CAT 4 Flashcards
After reviewing information related to advanced directives with a patient, which statement by the patient indicates the need for further discussion and education?
A. “A living will designates a person that can make decisions about my medical care if I can’t do that myself.”
B. “The person who I choose to make decisions about my medical care if I can’t is named on the durable power of attorney.”
C. “I can refuse to be intubated or placed on mechanical ventilation as part of a living will.”
D. “If I change my mind, I can revoke an advanced directive any time, just by verbally saying so.
Explanation
The correct answer is A. This statement indicates that the patient requires further teaching, as a living will provide specific instructions to health care providers regarding the patient’s preferences about life-sustaining interventions, eg: Cardiopulmonary resuscitation, mechanical ventilation, dialysis, tube feeding, organ and tissue donations, body donation and comfort care.
An advance directive in which a person is designated to make decisions for the patient when he/she is unable to do so is called a durable power of attorney or a healthcare proxy and is not a part of a living will.
Choice B is incorrect. This statement indicates the patient understands the purpose of a durable power of attorney. A living will differ from the durable power of attorney for health care because life will delineate the patient’s wishes precisely. In contrast, a power of attorney allows the patient’s designated agent to make health care decisions for the patient.
Choice C is incorrect. This statement indicates the patient understands the purpose of the living will.
Choice D is incorrect. This statement indicates that the patient understands that he can revoke an advanced directive any time and that this can be done either verbally or in writing.
Bloom’s Taxonomy – Analyzing
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8thEdition. Elsevier Mosby St Louis 2013.
The nurse is assessing a patient’s neurological status and notes 4+ deep tendon reflexes (DTR). Which of the following conditions would not be a possible cause of hyperactive DTRs?
A. Hypocalcemia
B. Muscular dystrophy
C. Upper motor neuron lesion
D. Hyperthyroidism
Explanation
B is correct. Hyperactive DTRs would not be expected in a patient with muscular dystrophy. Muscular dystrophy DTRs are typically decreased or absent.
A is incorrect. Hypocalcemia (low calcium levels) is a potential cause of hyperactive DTRs.
C is incorrect. The presence of an upper motor neuron lesion is a potential cause of hyperactive DTRs.
D is incorrect. Hyperthyroidism is a potential cause of hyperactive DTRs.
Subject: Fundamentals
Lesson: Skills/procedures
Topic: potential for complications from health alterations, system-specific assessments
Reference: (Jarvis, C, 2012, p. 645, 659)
The patient is diagnosed with VTE and started on warfarin for anticoagulation therapy. What teaching should the RN include for the patient/caregiver? (Select all that apply)
A. Eat a well-balanced diet with plenty of fruits and vegetables
B. Contact EMS if sudden shortness of breath. racing heart rate. or chest pain
C. If excessive bleeding noted. apply pressure for 15-30 minutes due to prolonged clotting time
D. Avoid aspirin and NSAID medications
Explanation
B and D are correct. The patient should contact EMS if pt develops any sudden shortness of breath, racing heart rate, or chest pain, as these symptoms may indicate pulmonary embolism. The patient should avoid aspirin and NSAID containing medications due to their potential to interfere with warfarin therapy.
A is incorrect. This teaching is not specific enough-“well balanced” and “plenty” do not provide the patient/caregiver with enough information. Additionally, many vegetables interfere with warfarin due to high vitamin K content. The patient should be instructed to avoid green, leafy vegetables such as broccoli, kale, and spinach.
C is incorrect. Warfarin therapy does prolong clotting time, which puts the patient at higher risk for bleeding. If excessive bleeding occurs, pressure should be applied for 10-15 minutes. If the bleeding persists, EMS should be called immediately.
Subject: Pharmacology
Lesson: Hematology
Topic: medical emergencies, illness management
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 889-890)
What tool, or graphic display, that is shown in the Exhibit can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory?
A. Histogram
B. A Scatter-gram
C. Genogram
D. Ecomap
Explanation
The Correct Answer is D.The tool, or graphic display that is shown above is an ecomap or an ecogram. Ecomaps can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory Ecomaps show the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Histograms and scattergrams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Choice A is incorrect. Histograms show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact the individual, family, and community.
Choice B is incorrect. Scatter grams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Choice C is incorrect. Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
NCSBN Client Need: Topic: Psychosocial Integrity; Sub-Topic: Family Dynamics.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).
Which of the following statements is false concerning changes in an older adult? Select All That Apply.
A. The lens of the eyes become smaller and less dense
B. The tympanic membrane becomes more flexible and retracted
C. Increased pupillary responses lead to difficulty in light accomodation
D. Changes in the inner ear can interfere with sound discrimination
Explanation
Answer and Rationale:
The correct answers are A, B, and C. D is incorrect. As adults age, sound discrimination is altered, which makes it difficult to hear voices when around a lot of background noise, such as a television.
