TEST BANK for Clinical Reasoning Cases in Nursing 7th Edition by Harding and Snyder. ISBN 9780323525

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Clinical Reasoning Cases in Nursing 7th Edition Harding Snyder Test Bank Chapter 1.Perfusion

involves the entire body.

c.

is decreased with hypertension.

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b.

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MULTIPLE CHOICE 1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student states, Central perfusion a. is monitored only by the physician.

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d. is toxic to the cardiac system.

ANS: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the bodys ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease could have happened to them. The nurses best response is Hypertension a. happens to everyone sooner or later. Dont be concerned about it. b.

can happen from eating a poor diet, so change what you are eating.

c.

can happen from arterial changes that impede the blood flow.

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d. happens when people do not exercise, so you should walk every day.

ANS: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient.

Hypertension does not happen to everyone. Changing the patients diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best response would be, The sinoatrial node a. provides the heart with the stimulation to beat in a normal rhythm. protects the heart from atherosclerotic changes.

c.

provides the heart with oxygenated blood.

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b.

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d. protects the heart from infection.

ANS: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. The nurses primary concern is to monitor for a. mental alertness. b.

perfusion.

c.

pain.

brain malformations.

c.

intestinal blockage.

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b.

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d. reaction to medications.

ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

5. A patients serum electrolytes are being monitored. The nurse notices that the potassium level is low. The nurse knows that the patient should be observed for a. tissue ischemia.

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d. cardiac dysthymia.

ANS: D Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

6. A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, Perfusion a. is a normal function of the body, and I dont have to be concerned about it. b.

is monitored by the physician, and I just follow orders.

c.

is monitored by vital signs and capillary refill.

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d. varies as a person ages, so I would expect changes in the body.

ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too.

Perfusion does not always change as the person ages.

7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a.

Blood pressure above the normal range

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c.

Bounding pedal pulses

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b.

Night blindness

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d.

Reflux disease ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

Chapter 2.Gas Exchange MULTIPLE CHOICE

1. The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL who has been on anticoagulants for 10 days

c.

with a hemoglobin of 8.5 g/dL

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b.

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d. with a heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased.

High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood.

A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

2. The nurse is reviewing the patients arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient? a.

Disorientation and tremors b.

Tachycardia and decreased blood pressure

c.

Increased anxiety and irritability

d.

ANS: A

Hyperventilation and lethargy

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The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis.

Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

3. The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with a. peripheral arterial disease of the lower extremities chronic obstructive pulmonary disease (COPD)

c.

chronic asthma

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b.

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d. severe anemia secondary to chemotherapy ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

4. The nurse is assessing a patients differential white blood cell count. What implications would this test have on evaluating the adequacy of a patients gas exchange? a.

An elevation of the total white cell count indicates generalized inflammation. b.

Eosinophil count will assist to identify the presence of a respiratory infection.

c.

White cell count will differentiate types of respiratory bacteria.

d.

Level of neutrophils provides guidelines to monitor a chronic infection.

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ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection.

Upper respiratory infections are common problems in altering a patients gas exchange.

Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria.

Monocytes are an indicator of progress of a chronic infection.

5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A patient with a. chronic lung disease with increased carbon dioxide retention acute anxiety, hyperventilation, and decreased carbon dioxide retention

c.

decreased cardiac output with increased serum lactic acid production

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b.

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d. gastric drainage with increased removal of gastric acid ANS: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

6. Which patient would the nurse identify as being at an increased risk for altered transport of oxygen? A patient with a. hemoglobin level of 8.0 bronchoconstriction and mucus

c.

peripheral arterial disease

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b.

There is an increase in intake of breast milk or formula.

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b.

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d. decreased thoracic expansion ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a.

The infant is becoming more active.

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c.

The infant is unable to maintain an adequate iron intake.

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d.

A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months.

Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

REF: 162 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a.

Decreasing venous stasis and risk for pulmonary emboli Implementation of strict hand washing routines

c.

Maintaining current vaccination schedules

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b.

b.

Endocrine system

c.

Pulmonary system

d.

Immune system

e.

Cardiovascular system

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d.

Prevention of pneumonia in patients with chronic lung disease ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.

MULTIPLE RESPONSE 1. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a.

Neurologic system

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f.

Hepatic system ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body.

The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a.

Respiratory rate is 24 breaths/min.

Oxygen saturation level is 98%.

c.

The right side of the thorax expands slightly more than the left.

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Trachea is just to the left of the sternal notch.

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d.

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b.

e.

Nail beds are pink with good capillary refill.

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f.

There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

Chapter 3.Mobility

of your immobility in the hospital. This is known as deconditioning.

c.

of your poor appetite. This is known as malnutrition.

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b.

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MULTIPLE CHOICE 1. A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurses best response is You are weak because a. your iron level is low. This is known as anemia.

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d. of your medications. This is known as drug induced weakness.

ANS: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning.

2. A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurses best response is which of the following? a.

Walk at least 5 miles every day for exercise. b.

Wear proper fitting shoes to prevent tripping.

c.

Talk with your physician about a calcium supplement.

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d.

Stand up slowly so you dont feel faint.

ANS: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

3. Mobility for the patient changes throughout the life span; this is known as the process of a. aging and illness. illness and disease.

c.

health and wellness.

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b.

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d. growth and development.

ANS: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they dont always affect mobility.

4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when he or she states, Patients must a. have a trapeze over the bed to move properly. b.

move themselves in bed to prevent immobility.

c.

always have a two-person assist to move in bed.

d.

ANS: D

be moved correctly in bed to prevent shearing.

like to have extra visitors.

c.

need to have a mechanical soft diet.

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b.

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Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional is the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able, but shearing may still occur.

5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, Patients with impaired bed mobility a. have an increased risk for pressure ulcers.

b.

80%

c.

90%

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d. are prone to constipation.

ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

6. What percentage of hip fractures are the result of falls? a.

50%

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d.

100% ANS: C About 90% of falls end with a hip fracture.

COMPLETION 1. The lack of weight bearing leads to bone _________ and __________ from the skeletal system.

ANS: demineralization, calcium loss calcium loss, demineralization Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it.

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Chapter 4.Digestion

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MULTIPLE CHOICE

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1.A student nurse is caring for a patient who has dehydration as a result of diarrhea. Diarrhea is a result of abnormally fast peristalsis in what organ? a.

Jejunum

c.

Duodenum

d.

Colon

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Stomach

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b.

