of the thyroid. Normally, production of carcinoembryonic antigen (CEA) stops before birth, but it may begin again if a neoplasm develops. CA-125 is a tumor marker for ovarian cancer.

Answer 1: Eating red meat, turnips, melons, aspirin, or vitamin C for 4 days before the test may cause a false-positive result.

Answer 1: The nurse conveys respect, but tries to remain available to help the patient.

The nurse avoids offering platitudes. The nurse could call the health care provider, but the patient is currently using the provider as a focus for his anger. If the nurse is skilled at therapeutic communication, it is likely that the patient will be more comfortable venting his anger with the nurse.

Answer 2: No lotion, cream, ointments, or powder should be applied over the markings.

The markings must not be washed off. If the skin should get wet, it should be patted dry.

Answer 2: The nurse must carefully plan the nursing care to limit the time spent in close contact with the patient. The nurse can protect self by standing back, limiting time, and being very organized.

Answer 1: The patient is on bedrest and the UAP should only help with hygiene from the waist up. Time spent should be limited. The patient should not be turned from side to side.

Answer 3: Catheterization should be avoided because it is a way to introduce infection.

The nurse would check to see if a midstream specimen would be adequate. The other interventions are correct.

Answer 3: The patient’s mouth will be sore and irritated with open lesions. Frequent, gentle mouth care with a soft brush or sponge and rinsing with normal saline will help. Cool fluids and bland foods are likely to feel more soothing.

Answer 2: Epoetin alfa (Epogen) is used to treat anemia, which is reflected by the red cell count.

Answer 4: Platelets help the blood to clot; therefore, spontaneous bleeding will occur at a count of less than 20,000/mm3.

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Answer Key 164

50.

51.

52.

53.

54.

55.

Answer 1: The hair will grow back, but it may be a different color or texture.

Answer 1, 3, 4: The symptom should resolve when treatment ends. In the meantime, encourage the patient to experiment with different spices: lemon juice, onion, mint, basil, and fruit juice marinades may improve the taste of certain meats and fish. Ham and bits of bacon may improve the taste of vegetables. Calories are important, but good nutrition is necessary for healing.

Answer 1, 2, 3, 6: People at different ages have different coping skills. If significant others are supportive and symptoms are minimal, it is easier for the patient to cope. Ability to express feelings also helps the patient to cope.

Socioeconomic status and gender have less impact.

Answer 1: Ondansetron (Zofran) is an antiemetic, so the nurse will try to eliminate noxious odors.

Answer 2: Early clinical manifestations include nausea, vomiting, anorexia, diarrhea, muscle weakness, and cramping. Later signs and symptoms may include tetany, paresthesias, seizures, anuria, and cardiac arrest.

Answer 3: For cancer patients, fixed-dose round-the-clock analgesia provides a constant blood level of the pain medication. Bolus doses can be given for breakthrough pain, but fixed doses should continue and the nurse should report a pattern of continuous breakthrough to the health care provider for reevaluation of dose. Patient-controlled analgesia and PRN medication are commonly used for patients with acute pain, such as postoperatively.

Critical Thinking Activities Activity 1 56. a. Although the American Cancer Society recommends testing begin at age 50, the presence of a family history of colon cancer may indicate the need to begin testing sooner. The history should be reported to the health care provider. b. The patient should be encouraged to add activity of at least 30 minutes per day into his routine. Dietary intake should be evaluated. Fruits, vegetables, and whole grains should be encouraged, and fatty foods should be avoided.

Activity 2 57. a. Chemotherapy involves the use of medications to slow or reduce the growth of metastatic cancer. Radiation is used to cure or control cancer that has spread to lymph nodes or cannot be removed. b. The patient should not have a bath below the level of the implant. She should be offered supplies for a sponge bath. c. A “Radiation in Use” sign should be posted. Never touch the implant if it becomes dislodged. d. Pregnant women and children younger than 18 years of age should not be allowed to visit the patient. e. Frequent assessment of vital signs and the integumentary system should be conducted. The diet should be low in residue to minimize peristalsis. The applicator should be checked every 4 hours.

CHAPTER 57—PROFESSIONAL ROLES AND LEADERSHIP Short Answer 1.

Key components of the cover letter include identification of interest in employment, a brief statement of qualifications, and availability for the position being sought. It is important to personalize the cover letter and emphasize strengths and desired qualities applicable to the position.

2.

By joining, the nurse has a voice in his/her own profession. The organization is stronger and more effective if there are many actively interested members. There are opportunities for continuing education, networking, and information-sharing. There are newsletters, publications, and other benefits such as insurance programs.