Physiological changes to ears and hearing include a widening and lengthening of the auricle, coarse, wiry hair growth in the external ears, narrowing of the auditory canal, and dry cerumen in the external auditory canal. The tympanic membrane in the middle ear becomes dull, less flexible, retracted, and turns gray. The organ of Corti atrophies, causing sensory hearing loss, and cochlear neurons are lost, causing neural hearing loss. Changes to the inner ear can reduce the older adult’s ability to discriminate sounds, especially in noisy conditions.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 28: Older Adults
Lesson: Ears and Hearing
You are instructing a 65-year-old adult patient about his risk for measles, mumps, or rubella and whether he needs to receive the vaccination. He has a history of allergy to neomycin. Your instruction should include: Select all that apply
A. Because of his age. the patient likely has natural immunity.
B. The vaccine does not include a live virus.
C. The individual with an unclear immunization history should not receive the vaccine.
D. He should not receive the vaccination due to his neomycin allergy.
Explanation
Correct Answer: A and D are correct.
Individuals born before 1957 typically have a natural immunity to the diseases; most older people were exposed to or contracted the diseases. Known allergy to neomycin is a contraindication to the vaccination. Although a contraindication in the past, an egg allergy is no longer considered a contraindication to this vaccine, and the treatment seems to be safe for these individuals. Response B is incorrect since the vaccine does contain a live, attenuated virus. Response C is erroneous: Those adults born after 1957 with an unclear immunization history should receive two immunizations one month apart. Even if the individual has received the MMR in the past, there is no danger in receiving the vaccine again.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Sub-Topic: Health Promotion/Disease Prevention
Subject: Adult Health
Lesson: Safety/Infection Control
Reference: Centers for Disease Control and Prevention. Vaccine Information for Adults. https://www.cdc.gov/vaccines/adults/index.html. Accessed online October 1, 2019.
A woman is in the labor and delivery suite at 37 weeks’ gestation. She has been under her obstetrician’s care for preeclampsia, during labor. The labor nurse notices that the fetus is experiencing heart rate decelerations. You are on the neonatal resuscitation team that responds to the call from the labor room nurse. The infant is born but does not respond to tactile stimulation. The group moves the infant to the warmer. You evaluate the infant and confirm he is still not breathing. You begin positive pressure blowing with room air. Another team member notes that the heart rate is 72 bpm, and the newborn’s chest is not moving with PPV on room air. The next appropriate action is to:
A. Reposition the infant to open the airway
B. Begin CPR
C. Suction the infant with a bulb syringe
D. Increase the oxygen concentration
Explanation
Correct Answer: A.
Reposition the infant to open the airway while ensuring that you have a good seal with the mask on the newborn’s face. Following that action, a team member should suction the infant’s mouth and nose. Until the team establishes sufficient ventilation, there is no indication to increase oxygen concentration or begin CPR. The AHA and AAP focus on positive-pressure ventilation as the single most crucial step in the resuscitation of the newborn.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Alterations in Body Systems
Subject: Maternal & Newborn Health
Lesson: Newborn
Reference: American Heart Association & American Academy of Pediatrics (2016). Textbook of neonatal resuscitation. 7th Edition. [Kindle version eBook: 978-1-61002-025-1].
The nurse is taking care of a patient that was recently rescued from a near-drowning experience. The patient is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process?
A. Water washes out the alveolar surfactant.
B. Water introduces bacteria into the lungs causing infection.
C. There is a decreased intrathoracic pressure in the lungs.
D. Because of a sudden change in temperature inside the lungs.
Explanation
A is correct. Freshwater and saltwater wash out the alveolar surfactant when they enter the lungs. This leads to alveolar collapse, intrapulmonary shunting, decreased lung compliance, and hypoxemia, eventually resulting in pulmonary edema.
B is incorrect. The introduction of bacteria into the lungs leading to infection may be possible; however, the initial result would be pneumonia not pulmonary edema.
C is incorrect. A decreased intrathoracic pressure does not cause fluid shifting into the lungs.
D is incorrect. Sudden temperature changes may bring about cardiac dysrhythmias but will least likely cause pulmonary edema.
Reference:
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university, and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment. You know that the medications that would be helpful in preventing this disease include: (Select all that apply)
A. Amoxicillin
B. Ciprofloxacin
C. Rifampin
D. Meningococcal conjugate vaccine
Explanation
Correct answers: B, C, and D. Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected patients. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often received this vaccination before attending school. Amoxicillin is not a treatment that will provide chemoprophylaxis.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies
Sub-Topic: Expected Actions/Outcomes
Subject: Adult Health
Lesson: Neurologic
Reference: Centers for Disease Control and Prevention. Guidance for the Evaluation and Public Health Management of Suspected Outbreaks of Meningococcal Disease. November 9, 2017. https://www.cdc.gov/meningococcal/downloads/meningococcal-outbreak-guidance.pdf. Accessed online October 2, 2019.
Which advice is most appropriate for a patient who is on neutropenic precautions to prevent infection?