ANS: D

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The large intestine is the primary organ of bowel elimination. If peristalsis is abnormally fast in the colon, there is less time for water to be absorbed and the stool will be watery. The stomach is part of the upper GI system. The duodenum and jejunum are part of the small intestines.

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2.The labor/delivery nurse is caring for a 33-year-old who is in labor with her first child. The patient complained to the nurse about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks, what can I do to prevent future problems with hemorrhoids?

What is the nurses best response?

Hemorrhoids are caused by defecation of stools that are loose and watery.

b.

You need to soften your stools by drinking plenty of fluids.

c.

You should eat less carbohydrates.

d.

There is nothing that you can do to prevent hemorrhoids.

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a.

ANS: B

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Hemorrhoids are dilated, engorged veins in the lining of the rectum. Increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses, such as congestive heart failure and chronic liver disease, are causative factors. A hemorrhoid forms either within the anal canal (internal) or through the opening of the anus (external). Passage of hard stool causes hemorrhoid tissue to stretch and bleed. Hemorrhoid tissue becomes inflamed and tender, and patients complain of itching and burning. Because pain worsens during defecation, the patient sometimes ignores the urge to defecate, resulting in constipation.

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3.The nurse caring for several patients on the surgical unit of the hospital. The nurse knows that constipation can be a significant health hazard and encourages the postoperative patients to drink fluids. Which one of the following patients is most at risk from complications related to constipation? a.

A 35-year-old man with back surgery

c.

A 29-year-old women with carpal tunnel surgery

d.

A 77-year-old man with hip surgery

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A 47-year-old woman with an abdominal hysterectomy

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b.

ANS: B

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Constipation is a significant health hazard. Straining during defecation causes problems for patients with recent abdominal, gynecological, or rectal surgery. An effort to pass a stool can cause sutures to separate, reopening a wound. In addition, patients with cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver. Constipation is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (e.g., unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits.

4.A patient will be undergoing abdominal surgeries, which will most likely result in an ostomy.

The patient asks the nurse, What will the stool from my ostomy look like? What is the best answer?

Your stools wont change from what they currently are.

b.

The consistency of your stools will be very soft.

c.

The consistency of your stools will be liquid.

d.

The consistency of your stools will depend on the location of stoma (ostomy).

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a.

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ANS: D

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The location of an ostomy determines stool consistency. The more intestine remaining, the more formed and normal the stool. For example, an ileostomy bypasses the entire large intestine, creating frequent, liquid stools. A person with a sigmoid colostomy will have a more formed stool.

5.A patient was involved in a motor vehicle accident and underwent a loop colostomy. The patient questions the nurse about what is draining out of each side of the colostomy. What is the nurses best response?

There is stool draining out of both sides.

b.

Stool is draining out the stomach side and mucus is draining from the rectum side.

c.

There is mucus and stool draining from both sides.

d.

There is stool draining out of the stomach side and nothing draining out of the rectum side.

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a.

ANS: B

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Loop colostomies are frequently performed on an emergency basis and are temporary large stomas constructed in the transverse colon. The loop ostomy has two openings through the stoma. The proximal end drains stool, and the distal portion drains mucus.

6.A 45-year-old Catholic Hispanic-American patient has been admitted to the hospital with pneumonia. On admission, the patient did not identify any food preferences or food allergies.

The nurse notes that the patient has requested that the family provide all meals during the hospital stay. This is most likely related to which of the following?

Food preferences

b.

Hispanic cultural traditions

c.

Religious preferences

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a.

Food sensitivities

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ANS: B

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d.

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The intake of certain foods also reflects the patients culture or beliefs. Foods in various cultures have different status relating to religion, availability, cost, and tradition. For example, some Hispanic-Americans use certain hot foods (e.g., chocolate, cheese, eggs) for conditions producing fever, and cold foods (e.g., fresh vegetables, dairy foods, honey) for disorders such as cancer or headaches. Understand the patients cultural heritage and the role diet plays in health promotion and maintenance.

7.The home health nurse is visiting a 67-year-old widow who lives at home by herself. The patient voices a concern about constipation. What is the best way for the nurse to approach the patients concern?

Have you noticed that your stools are hard?

c.

How frequently are you having a bowel movement?

d.

What color is your stool?

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Tell me why you think you are constipated.

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a.

ANS: A

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In determining the patients bowel habits, remember normal is unique to each individual. Far too often nurses do not acknowledge an older adults problems with intestinal elimination as an important consideration in their care. Remember that what appears at the outset to be a trivial complaint may be a significant problem physically and/or psychologically. Apply this knowledge in preparing questions for the patient interview to determine the presence and extent of GI alterations. Although the other questions will help determine if there is a problem, having the patient voice her concern will direct future questions. Determine your patients usual pattern of bowel elimination. Usual frequency and time of day are important, but also determine if any changes in elimination patterns have occurred. Ask the patient to make suggestions about the reason for any change.

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8.The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patients recent lab work, which lab test would the nurse expect to be decreased?

Total bilirubin

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a.

Hemoglobin and hematocrit

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b.

Serum amylase Ova and parasites

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d.

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c.

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ANS: B

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There are no blood tests to specifically diagnose most gastrointestinal disorders, but hemoglobin and hematocrit may be done to determine if anemia from gastrointestinal (GI) bleeding is present. Liver function tests such as bilirubin and serum amylase to assess for hepatobiliary diseases and pancreatitis are possible tests that may be ordered by the health care provider. A stool sample is needed to test for ova and parasites.

Malabsorption of fat

c.

Diarrhea

d.

Iron supplements or GI bleeding

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b.

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Absence of bile

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a.

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9.The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color change may be the result of which of the following?

ANS: D

Blood in the stool or melena causes stool to turn black and sticky, hence the term tarry stools.

Ingestion of iron supplements can also cause the stool to turn black. Stool that is white or claycolor is caused by the absence of bile. Stool that is oily or pale in color is caused by the malabsorption of fat. Liquid brown or yellow stool is caused by diarrhea.

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10.A student nurse is assisting with colon cancer screening at the local health care clinic. The student is completing fecal occult blood testing on the stool specimens. This test is also referred to as a(n) _____ test. melena

b.

guaiac

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a.

amylase

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c.

alkaline phosphatase

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ANS: B

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A common test is the fecal occult blood test (FOBT) or guaiac test, which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer. Melena refers to blood in the stool that causes stool to turn black and sticky. Amylase and alkaline phosphatase are blood tests.