3.

Certification for the LPN/LVN is available in a number of ways such as seminars and self-study for managed care, pharmacology, long-term care, and IV therapy. Continuing education units (CEUs) may be offered by the employer through seminars, conferences, workshops, or online. Also nursing journals, private education companies, and Internet education companies offer CEUs. In many states CEUs are a requirement; therefore, the LPN/ LVN should become familiar with requirements in the state of practice. There are many colleges, private schools, and universities

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Answer Key 165

4.

5.

6.

where the LPN/LVN could become a registered nurse. There are degree programs such as the associate of science in nursing (ASN), baccalaureate of science in nursing (BSN), or master’s of science in nursing (MSN). There are some programs that offer the LPN/LVN an accelerated pace for completion of their degree and may offer online or a combination of classroom and online curriculum. a. Minimum number of questions: 85 (including 25 trial questions) for PN; 75 for RN b. Maximum number of questions: 205 for PN; 265 for RN c. Maximum time allowed: 5 hours for PN; 6 hours for RN d. Goal of CAT testing: Determine competence based on the difficulty of questions, not on how many questions are answered correctly e. Average time to receive results: 1 week f. Approval to take the test is given by the state board of nursing g. Alternate-item format: multiple response; ordering of items; fill-ins (including calculations); drag and drop; and “hot spot” to identify an area, picture, or graphic A nurse practice act defines the title and the regulations governing the practice of nursing.

The act delineates the legal scope of the practice of nursing within the geographic boundaries. Its provisions assist the nurse in staying within the legal scope of nursing practice in each state. It also states the requirements for licensure and conditions for which a license may be revoked or suspended.

Job settings are hospitals, long-term care facilities, home health, office or clinic, insurance companies, temporary agencies, travel nursing, pharmaceutical or medical equipment sales, military, adult daycare, school, public health, outpatient surgery, private duty, civil service, occupational health, rehabilitation, mental health, hospice, and correctional facility nursing.

Fill-in-the-Blank Sentences 7. mentor 8.

Nursing informatics 9.

Malpractice insurance 10. to seek immediate assistance

Multiple Choice 11. Answer 2: Autocratic is the most efficient in an emergency situation. The style is very direct and there is no opportunity for discussion.

12. Answer 3: The student should take NCLEXPN® in the current state of residency and investigate reciprocity because 24 states have adopted mutual recognition licensure. If the student moves after successfully passing the examination and fulfilled the educational requirements, it is necessary to apply for a license or temporary practice permit before practicing nursing. The student should not delay taking NCLEX-PN® because long periods of delay increase likelihood of failing the examination.

13. Answer 4: Frequently a charge nurse or senior nurse will know what the health care provider has written, because the writing style will be familiar or the orders from that provider will be familiar. If no one can interpret the order, it is necessary to call the provider. Transcribing an order without knowing what it says is incorrect. Calling the nursing supervisor may be necessary if the problem cannot be resolved.

Waiting until the provider returns to the unit may cause serious delays in patient care.

14. Answer 3: Calling the provider, reporting the error, and getting a one-time order for additional pain medication is the first step. Then check the postoperative orders and inform the patient about the next time that a dose will be available. An incident report is likely to be required by facility policy that documents the actions taken (calling provider and administering additional dose should be documented in the patient’s record, but avoid using language that points out the error).

15. Answer 1, 2, 4: Vital signs, linen changes, and ambulating patients are within the scope of practice for the UAP. The nurse must ensure that the UAP understands isolation precautions. Restocking medications and IV fluids is usually done by the pharmacy. Assessing skin and transcribing orders are nursing responsibilities.

16. Answer 2: Negligence is the commission of an act that a prudent person would not have done or the omission of a duty that a prudent person would have fulfilled, resulting in injury or harm to another person. Proof is necessary that other prudent members of the

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Answer Key 166

17.

18.

19.

20.

same profession would ordinarily have acted differently under the same circumstances.

Answer 1: Since the nurse is a friend, taking her aside and warning her that others are listening is a good way to stop the behavior and it also puts the responsibility on that nurse to take corrective action. Ideally, the nurse who broke confidentiality should take responsibility to contact risk management, the nursing supervisor, and write an incident report.

Answer 4: The group is mixed in terms of experience, task responsibilities, and work setting; thus the leader will have to be flexible to use the strengths of the members. There may be elements of committee work where the leader will be more directive and other times when the leader will want input from the members.