A. Brush teeth once a day or every other day
B. Avoid the use of tampons for menstrual periods
C. Do not let visitors within 10 feet
D. Wash hands after cleaning up after pets
Explanation
The correct answer is B. Tampons may cause vaginal mucosal tears that could lead to infection. Therefore, patients on neutropenic precautions should avoid using them.
A is incorrect. Teeth should be brushed twice daily with a soft toothbrush to help prevent infection. C is incorrect. Healthy visitors are usually acceptable. However, in some circumstances, it may be best for them to wear a mask, gown, or gloves when in close contact. D is incorrect. People with low neutrophil count should avoid cleaning up after pets and should have some else take on this task. Pets are often a source of infection.
NCSBN Client Need
Topic: Safe and Effective Care Environment;Subtopic: Safety and Infection Control
Resource: Fundamentals of Nursing (Taylor/Linnis/Lynn);Chapter 23: Asepsis and Infection control;Lesson: Providing Care in Special Situations
Which of the following signs are indicative of heart failure in an infant? Select all that apply.
A. Weight loss
B. Tachycardia
C. Diaphoresis
D. Irritability
Explanation
Answer: B and C
A is incorrect. Weight gain, not a loss, is a sign of heart failure in an infant. For infants experiencing heart failure, their hearts will not be pumping blood effectively. This means that fluid is not moving forward, and blood is backing up in the body. This back up of blood leads to many complications, one of which is weight gain. When there are sudden changes in weight, think fluid, not fat. Fluid changes most often are caused by cardiac problems.
B is correct. Tachycardia is a sign of heart failure. The heart is not pumping effectively, and the cardiac output is therefore decreasing. The infant’s body notices a decrease in oxygen delivery to the tissues and increases the heart rate to compensate for the decreasing cardiac output. This is why tachycardia is a sign of heart failure.
C is correct. Diaphoresis is a sign of heart failure. Infants will become very sweaty when they are in heart failure, and you can notice this, especially on their scalp, where healthy babies would not usually sweat. They are diaphoretic because their body is working hard to compensate for the decrease in cardiac output due to heart failure.
D is incorrect. Irritability is not a typical sign of heart failure; instead, you will notice fatigue. This is because of the decreased cardiac output and therefore reduced delivery of oxygen to the tissues. The infant’s body is demanding more oxygen, and they cannot keep up with this demand, so they are very fatigued.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Pediatrics
Lesson: Cardiac
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
The nurse manager encountered several problems in the unit. She calls a staff meeting and presents several solutions to the staff during the meeting to ask for input. Upon hearing the staff’s opinions, the nurse manager implements several options presented. Which management style does the manager represent?
A. Autocratic
B. Democratic
C. Participative
D. Laissez-faire
Explanation
A is incorrect. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit.
B is incorrect. In Democratic style management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style.
C is correct. In a Participative management style, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input; however, the manager makes the final decision.
D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision making whenever possible in this type of control.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
Which of the following nursing diagnoses is the most appropriate for your client who is adversely affected by Addison’s disease?
A. At risk for fluid overload related to Addison’s disease
B. At risk for physical injuries related to Addison’s disease
C. At risk for impaired health maintenance related to Addison’s disease
D. At risk for muscular rigidity related to Addison’s disease
Explanation
Correct Answer is B. The nursing diagnoses that is the most appropriate for your client who is adversely affected with Addison’s disease is “At risk for physical injuries related to Addison’s disease” because clients with Addison’s disease are affected with muscular weakness and fatigue, both of which place the client at risk for injuries like a fall, for example.
Choice A is incorrect. Clients with Addison’s disease are adversely affected by several nursing diagnoses, but they are not affected by the risk of fluid overload. Instead, they are at risk for decreased fluid volumes as to the result of their Addison’s disease.
Choice C is incorrect. Clients with Addison’s disease are adversely affected by several nursing diagnoses. Still, they are not concerned with a risk for impaired health maintenance because there is no evidence that impaired health maintenance is associated with Addison’s disease.
Choice D is incorrect. Clients with Addison’s disease are adversely affected by several nursing diagnoses, but they are not affected by risk for muscular rigidity. Instead, they are at risk for muscular weakness as the result of their Addison’s disease.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
Which type of social support would be the most beneficial to a young new father with the nursing diagnosis of “At risk for the lack of parental bonding related to the lack of parenting skills”?
A. A competent local maternal child health nurse
B. A competent doula who has cared for the family
C. A competent contemporary who has had children
D. A competent clergy member who counsels families
Explanation
Correct Answer is C
Correct. A competent contemporary who has had children and can offer the new father ways to facilitate and provide helpful tips on cuddling, cooing, feeding, and bathing the child to promote paternal bonding.
Choice A is incorrect. Although a competent local maternal child health nurse is responsible for promoting paternal bonding, a maternal-child health nurse is not considered social support. Instead, this is a member of the healthcare team. Social supports are individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks.
Choice B is incorrect. Although a competent doula that has cared for the family and coached the mother during the labor and delivery process may be able to promote paternal bonding, doulas are not considered social support. Instead, this is a member of the healthcare team. Social supports are individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks.