11.A patient is concerned about intermittent constipation and is confused about all the laxatives that are available. One of the laxatives that the patient has used in the past was mineral oil. The nurse explains that this type of laxative is an example of a(n) _____ laxative.

osmotic agent

c.

emollient

d.

lubricant

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b.

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stimulant

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a.

ANS: D

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Cathartics are classified by the method by which the agent promotes defecation. Stimulant cathartics cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit reabsorption of water in the large intestine. Saline or osmotic agents contain a salt preparation that the intestines do not absorb. The cathartic draws water into the fecal mass. This osmotic action increases the bulk of the intestinal contents and enhances lubrication. Emollient or wetting agents are detergents and act as stool softeners to lower the surface tension of feces, allowing water and fat to penetrate the fecal material. Bulk-forming cathartics absorb water and increase solid intestinal bulk. The fecal bulk stretches the intestinal walls, stimulating peristalsis.

Lubricants soften the fecal mass, thus easing the strain of defecation. The only lubricant laxative available is mineral oil.

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12.The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized following surgery. The nurse recognizes that this condition most likely a result of which of the following?

Diarrhea

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a.

Flatulence

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b.

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Fecal impaction The Valsalva maneuver

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d.

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c.

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ANS: C An obvious sign of impaction is the inability to pass a stool for several days, despite a repeated urge to defecate. Continuous oozing of liquid stool after several days with no fecal output may indicate an impaction. Loss of appetite, abdominal distention and cramping, nausea and/or vomiting, and rectal pain also occur. Diarrhea is an increased frequency in the passage of loose stools. Flatulence is a sense of bloating and abdominal distention usually accompanied by excess gas. The Valsalva maneuver occurs when pressure is exerted to expel feces through a voluntary

contraction of the abdominal muscles while maintaining forced expiration against a closed airway.

Mass colonic peristalsis occurs at this time.

c.

Irregularity helps to develop a habitual pattern.

d.

Neglecting the urge to defecate can cause diarrhea.

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The presence of food stimulates peristalsis.

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a.

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13.To maintain normal elimination patterns in a hospitalized patient, why should the nurse encourage the patient to take time to defecate 1 hour after meals?

ANS: B

Defecation is most likely to occur after meals. If the patient attempts to defecate during the time when mass colonic peristalsis occurs, the chances of successfully evacuating the rectum are greater. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. Establishing a consistent time for bowel hygiene is one evidenced-based practice to avoid constipation. Ignoring the urge to defecate and not taking time to defecate completely are common causes of constipation.

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14.The health care provider orders a patient to have a fecal occult blood test. To obtain an accurate result, the nurse instructs the patient to do which of the following?

Submit one sample for analysis.

b.

Take extra amounts of vitamin C supplements.

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a.

Refrain from ingesting red meats for 3 days before testing.

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d.

Stop taking aspirin 14 days prior to the beginning of the test.

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c.

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ANS: D The patient needs to repeat the test at least three times on three separate bowel movements while the patient refrains from ingesting foods and medications that cause a false-positive or falsenegative result. Foods to avoid include red meat, vitamin C, and citrus fruit and juices for 3 days.

Medication such as aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs should be avoided for 7 days.

Provide tube feedings until peristalsis resumes.

c.

Allow for the release of flatulence.

d.

To keep the stomach expanded until peristalsis resumes.

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b.

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Decompress the stomach until peristalsis returns.

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a.

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15.The nurse receives a patient from the emergency department with the diagnosis of ileus. The nurse expects the health care provider to order NPO for dietary status, and insert a nasogastric tube. The nurse knows that the purpose of the nasogastric tube is to do which of the following?

ANS: A

A patient cannot eat or drink fluids without causing abdominal distention and nausea and vomiting to occur. The insertion of a nasogastric (NG) tube into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. Flatulence (having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. Normally, intestinal gas escapes through the mouth (belching) or the anus.

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16.Elevating the head of the bed to the maximum allowed amount of 30 degrees for a patient in balanced suspension traction helps to promote normal elimination by which of the following?

Decreasing peristaltic movement

b.

Promoting contraction of the thigh muscles

c.

Strengthening the resistance of the internal and external sphincters Exerting increased pressure on the rectum

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d.

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a.

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ANS: D

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To help patients evacuate contents normally and without discomfort, recommend interventions that stimulate the defecation reflex or increase peristalsis. Helping the patient into an upright sitting position increases pressure on the rectum and facilitates use of intraabdominal muscles.

Patients who have had surgery have muscular weakness or mobility limitations and benefit from the use of elevated toilet seats.

17.A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The assistive personnel demonstrates understanding of the procedure when she states which of the following? (Select all that apply.)

I will lower the enema when the patient complains of cramping.

b.

I will speed up the enema administration when the patient complains of cramping.

c.

I will withdraw the tube when the patient complains of cramping.

d.

I will clamp the tubing when the patient complains of cramping.

e.

I will fill the bag with hot water because it will cool while I am administering the enema.

f.

I will have the patient sit on the toilet while I am administering the enema.

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a.

ANS: A, D

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When the enema is instilled too rapidly, the instillation will cause pain and cramping. The instillation should be slowed down. When a patient complains of cramping, lower the container, clamp the tube, or temporarily stop the instillation. Filling the bag with hot water demonstrates that the assistive personnel does not understand the directions for this procedure. Having the patient sit on a toilet demonstrates that the assistive personnel does not understand the proper position for administering an enema.

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18.Which of the following conditions could affect the function of the digestive process? (Select all that apply.)

Increase in mobility

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a.

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Diagnostic testing Increase in nutrition

d.

Medications

e.

Increase in fluid intake

f.

Surgery

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c.

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b.

ANS: A, B, D, F

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Individuals of any age sometimes experience changes in intestinal elimination. These changes are often the result of illness, medications, diagnostic testing, or surgical intervention. Aging when accompanied by chronic illness, cognitive decline, decreased mobility, and a decrease in food and fluid intake will change digestive system function, but aging alone does not necessarily alter the digestive process.

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19.A patient with colon cancer has recently undergone surgery to remove a portion of the colon.

The patient asks how often the colostomy pouching system should be changed. What is the best response by the nurse?

Every 3 to 7 days

b.

Every 10 to 14 days

c.

When the pouch is one third to one half full of stool

d.

Not until the system starts to leak or smell bad

ANS: A, C

ST BA N KS W O

a.