Answer 3: “If anyone is having any problems” is too vague. These instructions put the UAP in the position of having to assess and make decisions about behavior and symptoms (or lack of symptoms). Assisting several patients with am hygiene is within the scope of practice of the UAP. Giving feedback is usually best immediately after the task is completed.

Answer 3: First, the nurse should try to figure out how he/she is using time. When the nurse recognizes the pattern, he/she can make an action plan. Asking for help is always a possibility, but others cannot help out on a daily basis; therefore, the nurse has to learn how to manage the patient load. Socializing with colleagues is important and should not be eliminated, but can be done during break times. Setting goals is important, but patients’ needs or conditions can change, so the nurse will have to learn to continuously reevaluate priorities and adjust accordingly.

Critical Thinking Activities 21. Once you have identified a position, do some research about the facility and mission statement. Try to interview one or two nurses who work there, if possible. This research will help you compose a focused cover letter. Create a professional résumé and have an objective colleague review it. Role play a face-to-face interview (see Box 57-4, p. 2047). Prepare examples of how your experiences can transfer into the new job. For example, if you have worked as a waitress, describe how you mentally organized multiple tasks and needs of

22.

23.

the customers. Visit the facility before the day of the interview, so that you will know where to park and how to find the location of the interview.

Examples of how the nurse can “survive” on the night shift are: a. Staying alert at work—Sleep and eat well before the shift, wear a 24-hour watch, eat or drink something warm when feeling chilled. b. Getting to sleep—Make the sleeping area cool, quiet, and dark. Unplug the phone; allow an hour to unwind after work. c. Balancing life with work—Eat right, exercise regularly, get outside for fresh air, maintain strong family and social relationships. d. Frequently, night-shift pay will include a shift differential. (Note to student: Consider this point when you are looking for a job.) Night shift can be a time when the nurse gets to focus on the patient, because there will be fewer visitors and students, less time off the unit for diagnostic testing, fewer requests from other departments, and fewer interactions with health care providers. Night-shift staff frequently report bonding and cohesiveness among themselves. a. Most nurses know what should be included in shift report, but fewer nurses are able to give a concise, well-organized report that includes relevant details and excludes gossip, complaints, or tangential experiences.

Information that should be included: vital signs (if abnormal), type of intravenous (IV) fluids (including rate of infusion, amount left to infuse, and IV site), and intake and output for feces, urine, and gastric secretions; output from all drainage tubes and appearance of drainage; PRN medications including the time of administration and amount of patientcontrolled analgesia. Dressing changes, amount and color of exudate, and the condition of any incisions or wounds should be reported. Report any abnormal signs and symptoms such as dyspnea, tachycardia, or abnormal mental status or level of consciousness, as well as neurologic deficits. It is also very helpful to know if events are pending such as surgery, x-ray, outstanding laboratory results,

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Answer Key 167

social service consults, etc. It is also very helpful for new nurses to ask experienced nurses who are giving report to identify patients who are at risk for worsening. b. Report can be given to all nurses sitting around a conference table behind a closed door. Report may be given one-to-one in the conference room, standing outside the patient’s room, or standing inside the patient’s room (in which case, patient input is included in the report). Report may be taped by off-going shift. Report can be given to charge nurse, who then gives it to oncoming shift verbally or in written form. There are advantages and disadvantages to any method. For example, if all of the nurses listen to report on all of the patients, report is very long and time-consuming. The advantage is that all of the nurses are aware of potential problems for all of the patients. There is a danger of violation of confidentiality when standing outside the patient’s room.

The advantage is that the patient’s chart or flow sheet is usually at hand and if the nurses need to quickly check on the patient they are there at the door. Another disadvantage of this method is that the off-going nurse may have to give report to other nurses on other patients; thus unless the assignments are identical shift after shift, there are delays in getting report on all patients. Taped or written reports can save time. However, taped reports are often difficult to understand and the offgoing shift must stay to answer any questions for taped or written reports.

24.

a.

Burnout among nurses is attributed to higher patient acuity, less available support staff, and the nursing shortage. Concurrent personal or family problems can add to the stress. b. Burnout is characterized by constant exhaustion, depression, irritability, insomnia, negative feelings toward one’s job, difficulty focusing, becoming emotionally detached, and feeling that one’s actions don’t make a difference to others. Difficulty delegating tasks and taking time for self may occur. Dysfunctional coping such as overspending, overeating, or addictions may occur. c. Awareness of the problem is the first step.

Seek a balance among work, family, and leisure activities. Choose to change to a different work environment. Compartmentalize work responsibilities. Pay attention to own needs. Focus on finishing one project at a time. Set achievable goals.

Seek advice and support from people who are solution-focused. Restore personal integrity.

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