Choice D is incorrect. Although a competent clergy member who counsels families may be able to promote paternal bonding and a loving relationship with the new infant, this is not considered their primary role in terms of social support.
Reference: Davidson, Michele C, Marcia L. London, and Patricia W. Ladewig (2015). Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan (10th Edition).
Which of the following medications is not typically recommended for the elderly population?
A. Allegra
B. Cimetidine
C. Claritin
D. Ativan
Explanation
Correct Answer is B
Correct. Cimetidine is not typically recommended for the elderly population because cimetidine interacts with several drugs, and it can lead to confusion among the elderly. Instead, another H2-agonist is preferred over cimetidine.
Choice A is incorrect. Allegra is preferred over other antihistamines such as diphenhydramine and promethazine because it is less prone to sedation; therefore it can be recommended for the elderly population.
Choice C is incorrect. Claritin is preferred over other antihistamines such as diphenhydramine and promethazine because it is less prone to sedation; therefore it can be recommended for the elderly population.
Choice D is incorrect. Ativan is preferred over other sedatives such as diazepam, benzodiazepines, and meprobamate because it is shorter acting and not as prone to addiction and long periods of sedation; therefore it can be recommended for the elderly population.
Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier
Which of the following would not be included when documenting objective data regarding the patient’s general appearance and behavior? Select All That Apply.
A. “Thoughts logical.”
B. “Clothes disheveled”
C. “Alert and oriented to place, person, and time”
D. “Judgment intact”
Explanation
Choices A, C, and Dare correct. Each of these answer options is subjective data based on a conversation with the patient. These would not be included in the objective assessment of general appearance and behavior.
Subjective data are information from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing.
Observations of the patient’s appearance and behavior provide information about various aspects of the patient’s health. Representation of the patient’s body build, posture and gait are essential. Uncoordinated or spontaneous body movements should be documented. Hygiene and grooming should be observed, and any deficits should be noted. Clues to mood and mental health care are provided by speech, facial expressions, ability to relax, eye contact, and behavior.
Choice B is incorrect. General appearance and behavior represent objective data that the nurse obtains through observation. This would be included in the documentation asked in the question.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer);Chapter 25: Health Assessment;Lesson: Performing a General Survey
What EKG rhythm represents a third-degree heart block?
A. 3RD DEGREE HEART BLOCK
B. 1ST DEGREE HEART BLOCK
C. 2ND DEGREE HEART BLOCK
D. SINUS TACHYCARDIA
Explanation
A is the correct answer. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other.
B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when the AV conduction is slowed, therefore creating a more extended time between the p wave and the QRS complex.
C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz 2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or lengthened. This rhythm indicates problems in the Purkinje system.
D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Diagnostic Tests
Subject: Adult Health
Lesson: Dysrhythmias
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
Patients with which of the following medical history would be safe to take Warfarin (Coumadin)? Select All That Apply.
A. Atrial fibrillation
B. Hemorrhagic stroke
C. Thrombotic stroke
D. Mitral valve replacement
Explanation
Anticoagulants, such as Warfarin, are drugs that increase clotting time to prevent thrombi from forming or growing larger. Because the thromboembolic disease can be life-threatening, therapy is often begun by administering anticoagulants intravenously or subcutaneously. As the condition stabilizes, the patient is switched to oral anticoagulants.
Answer and Rationale:
The correct answers are A, C, and D. B is incorrect. History of hemorrhagic stroke is a contraindication for taking Warfarin.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacologic Intervention
Chapter 18: Drugs for Angina Pectoris, Myocardial Infarction and Cerebrovascular Accident
Lesson: Anticoagulation Therapies
Reference: Core Concepts in Pharmacology (Holland/Adams)
The health care team is determining a prenatal client’s estimated due date. Which of the following methods used to determine the estimated due date is the most accurate?
A. Nagele’s Rule
B. Embryonic Ultrasound
C. Early hCG levels
D. Chadwick’s sign
Explanation
NCSBN client need | Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care
Rationale:
The correct answer is B. An early ultrasound is the most accurate way to determine the estimated due date. One study found that birth occurred within seven days of the estimated due date determine by ultrasound alone.
Choice A is incorrect. Nagele’s rule is not the most accurate way to determine a prenatal client’s due date.
Choice C is incorrect. HCG levels vary from woman to woman and are not accurate in predicting a due date.
Choice D is incorrect. Chadwick’s sign can be used as a probable sign of pregnancy, but it does not help determine a due date.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981?
A. Either irreversible cessation of circulatory and respiratory functions OR irreversible cessation of all functions of the entire brain including the brain-stem.
B. Both irreversible cessation of circulatory and respiratory functions AND irreversible cessation of all functions of the entire brain including the brain-stem.
C. Irreversible cessation of circulatory and respiratory functions only.
D. Irreversible cessation of all functions of the entire brain including the brain-stem only.
Explanation
Choice A is correct.