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An ostomy is managed with an odor-proof pouch with a skin barrier surrounding the stoma.

Empty the pouch when it is one third to one half full. Change the pouching system approximately every 3 to 7 days, depending upon the patients individual needs.

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Chapter 5.Urinary Elimination

The patient forgets where the bathroom is located due to the dementia.

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c.

The patient is losing sphincter control due to the dementia.

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b.

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MULTIPLE CHOICE 1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patients daughter asks the nurse why this is happening. The best response by the nurse is: a.

The patient is angry about the dementia diagnosis.

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d.

The patient wants to leave the hospital.

ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

2. You are caring for a patient who has suffered a spinal cord injury. You are concerned about the patients elimination status. As the nurse, your primary concern is to a. speak with the patients family about food choices.

b.

establish a bowel and bladder program for the patient.

c.

speak with the patient about past elimination habits.

Stomach

c.

Small intestine

ST BA N KS W O

b.

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d. establish a bedtime ritual for the patient.

ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is okay, but it is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a.

Large intestine

d.

Pancreas ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

REF: 140

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4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening.

The best response from the nurse would be which of the following? a.

Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.

Some people have a slower bowel than others, and this is nothing to be concerned about.

c.

The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.

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b.

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d.

Bowel peristalsis is slow because you are not walking. Get more exercise during the day.

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

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5. A primary prevention tool used for colon cancer screening is a. abdominal x-rays. blood, urea, and nitrogen (BUN) testing.

c.

serum electrolytes.

d.

ANS: D

occult blood testing.

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b.

Increase water consumption.

c.

Decrease physical exercise.

d.

Refrain from alcohol.

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b.

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Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

MULTIPLE RESPONSE 1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a.

Increase fiber intake.

ST BA N KS W O

e.

Refrain from smoking.

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on bowel movements.

2. When conducting a health history assessment, the nurse would want to know what important information about the patients elimination status? (Select all that apply.) a.

Recent changes in elimination patterns Changes in color, consistency, or odor of stool or urine

c.

Time of day patient defecates

d.

Discomfort or pain with elimination

e.

List of medications taken by patient

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b.

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f.

Patients preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patients preferences for toileting. They are personal preferences and do not affect elimination.

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Chapter 6.Intracranial Regulation

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MULTIPLE CHOICE 1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a.

Aligning the neck with the body b.

Clustering many nursing activities

c.

Elevating the head of the bed 30 degrees

b.

inability to focus visually.

c.

loss of primitive reflexes.

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d.

Providing stool softeners or laxatives as ordered ANS: B It is important to minimize stress and activities that could increase intracranial pressure.

Combining many nursing activities could increase oxygen demand and intracranial pressure.

This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.

2. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be a. change in level of consciousness.

G TE

ST BA N KS W O

d. unequal pupil size.

ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. 3. When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. hypertension, and tachycardia.

c.

hypotension, and bradycardia.

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b.

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d. hypotension, and tachycardia.

ANS: A Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushings triad). It is bradycardia, not tachycardia, which is the component of this ominous triad.

It is hypertension, not hypotension, which is the component of this ominous triad.

4. Components of the GCS the nurse would use to assess a patient after a head injury include a. blood pressure. b.

cranial nerve function.

c.

head circumference.

d. verbal responsiveness.

ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness.

The nurse would want to assess the blood pressure, but this is not a component of the coma scale.

smoking cessation.

c.

maintaining a healthy weight.

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b.

M

Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

5. Primary prevention strategies to reduce the occurrence of head injuries would include a. blood pressure control.

b.

antipyretic.

c.

osmotic diuretic.

ST BA N KS W O

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d. violence prevention.

ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

6. The nurse preparing to care for a patient after a suspected stroke would question an order for a(n) a. antihypertensive.

R

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d. sedative.

ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

7. After shunt procedure, the nurse would monitor the patients neurologic status by using the a. electroencephalogram.

GCS.

c.

National Institutes of Health Stroke Scale.

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b.

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d.

Monro-Kellie doctrine.

ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood.

Chapter 7.Metabolism and Glucose Regulation

MULTIPLE CHOICE 1. The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a.

Furosemide (Lasix) Dicumarol (Bishydroxycoumarin)

c.

Reserpine (Serpasil)

M

b.

ST BA N KS W O

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d.

Cimetidine (Tagamet) ANS: A Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.

2. When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl?

Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic a. activity. b.

The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.

c.

Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP. The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.

G TE

d.

ANS: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system.

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3. The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a.

Ketone bodies in the urine during acidosis Glucose in the urine during hyperglycemia

c.

Protein in the urine during a random urinalysis

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b.

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d.

White blood cells in the urine during a random urinalysis ANS: C Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease.

Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

4. What is the nurses best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a.

You have a greater susceptibility for development of the disease because of your family history. b.

Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes.

Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.

c.

Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.

b.

Middle-aged African-American man

c.

Young African-American woman

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d.

ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

5. The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a.

Young white man

ST BA N KS W O

d.

Middle-aged Native American woman ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

6. A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a.

Oral temperature of 38.9 Celsius Severe orthostatic hypotension

c.

Increased rate and depth of respiration

G TE

b.

Nervousness

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b.

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d.

Extremity tremors followed by seizure activity ANS: C Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmauls respirations) to excrete more acids by exhalation.

MULTIPLE RESPONSE 1. Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a.

Tremors Extreme thirst

d.

Flushed skin

e.

Profuse perspiration

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c.

f.

Constricted pupils ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also

occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

Chapter 8.Immunity

Basic infection control techniques

c.

The importance of wearing a face mask in public

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b.

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MULTIPLE CHOICE 1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patients discharge planning? a.

The mechanisms of the inflammatory response

G TE

ST BA N KS W O

d.

Limiting contact with the general population ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control.

The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months.

The physician notes that the childs growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for a. primary immunodeficiency. secondary immunodeficiency.

c.

cancer.

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b.

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d. autoimmunity.

ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems.

Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if a. his immune system is functioning properly. b.

he is properly vaccinated.

c.

he has an infection.

d.

ANS: A

the suppressor T-cells in his body are activated.

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Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the bodys response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following? a.

My body will treat the new kidney like my original kidney.

I will have to make sure that I avoid being around people.

c.

The medications that I take will help prevent my body from attacking my new kidney.

ST BA N KS W O

b.

G TE

d.

My body will only have a problem with my new kidney if the donor is not directly related to me.

ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they dont have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patients respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n) a. suppressed immune response. hyperimmune response.

c.

allergic reaction.