Important Fact:
The Uniform Determination of Death Act of 1981 defines death as either irreversible cessation of circulatory and respiratory functions OR the irreversible cessation of all functions of the entire brain, including the brainstem.
Choice B is incorrect because the Uniform Determination of Death Act of 1981 does not require both the cessation of circulation and respiratory functions AND irreversible end of all functions of the entire brain, including the brain stem.
Choices C and D are incorrect. Although C or D could constitute a death call, the Uniform Determination of Death Act of 1981 states that death is defined as EITHER option “C” or option “D” above. Hence, C and D are incorrect because these options use the term “Only.”
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Physiological Adaptation
Reference:
Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith); Chapter17: Loss, Grief, and Dying; Lesson: Death and Dying
A nurse is evaluating an 83-year-old client who has been hospitalized after a fall. He has not moved his bowel for five days, and a possible fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction?
A. Rigid, boardlike abdomen
B. The client has lost the urge to defecate
C. Liquid stool
D. Complaints of abdominal pain
Explanation
Rationale: A rigid, boardlike abdomen is associated with a perforated bowel, not fecal impaction. In a client with fecal impaction, the client has the urge to defecate but is unable to do so. A liquid stool is usually observed as it is the only thing that will be able to pass around the impacted site. Abdominal pain without enlargement is also not associated with fecal impaction. Option C is the correct answer. Options A, B, and D are incorrect.
Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
A 25-year-old female client at ten weeks gestation has mild fatigue. While reassuring her that this is expected, the nurse also knows all the following are regular changes during various trimesters of a healthy pregnancy? Select all that apply.
A. Thyroid gland decreases in size
B. Maternal blood volume increases
C. Intestinal mobility increases
D. Diastolic blood pressure decreases
Explanation
Choices B and D are correct.
To provide adequate nutrition and gas exchange for the developing fetus, a woman’s body undergoes several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes.
In a healthy pregnancy, maternal blood volume may increase by as much as 40 to 50% by week 32 of the pregnancy. Despite this increase in red blood cell production, the mother may develop dilutional physiological anemia. Mild to moderate fatigue may be experienced.
During the second trimester, the nurse might note a decrease in diastolic blood pressure. Cardiac output may decrease as the mother changes positions.
Choice A is incorrect. The thyroid and pituitary glands typically increase in size during pregnancy, not decrease. Reflecting the increased metabolic needs during pregnancy, TSH (thyroid-stimulating hormone) increases, and therefore, thyroid volume increases.
Choice C is incorrect. Intestinalmobility decreases as progesterone levels increase to allow for increased absorption of nutrients. The nurse should be aware that this change may also increase the risk of constipation.
NCSBN Client Need
Topic: Health Promotion and Maintenance; Sub-topic: Ante/Intra/Postpartum Care
Reference: Brown KP. Antenatal care. In: Management Guidelines for Nurse Practitioners Working with Women. 2nd ed. Philadelphia, PA: FA Davis; 2004:177–223.
Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply.
A. Scalding on the anterior trunk
B. Circumferential burns on the feet
C. Same thickness of skin damage throughout the burn
D. Burns to the soles of the feet
Explanation
Answer: B and C
A is incorrect. It is more likely for a 1-year old to spill something on their anterior trunk accidentally. If they pull down on anything, such as a pot on the stove, it can spill onto their torso and burn them. Burns on the posterior surface of a one-year-old would be suspicious for non-accidental trauma.
B is correct. Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. In this case, it is unlikely a one-year-old could inflict a circumferential burn of the feet to himself accidentally. This burn pattern can be caused by holding the child’s feet in scalding water.
C is correct. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental.
D is incorrect. Burns to the soles of the feet are not necessarily a concern for non-accidental trauma. The child could have stepped onto something hot causing the burns accidentally. Areas of suspicion should include the back, buttocks, inside of the thighs, and genitalia.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Integumentary
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
The nurse is caring for a patient with septic shock presenting with a temperature 102F, heart rate 98 beats/minute, and blood pressure of 126/84 mm Hg. Which phase of septic shock is this patient experiencing?
A. Progressive
B. Hypodynamic
C. Initial stage
D. Hyperdynamic
Explanation
Choice D is correct. The hyperdynamic phase is the first phase, occurring in the early or compensated stage of septic shock. In this phase, the blood pressure may still be within normal limits, but the heart rate and temperature increase due to increased cardiac output and systemic vasodilation. During this phase, nursing interventions include intravenous fluids to increase the peripheral vascular resistance and administration of prescribed antibiotics as soon as possible. Addressing septic shock appropriately at this stage significantly improves the outcomes.
The formula for mean arterial blood pressure = cardiac output x systemic vascular resistance ( peripheral vascular resistance, PVR). Septic shock is a type of distributive shock. In septic shock, bacterial toxins lead to systemic vasodilation and, thereby, reduce systemic vascular resistance. The toxins also increase capillary permeability, causing third spacing. This reduces venous return and, subsequently, stroke volume. When stroke volume decreases, the body tries to increase the cardiac output by increasing the heart rate and tries to restore the blood pressure to normal. Therefore, the initial response to systemic vasodilation is an increase in the heart rate because the cardiac output = heart rate x stroke volume. As a result, the patient is in a hyperdynamic state that is characteristic of septic shock.
During this hyperdynamic phase, patients have dynamic precordium with tachycardia and bounding peripheral pulses. The extremities are warm to the touch. This phase is, therefore, described as a “warm shock.”
Choice A is incorrect. The progressive stage occurs in all types of shock and is characterized by decreased cardiac output, hypotension, and anasarca (generalized edema). During this stage, the compensatory mechanisms begin failing to meet tissue metabolic needs. Elevated catecholamine production increase the peripheral vascular resistance as the body attempts to shunt blood away from non-vital organs (gastrointestinal (GI) tract, kidneys, muscle, and skin) to the vital organs (brain and heart). This phase is also described as a “cold shock.”
Choice B is incorrect. The hypodynamic phase is the final/irreversible phase of septic shock, characterized by decreased cardiac output, decreased blood pressure, and vasoconstriction. At this stage, the shock becomes unresponsive to therapies and hence, fatal.
Choice C is incorrect. The initial stage is the first stage, which occurs in all types of shock—this stage is characterized by hypoxia and anaerobic cell respiration leading to lactic acidosis. Almost immediately, the compensatory stage follows as the body initiates neural, hormonal, and biochemical compensation efforts to maintain homeostasis. Clinically, the initial stage of shock may not show any manifestations. As soon as the compensatory stage of septic shock begins, tachycardia is noticed.
NCSBN Client need
Topic: Changes/abnormalities in vital signs, medical emergencies, pathophysiology
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1725-1727)
Which of the following skin lesions may be papular? Select All That Apply.
A. Acne
B. Herpes zoster
C. Nevi
D. Warts
Explanation
Answer and Rationale:
The correct answers are A, C, and D.
Acne lesions may include papules as well as pustules.
Warts and nevi (or moles) are benign papules.
B is incorrect. The lesions of herpes zoster are vesicular.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 11: Skin, Hair and Nails Assessment
A 9-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration tomorrow. Regarding his informed consent, which initial nursing action is most appropriate?
A. Obtain assent from the child.
B. Have his parents sign the consent.
C. Have the physician sign the consent.
D. Witness the informed consent
Explanation
A is correct. The child needs to have some control and input in the decision making process regarding his care. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent.
B is incorrect. A minor is a person under 18 years of age, not married and has not been married, or has not had the disabilities of minority removed by the court. Since the child is under 18, the parents must sign the informed consent form. However, the initial action should be to obtain a child’s assent. Both the parents and the nurse must first obtain permission from the child.
C is incorrect. The physician cannot sign informed consent for the minor child. Legally, informed consent for a minor can be signed by the natural mother/ father; adoptive mother/father, a parent who is appointed managing conservator (even for invasive procedures), and a parentwho is appointed possessory conservator (as long as not for invasive procedures). In the absence of the above persons to sign the consent, a grandparent, adult sister/ adult brother, or an educational institution who has possession of the minor child can sign the informed consent.
D is incorrect. The nurse can witness the signing of the informed consent for the procedure. However, it is not the priority action for the situation.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition.
Select the fact about nonsteroidal anti-inflammatory drugs (NSAIDs) that is accurate. Nonsteroidal anti-inflammatory drugs (NSAIDs):
A. Vary significantly and greatly in terms of their analgesic effects among the different medications in this classification of medications.
B. Vary very little in terms of their antiinflammatory effects among the different medications in this classification of medications.
C. Cannot be given with an antacid medication because it will interact with the NSAID in terms of its effectiveness.
D. Have more dangerous side effects than opioids and they can lead to life threatening complications with long term use.
Explanation
Correct Answer is D
Correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have more dangerous side effects than opioids, and they can lead to life-threatening complications, such as gastrointestinal system bleeding and renal dysfunction, with long term use. Opioids, on the other hand, are associated with constipation, which is far less dangerous than gastrointestinal system bleeding and renal dysfunction.
Choice A is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) vary significantly and greatly in terms of their analgesic effects among the different medications in this classification of drugs. There is little difference between the different NSAID medications in terms of their analgesic effects.
Choice B is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) vary very little in terms of their anti-inflammatory effects among the different medications in this classification of drugs. There are significant differences among the different NSAID medications in terms of their anti-inflammatory effects.
Choice C is incorrect. It is not accurate to state that nonsteroidal anti-inflammatory drugs (NSAIDs) cannot be given with an antacid medication because it will interact with the NSAID in terms of its effectiveness. It is recommended that an antacid medication is given when the client is taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal bleeding.
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.
You are providing education to a group of parents about toilet training their toddler age children. Which of the following educational points should you include? Select all that apply.