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b.

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d. anaphylactic reaction.

ANS: D The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication.

These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

REF: 210 6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA).

The nurse explains to the patient that the goal of medication treatments for RA is to a. eradicate the disease. b.

enhance immune response.

c.

control inflammation.

ST BA N KS W O

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d. manage pain.

ANS: C Medications for RA are intended to control the inflammation that results from the bodys hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

MULTIPLE RESPONSE 1. The parents of a newborn question the nurse about the need for vaccinations: Why does our baby need all those shots? Hes so small, and they have to cause him pain. The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a.

Are only required for infants b.

Are part of primary prevention for system disorders

c.

Prevent the child from getting childhood diseases

d.

Help protect individuals and communities

e.

Are risk free

G TE

f.

Are recommended by the Centers for Disease Control and Prevention (CDC) ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient wont get the disease, but it decreases the potential to contract the illness. No medication is risk free.

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Chapter 9.Cellular Regulation

Colonoscopy at age 50 and every 10 years as follow-up

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c.

Using skin protection during sun exposure while at the beach

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MULTIPLE CHOICE 1. The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a.

Yearly mammography for women aged 40 years and older

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d.

Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over ANS: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.

2. While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a.

Have you noticed any blood in your stool? b.

Have you been experiencing nausea?

c.

Do you have back pain?

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d.

Have you noticed any swelling in your abdomen?

ANS: A Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.

3. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a.

Prioritization and administration of nursing care throughout the day b.

Completing all nursing care in the morning so the patient can rest the remainder of the day

c.

Completing all nursing care in the evening when the patient is more rested

Confusion

c.

Depression

G TE

b.

ST BA N KS W O

d.

Limiting visitors, thus promoting the maximal amount of hours for sleep ANS: A Pacing activities throughout the day conserves energy, and nursing care should be paced as well.

Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

4. The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a.

Mucositis

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d.

Mild temperature elevation ANS: D During the first 100 days after a bone marrow transplant, patients are at high risk for lifethreatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

5. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a.

Being a 75-year-old woman Family history of hypertension

c.

Cigarette smoking as a teenager

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b.

d.

Advancing age ANS: D According to the American Cancer Society, 2007, the most important risk factor for cancer development is advancing age.

6. In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care?

a.

Position the patient on the operative side only.

b.

Avoid administering narcotic pain medications.

c.

Keep the patient on strict bed rest.

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d.

Instruct the patient to cough and deep breathe.

ANS: D Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted, because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on the operative side is avoided.

7. A female patient complains of a scab that just wont heal under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurses next steps?

Continue to conduct a symptom analysis to better understand the patients symptoms and a. concerns. b.

End the appointment and tell the patient to use skin protection during sun exposure.

c.

Suggest further testing with a cancer specialist and provide the appropriate literature.

G TE

d.

Tell her to put a bandage on the scab and set a follow-up appointment in one week.

ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

Chapter 10.Tissue Integrity

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MULTIPLE CHOICE 1. A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself? a.

Limit the time you spend in the sun.

Monitor for signs of infection.

c.

Monitor spots for color change.

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d.

Use skin creams to prevent drying.

ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer.

Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

2. A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?

a.

Obtaining a complete blood count (CBC)

b.

Protection from excessive heat

c.

Protection from excessive UV exposure

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d.

Instructing the patient to take their multivitamin prior to treatment ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

3. A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a.

Apply the cream generously to affected areas.

Apply a thin coat to affected areas.

c.

Apply a thin coat to affected areas; avoid the face and groin.

ST BA N KS W O

b.

G TE

d.

Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

4. A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a.

Decreasing pain b.

Decreasing pruritus

c.

Preventing infection

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d.

Promoting drying of lesions ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

5. To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a.

Apply sunscreen 1 hour prior to exposure.

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b.

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c.

Drink plenty of water to prevent hot skin.

Use vitamins to help prevent sunburn by replacing lost nutrients.

d.

Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

6. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching? a.

I wear a hat and sit under the umbrella when not in the water.

I dont bother with sunscreen on overcast days.

c.

I use a sunscreen with the highest SPF number.

M

b.

group A beta-hemolytic streptococci.

c.

Staphylococcus aureus.

ST BA N KS W O

b.

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d.

I wear a UV shirt and limit exposure to the sun by covering up.

ANS: B The suns rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

7. A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate a.

Candida albicans.

G TE

d.

Streptococcus pyogenes.

ANS: D Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

8. A nurse is conducting community education classes on skin cancer. One participant says to the nurse: I read that most melanomas occur on the face and arms in fair-skinned women. Is this true? The nurses most helpful response would be which of the following? a.

That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.

That is correct, because the face and arms are exposed more often to the sun.

c.

That is not correct. Melanoma occurs on the top of the head in men but is rare in women.

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b.

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d.

That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.

ANS: A Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

9. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to a. bathe and dry the skin vigorously to stimulate circulation. b.

keep the head of the bed elevated 30 degrees.

c.

limit intake of fluid and offer frequent snacks.

d. turn the patient at least every 2 hours.

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient

The lamp can help detect skin cancers.

c.

Some patients feel a pressure-like sensation.

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must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

10. A patient asks the nurse what the purpose of the Woods light is. Which response by the nurse is accurate? a.

We will put an anesthetic on your skin to prevent pain.

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It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.

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d.

ANS: D The Woods light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

Chapter 11.Cognition

MULTIPLE CHOICE 1. A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a.

An infant who is being fed reconstituted powdered formula A toddler living in an older home that is being remodeled

c.

A preschooler who attends a play group 3 days a week

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d.

A school-age child who rides a school bus 5 days a week ANS: B Older homes frequently have lead-based paint; paint chips generated by remodeling put toddlers, who often put foreign objects in their mouths, at risk for exposure to lead which is a known toxic substance that can affect cognitive function. Powdered formulas, attendance at play groups, or riding on a school bus are not known to impair cognitive development.

2. The nurse is reviewing new medication orders for several patients in a long-term care facility.

Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a.

The patient prescribed an antibiotic for a urinary tract infection The patient prescribed a cholinesterase inhibitor for early Alzheimers disease

c.

The patient prescribed a beta-blocker for hypertension

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d.

The patient prescribed a bisphosphonate for osteoporosis ANS: C Anti-hypertensives such as the beta-blockers can cause adverse changes in cognition. While an infection can affect cognition, antibiotics do not generally cause cognitive changes. The cholinesterase inhibitors are prescribed to slow the progression in cognitive decline for patients diagnosed with Alzheimers disease. Bisphosphonates are used for osteoporosis and are not generally a risk for altered cognition.

b.

Schedule frequent field trips off the unit for cognitive stimulation.

c.

Plan for attendance at activities with several other patients on the unit.

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3. The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a.

Allow food selections from a menu with several choices.

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Plan for a structured daily routine of events and caregivers.

ANS: D Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers.

Trips off of the unit may confuse the patient and disrupt their normal routine. Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a.

Dont worry; the patient should be fine once they are in a familiar environment. b.

I can make a referral for a home health aide to assist with the patient.

c.

Once the dehydration is corrected, the patients confusion should improve.

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d.

I can show you how to care for the patient once you return home.

ANS: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which signs and symptoms would the nurse expect to be exhibited by the patient? a.

Severe headache Flank pain

c.

Increased confusion

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Decreased blood glucose ANS: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. How does the nurse respond? a.

Hormone therapy will reverse the condition. b.

Vitamin C and zinc will reverse the condition.

c.

There is no treatment that reverses dementia.

Leave the television on at night with the volume up.

c.

Restrain the patient to maintain safety during the confusion.

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d.

Dementia can be reversed with diet, exercise, and medications.

ANS: C Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a.

Leave a night light on in the room at all times.

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d.

Administer a sleeping medication to help the patient sleep.

ANS: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

8. An 82-year-old patient who is in the hospital awakens from sleep disoriented to where she is.

The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patients confusion? a.

Pain medication received earlier in the night The death of the patients spouse 2 years ago

c.

The patients history of diabetes

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The age of the patient ANS: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation. Normal aging alone does not cause disorientation, although it is a risk factor.

MULTIPLE RESPONSE 1. The nurse is teaching primary prevention of cognitive impairment at a community health fair.

Which topics would be included in the presentation? (Select all that apply.) a.

Do not use substances such as cannabis (marijuana) and alcohol.

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Wear helmets when riding bicycles and motorcycles.

c.

Complete a Mini Mental Status Exam (MMSE) yearly.

d.

Correct acid-base imbalances related to underlying disease processes.

e.

Wear a seat belt whenever riding in a motorized vehicle.

f.

Complete a Confusion Assessment Method (CAM) scale yearly.

ANS: A, B, E

Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

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Chapter 12.Infection and Inflammation

mode of transmission.

c.

portal of entry.

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b.

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MULTIPLE CHOICE 1. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a a. host.

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d. reservoir.

ANS: C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

2. While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of a _____ infection. a. bacterial fungal

c.

parasitic

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d. viral ANS: C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels.

Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

3. Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine a. output 1200 mL in past 24 hours b.

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

c.

BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours

d.

BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

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ANS: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

4. A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following? a.

When traveling outside of the country, I need to be sure that I receive appropriate vaccinations. b.

Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance.

c.

If I dont feel sick, then I dont have to worry about transmitted diseases.

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d.

I need to be sure to have good hygiene practices when traveling in crowded planes and trains.

ANS: C People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

5. In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify a. whether a patient has an infection. where an infection is located.

c.

what cells are being utilized by the body to attack an infection.

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d. what specific type of pathogen is causing an infection.

ANS: D People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

6. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a.

Administration of protease inhibitors b.

Use of personal protective equipment

c.

Patient teaching on methods to inhibit transmission

d.

Preventing visitors from entering the room

e.

Administration of intravenous fluids

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f.

Strict monitoring of intake and output ANS: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

7. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a.

Uninsured or underinsured status b.

Easy access to health screenings

c.

High cost of medications

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Inadequate nutrition ANS: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.

8. A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a.

The coating on these medications is irritating to my intestines.

I need a more immediate response from my medications than can be obtained from enteric coated medications.

c.

Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.

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ANS: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

9. A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. The nurse should tell the patient that

a.

she should use ice only when the ankle hurts.

b.

ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days.

c.

she should wrap an ice pack around the injured ankle for the next 24 to 48 hours.

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d. ice is not recommended for use on the sprain because it would inhibit the inflammatory response.

ANS: B Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

10. A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication a. will decrease the pain at the site. b.

helps to kill the infection causing the inflammation.

c.

inhibits cyclooxygenase.

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d. will reduce the patients fever.

ANS: B Antimicrobials treat the underlying cause of the infection which leads to inflammation.

Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

11. On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patients wound. The nurse realizes that this fluid a. contains the materials used by the body in the initial inflammatory response. indicates that the patient has an infection at the site of the wound.

c.

is destroying healthy tissue.

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d. results from ineffective cleansing of the wound area.

ANS: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.

12. The nurse reviews the patients complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates _____ inflammatory response. a. chronic b.

resolved

c.

early stage acute

avoid sharing razors and other personal items.

c.

have his CBC checked monthly.

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d. late stage acute ANS: C Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation.

Elevations in monocytes occur later in the inflammatory response.

13. A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. The nurse plans to teach the patient to a. not eat with the other students.

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d. disinfect showers and bathroom floors weekly after use.

ANS: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment wont relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

14.. The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. a.

Oral temperature 38.6 C/101.5 F Thick, green nasal discharge

c.

Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses

d.

WBC 20 109/L

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Patient reports, Im tired all the time. I havent felt like myself in days.

ANS: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

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Chapter 13.Developmental MULTIPLE CHOICE 1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance.

b.

low-risk adolescents.

c.

physical development.

formal operational.

c.

preoperational.

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d. sexual development.

ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying highrisk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not lowrisk, adolescents. Physical development is assessed with anthropometric data. Sexual development is assessed using physical examination.

2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational.

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d. sensorimotor.

ANS: C The expected stage of development for a preschooler (3 to 4 years old) is preoperational.

Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.

3. The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b.

psychosocial and cognitive changes.

c.

qualitative changes associated with aging.

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d. quantitative changes in size or weight.

ANS: D Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to asdifferentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation.

4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b.

identifies a need for physical therapy.

c.

is a developmental screening tool.

d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by health care professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis

failure to thrive.

c.

fetal alcohol syndrome.

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requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy.

b.

environment.

c.

functional status.

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d. hydrocephaly.

ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.

6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture.

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d. nutrition.

ANS: C Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes), hence determination of development and would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurses best initial response is to a. refer the child to a psychologist. explain that playing make believe with dolls and people is normal at this age.

c.

complete a developmental screening.