A. Most children are ready to begin toilet training between 12 and 18 months old.
B. Stay with the child while they are trying to use the toilet.
C. Limit sitting on the toilet to 5-8 minutes at a time.
D. A child should be able to stay dry throughout the night before you begin toilet training.
Explanation
Answer: B and C
A is incorrect. This statement is incorrect. It is not true that most children are ready to begin toilet training between 12 and 18 months old. The development of control of the sphincter muscles occurs between 18 and 24 months. This is when children will be ready to begin toilet training. Signs that they may be ready are waking up dry from their naps, telling you that they need to go, and the ability to stay dry for at least 2 hours during the day time.
B is correct. This is a good educational point. Parents should stay with the child while they are trying to use the toilet. Toilet training may be scary for some toddlers; it is a new and unfamiliar item and they are learning about their bodies and how to control something that they have not controlled before. It is important to their psychosocial development that the toddler feels safe and supported, and therefore providing education to stay with the child while they are using the toilet is a good educational point.
C is correct. This is a good educational point. Parents should limit sitting on the toilet to 5-8 minutes at a time. Toilet training can be a frustrating task for toddlers, and it is important to foster their autonomy instead of increasing their frustration. If they have not been able to use the toilet after 5-8 minutes, it is unlikely that they will be able to do so. They may just not have a full bladder, and they should not be forced to keep sitting on the toilet if it is not going to be successful. Limiting the time on the toilet to 5-8 minutes will limit frustrations for the toddler and foster autonomy and success in the task of toilet training.
D is incorrect. This statement is incorrect. It is not true that a child should be able to stay dry throughout the night before you begin toilet training. Remaining dry throughout the night often does not occur until 4 to 5 years of age. Children are typically ready to begin potty training long before that; around 18-24 months of age. Signs that they may be ready are waking up dry from their naps, telling you that they need to go, and the ability to stay dry for at least 2 hours during the day time.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Development
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
When nurses advocate for underserved populations to help reduce health disparities. what does this promote?
A. Human dignity
B. Altruism
C. Respect
D. Autonomy
Explanation
Answer and Rationale:
The correct answer is C. When nurses treat individuals, families, and communities to improve the disparities present within the healthcare system, they promote respect and social justice. A is incorrect. Human Dignity means having respect for human individuality and treating each individual as a unique human being. Respect for human dignity is a basic necessity not only for patients but also for all human beings. B is incorrect. Altruism is the principle and moral practice of concern for the happiness of other human beings and animals, resulting in a quality of life both material and spiritual. It is a traditional virtue in many cultures and a core aspect of various religious traditions and secular worldviews. However, the concept of "others" toward whom concern should be directed can vary among cultures and religions. D is incorrect. Autonomy is the capacity to make an informed, uncoerced decision. Autonomous organizations or institutions are independent or self-governing.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 1:The Nurse’s Role in Health Assessment
Lesson: Nursing and Health Promotion
The nurse is caring for a patient who has suffered 3rd-degree wounds and is in the Resuscitative phase. The nurse knows that the goal of this phase is what?
A. Promoting hemodynamic stability and restoring capillary permeability.
B. Maintain a patent airway
C. Achieve maximum functionality
D. Initiation of fluids ending when great fluid shifts decrease
Explanation
NCSBN client need | Topic: Physiological Integrity, Reduction of risk potential
Rationale:
The correct answer is D. The treatment of burns is separated into two several categories. The goal of the Resuscitative phase is to initiate fluids and manage capillary permeability. The stage is complete when the massive third-spacing of fluids has nearly resolved.
Choice A is incorrect. The promotion of hemodynamic stability to restore capillary permeability is known as the Acute Phase.
Choice B is incorrect. The maintenance of a patent airway is known as the Emergent phase. This phase is usually complete 48 to 72 hours after injury.
Choice C is incorrect. The achievement of maximum functionality takes place during the Rehabilitative phase and sometimes overlaps with the Acute phase.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
A patient presents with around. Non-tender nodule on the left wrist that is more pronounced upon flexion. The nurse would recognize this as what condition?
A. Olecranon bursitis
B. Bouchard node
C. Ganglion cyst
D. Pillar cyst
Explanation
C is correct. Ganglion cysts are common, benign tumors over a tendon sheath or joint capsule. They are typically non-tender unless the tumor puts pressure on a nerve. When on the wrist, they become more noticeable with flexion. A ganglion cyst generally resolves on its own and does not require treatment, but maybe drained/removed if causing discomfort.
A is incorrect. Olecranon bursitis is a common form of bursitis that occurs at the tip of the elbow. It typically presents as a large, soft, red, painful nodule due to inflammation of the bursa.
B is incorrect. A Bouchard node refers to hard, non-tender bony overgrowths on the proximal interphalangeal joint, commonly seen in osteoarthritis.
D is incorrect. A pilar cyst is a fluid-filled cyst that originates in a hair follicle. Pillar cysts are commonly found on the scalp.