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ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. rebel against rules.

c.

regress because of stress.

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Chapter 14.Reproductive

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d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to know everything with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

MULTIPLE CHOICE 1. A female college student is planning to become sexually active. She is considering birth control options and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in preventing pregnancy, which option should be given the strongest consideration? a.

Intrauterine device Coitus interruptus

c.

Natural family planning

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Primary anovulation

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Oral contraceptive pills ANS: D Oral contraceptive pills prevent ovulation and are 99% effective in preventing pregnancy when taken as directed. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation while reaching 99% effectiveness in preventing pregnancy,so they are not recommended for this college student.

2. The RN at the Preconception Counseling Clinic takes a male history for infertility evaluation.

Which finding has the greatest implication for this patients care? a.

Practice of nightly masturbation

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High testosterone levels

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Impotence due to alcohol ingestion ANS: D Factors affecting male infertility include impotence due to alcohol. Nightly masturbation and high testosterone levels do not have the greatest implication on male infertility in a patient with admitted alcohol issues. Primary anovulation refers to female infertility, so it is not a consideration for this question about male infertility.

3. Many females experience problems achieving and maintaining a pregnancy. The ER nursing assessment of a childbearingage female shows back pain, elevated blood pressure, and leaking of

clear fluid from the vagina. Maternal-fetal complications described above are most often associated with which child-bearing stage? a.

Preconception First trimester

c.

Second-third trimester

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Postpartum ANS: C Second and third trimester complications include anencephalus, chromosomal anomalies, gestational diabetes, group B strep, cystitis, pyelonephritis, cholecystitis, hypertension, preeclampsia, oligohydramnios, polyhydramnios, and premature rupture of membranes, etc.

Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes, a second trimester complication of pregnancy. Preconception is prior to becoming pregnant; postpartum is after delivery of the infant; and first trimester is not associated with premature rupture of the membranes usually.

4. The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked weed in the remote past, and is a social drinker. Which action should the nurse first take? a.

Strongly advise immediate tobacco cessation b.

Elimination of all caffeinated beverages

c.

Serum and urine testing for drug use and alcohol use

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d.

Referral to a 12-step program ANS: A There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug abuse, psychologic status including impaired mental health, addictive lifestyles, spouse abuse, and noncompliance with cultural norms. Drinking a cup of a caffeinated beverage a day is not associated with adverse fetal outcomes usually. Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to a 12-step program is usually advisable for current alcohol and/or drug use.

5. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit. She asks the nurse why she has never been able to get pregnant. Which response is best? a.

Circulating estrogen contributes to secondary sex characteristics. b.

Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility.

c.

Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer.

d.

The corona radiata is preventing fertilization of the ovum.

ANS: B The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum wont reach the uterus. The results of a series of events

primary prevention.

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secondary prevention.

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occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: 1) gonadotropic hormone, 2) follicle stimulating hormone (FSH), and 3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high 4) estrogen levels, which propel the ovum toward the uterus.

The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a womans body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic.

Without sufficient estrogen, there can be no fertilization of the ovum.

6. An obstetric multipara with triplets is placed on bed rest at 24 weeks gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This is an example of a. antenatal diagnostics.

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d. tertiary prevention.

ANS: D An example of tertiary prevention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is performed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of secondary prevention is prenatal care in the second trimester of pregnancy to prevent problems for the developing fetus.

7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patients plan of care? a.

Electrical power lines are a potential hazard to the woman and her fetus.

Living near an oil field may mean the water supply is polluted.

c.

Alcohol exposure should be avoided during pregnancy due to teratogenicity.

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Eating sweets may cause gestational diabetes or miscarriage.

ANS: C Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patients plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal

gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

Chapter 15.Mood, Stress, and Addiction

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MULTIPLE CHOICE 1. A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.

After taking the new medication, the patient states, This medication isnt working. I dont feel any different. What is the best response by the nurse? a.

I will call your care provider. Perhaps you need a different medication.

Dont worry. You can try taking it at a different time of day to help it work better.

c.

It usually takes a few weeks for you to notice improvement from this medication.

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Your life is much better now. You will feel better soon.

ANS: C Seeing a response to antidepressants takes 3 to 6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

REF: 304 OBJ: NCLEX Client Needs Category: Physiological Integrity 2. A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a.

I will tell myself that I am a good person when things dont go well at work. b.

My medications will make my problems go away.

c.

My family will help take care of my children while I am in the hospital.

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This therapy will improve my response to neurotransmitter impulses.

ANS: A Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy. Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

REF: 304 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 3. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a.

Serum blood levels must be regularly monitored to assess for toxicity. b.

To prevent side effects, the medication should be administered as an intramuscular injection.

c.

Eating foods such as blue cheese or red wine will cause side effects.

d.

ANS: C

This medication class may only be used safely for a few days at a time.

Treatment is successful, and medication can be stopped.

c.

The patient is ready to return to work.

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MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; shortterm use will not be effective.

REF: 304-305 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 4. A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a.

The medication dose needs to be decreased.

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d.

Specific assessment for suicide plan must be evaluated.

ANS: D Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan.

An increase in mood would not indicate a decrease or discontinuation of prescribed medication.

The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

REF: 306 OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment 5. A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a.

0 to 0.5 mEq/L b.

0.6 to 0.9 mEq/L

c.

1.0 to 1.4 mEq/L

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1.5 or higher mEq/L ANS: D Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8 to 1.4 mEq/L are not likely to cause signs of toxicity.

REF: 305 OBJ: NCLEX Client Needs Category: Physiological Integrity 6. A patient newly diagnosed with depression states, I have had other people in my family say that they have depression. Is this an inherited problem? What is the nurses best response?

There are a lot of mood disorders that are caused by many different causes. Inheriting these a. disorders is not likely. b.

Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders.

c.

All of your family members raised in the same area have probably learned to respond to problems in the same way.

d.

ANS: D

Members of the same family may have the same biological predisposition to experiencing mood disorders.

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Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

REF: 301 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 7. As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a.

Assess for depression and ask directly about suicide thoughts.

Ask the care provider to prescribe blood lab work to assess for depression.

c.

Focus on the presenting problems and refer the patient for a mental health evaluation.

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Interview the patients family to identify their concerns about the patients behaviors.

ANS: A Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

REF: 301|306 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 8. An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a.

There are no special preparations needed before this treatment.

Common side effects include headache and short-term memory loss.

c.

One treatment will be needed to cure the depression.

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This treatment will leave you unconscious for several hours.

ANS: B Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

REF: 305 OBJ: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.) a.

Risk for caregiver strain b.

Impaired verbal communication

c.

Risk for injury

d.

Imbalanced nutrition, less than body requirements

e.

Ineffective coping

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Sleep deprivation ANS: C, D, F Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns. Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

1. An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patients chief complaint? a.

The patient is responsible for caring for two school-age grandchildren. b.

The patients daughter works to support the family.

c.

The patient is being treated for hypertension and is overweight.

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The patient has recently lost her spouse and needed to move in with her daughter.

ANS: D The stress of losing a loved one and having to move are important contributing factors for stressrelated symptoms in older people. Caring for children will increase the patients sense of worth.

Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patients daughter may have added stress due to working, but this should not directly affect the patient.

REF: 284 OBJ: NCLEX Client Needs Category: Physiological Integrity 2. A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a.

Ask the health care provider for a psychiatric referral.

Administer the PRN sedative medication every 4 hours.

c.

Suggest the use of a home caregiver to the patients family.

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Plan to reinforce and repeat teaching about diabetes management.

ANS: D Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes.

Sedation will decrease the patients ability to learn the necessary information for selfmanagement.

REF: 285 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 3. A diabetic patient who is hospitalized tells the nurse, I dont understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.

Which response by the nurse is appropriate?

a.

It is probably just coincidental that your blood sugar is high when you are ill.

b.

Stressors such as illness cause the release of hormones that increase blood sugar.

c.

Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.

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Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level.

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ANS: B The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

REF: 282 OBJ: NCLEX Client Needs Category: Physiological Integrity 4. A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patients vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a.

Go to sleep 30 to 60 minutes earlier each night to increase rest. b.

Relax by spending more time playing with his pet dog.

c.

Slow and deepen breathing via use of a positive, repeated word.

alter the internal state by modifying electronic signals related to physiologic processes.

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Consider that a new job might be better than his present one.

ANS: C The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Bensons relaxation response) will counter the sympathetic nervous systems arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body.

Other options do not address his physiologic response pattern as directly or immediately.

REF: 285 OBJ: NCLEX Client Needs Category: Psychosocial Integrity and Physiological Integrity 5. The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to switch from the sympathetic mode of the autonomic nervous system to the parasympathetic a. mode.

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replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities.

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d. reduce catecholamine production and promote the production of additional beta-endorphins.

ANS: A When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative.

Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the

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cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagerys effectiveness.

REF: 283 OBJ: NCLEX Client Needs Category: Physiological Integrity 6. A patient tells the nurse, Im told that I should reduce the stress in my life, but I have no idea where to start. Which would be the best initial nursing response? a.

Why not start by learning to meditate? That technique will cover everything.

In cases like yours, physical exercise works to elevate mood and reduce anxiety.

c.

Reading about stress and how to manage it might be a good place to start.

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Lets talk about what is going on in your life and then look at possible options.

ANS: D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

REF: 284 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 7. A patient tells the nurse My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking. Which response would be in keeping with the doctors recommendations? a.

Teaching the patient to recognize, reconsider, and reframe irrational thoughts b.

Encouraging the patient to imagine being in calming circumstances

c.

Teaching the patient to use instruments that give feedback about bodily functions

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Provide the patient with a blank journal and guidance about journaling ANS: A Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback.

Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patients manner of thinking.

REF: 286 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 8. A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a.

The patients wife reports that he spends more time sitting quietly at home. b.

He reports that his appetite, mood, and energy levels are all good.

c.

His systolic blood pressure has gone from the 140s to the 120s (mm Hg).

d.

ANS: C

He reports that he feels better and that things are not bothering him as much.

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Objective measures tend to be the most reliable means of gauging progress. In this case, the patients elevated blood pressure, an indication of the bodys physiologic response to stress, has diminished. The wifes observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patients report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

1. The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient states which of the following? a.

I go to meetings once a day and still drink.

My family and friends have been avoiding me lately.

c.

I dont have a problem with alcohol. I can quit anytime I want to.

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I know it will be hard to quit, but I am willing to try.

ANS: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

REF: 342-343 OBJ: NCLEX Client Needs Category: Psychosocial Integrity 2. A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. The nurse suspects a. alcohol-induced psychosis. delirium tremens (DTs).

c.

neurologic injury related to a fall.

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ANS: B During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

REF: 343 OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 3. To prevent Wernickes encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a.

Benzodiazepine b.

Thiamine and B complex IV

c.

Vitamins C and D3

d.

ANS: B

Klonopin

Leave the patient by him/herself so as not to cause agitation.

c.

Promote a safe, calm, and comfortable environment.

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The B vitamins will prevent or reverse Wernickes if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension.

Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

REF: 344 OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the main priority for this patient? a.

Describe how the alcohol is causing the withdrawal effects.

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Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patients safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

REF: 343 OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with DTs and determines that the communication was nontherapeutic. What should the nurses next priority be? a.

Encourage the patient to think of ways to change environmental triggers to abuse substances.

c.

Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion.

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Ask the patient what methods they think would work and encourage participating in self-help groups.

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Notify provider to obtain order for CT scan and psychologic consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions.

Oxazepam and vitamin B are the two therapies that work for DTs. REF: 344 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. The most appropriate question the nurse should ask the patients friend is a.

Does he take amphetamines or uppers? b.

Has he ever used LSD?

c.

Have you two been out of the country in the last 2 days?

d.

ANS: D

Is he using any opioids such as heroin?

DTs

c.

Overdose

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The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency.

Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality.

Travel outside the country is unrelated.

REF: 343 OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 7. During history-taking, a patient tells the nurse that he is addicted to alprazolam (Xanax) and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a.

Stress reaction

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Relapse ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

REF: 342 OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a.

Educating the patient on the physical damage the substance is causing Encouraging the patient to think of ways to change environmental triggers to abuse substances

c.

Asking the patient how they think substance abuse affects their family life

d.

Explaining to the patient that substance abuse affects everyone in the family and give examples

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Asking the patient what methods they think would work and encouraging participating in selfe. help groups ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

REF: 344-345 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 2. The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram (Antabuse) when the nurse reads in the health record that the patient is also which of the following? (Select all that apply.) a.

On blood thinners b.

Taking diphenhydramine (Benadryl) tablets

c.

Ingesting alcohol

d.

On penicillin

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e.

Using mouthwash ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.