Subject: Adult health
Lesson: Musculoskeletal
Topic: alterations in body systems, pathophysiology
Reference: (Jarvis, 2012, p. 609-612)
The patient on IV heparin is started on Warfarin because:
A. Additional medication is needed
B. Warfarin is more effective than heparin
C. Warfarin is not effective until 12-24 hours after the first dose
D. Heparin has a low molecular weight and is only effective for a short time
Explanation
Answer/Rationale:
The correct answer is C. Unlike heparin, the anticoagulant activity of warfarin can take several days to reach maximum effect. For this reason, heparin and warfarin therapy are often overlapped. A is incorrect Although additional medication may be needed, this is not the reason the patient is started on warfarin at the same time as the heparin. B is incorrect. Both warfarin and heparin are effective medications. Warfarin can be given as a pill and taken at home. Heparin is administered by IV or injection by a healthcare professional. D is incorrect. Although some forms of heparin are classified as low molecular weight heparins and the effectiveness is usually 3-6 hours, that is not the reason for starting the patient on both medications.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 14: Drugs for Coagulation Disorders
Lesson: Abnormal Coagulation
Reference: Core Concepts in Pharmacology (Holland/Adams)
Of the following options, select all of the barriers that clients may have in terms of their reporting pain to the nursing staff?
A. A feeling that the nursing staff will not answer their call bell for complaints of pain
B. Fears revolving around addiction and dependence on pain medications
C. Not wanting to be viewed as a complainer or drug seeker
D. A cultural bias
E. An ethnical bias
F. Fears about incurring more healthcare costs
Explanation
Correct Answers are B, C, D, E, and F
Barriers that clients may have in terms of their reporting pain to the nursing staff:-
Fears revolving around addiction and dependence on pain medications Not wanting to be viewed as a complainer or drug seeker A cultural bias An ethnical bias Fears about incurring more healthcare costs
Choice A is incorrect. Although some clients may have a feeling that the nursing staff will not answer their call bell for complaints of pain, this is not a client barrier to their reporting of illness to the nursing staff; it is, however, a nursing barrier to effective pain management and control.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016).
When assessing a client complaining of severe abdominal pain. the nurse would not be surprised to which of the following assessments? Select All That Apply.
A. An increased pulse rate
B. A decrease in body temperature
C. A decrease in blood pressure
D. An increase in respiratory depth
E. An increased respiratory rate
F. An increased in body temperature
Explanation
Answer and Rationale:
The correct answers are A and E. The pulse often increases when a person is experiencing pain. B and F are incorrect. Pain does not affect body temperature. C is incorrect. A patient experiencing pain may have increased blood pressure, not decreased. D is incorrect. Acute pain may increase respiratory rate but decrease respiratory depth.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Resource: The Art and Science of Patient-Centered Nursing
Chapter 24: Vital Signs
Lesson: The Effect of Pain on Vital Signs
What characteristics best describe physical changes occurring in the aging adult? Select All That Apply.
A. Fatty tissue is redistributed
B. The skin is drier and wrinkles appear
C. Cardiac output increases
D. Muscle mass increases
E. Hormone production increases
F. Visual and hearing acuity diminishes
Explanation
Answer and Rationale:
The correct answers are A, B, and F. Physical changes occurring with aging include fatty tissue redistribution, the skin is drier with the appearance of wrinkles and visual, and hearing acuity diminishes. C is incorrect. Cardiac output decreases with age. D is incorrect. Muscle mass decreases with age. E is incorrect. Hormone production decreases, causing menopause and andropause.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Fundamentals of Nursing (Taylor/Linnis/Lynn)
Chapter 19: The Aging Adult
Lesson: Age-Related Changes
When orienting an older patient to the safety measures in his hospital room. What is the priority component of this admission routine?
A. Explain how to use the telephone
B. Introduce the patient to her roommate
C. Review the hospital policy on visiting hours
D. Explain how to operate the call light
Explanation
Answer and Rationale:
The correct answer is D. Knowing how to use the call light is a safety priority. A, B, and C are incorrect. Knowledge of how to use the telephone, meeting a roommate, and knowing the hospital policy about visiting hours will not necessarily prevent accidental injury.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Resource: The Art and Science of Person-Centered Nursing Care
Chapter 26: Safety, Security, and Emergency Preparedness
Lesson: Orienting the Patient to Surroundings
What intervention is appropriate for the nurse to teach her pregnant patient about relieving and/or constipation?
A. Increasing the consumption of fruits and vegetables
B. Taking a mild over-the-counter laxative
C. Lying flat on the back when sleeping
D. Reduce consumption of iron by at least ½
Explanation
Constipation in pregnant women is thought to occur due to hormones that relax the intestinal muscle and by the pressure of the expanding uterus on the intestines. Relaxation of the intestinal muscle causes food and waste to move slower through your system. Sometimes iron tablets may contribute to constipation.
The correct answer is A. Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation.
B is incorrect. Over-the-counter medications should be avoided during pregnancy.
C is incorrect. The supine position can place additional pressure on the aorta and vena cava, leading to vena cava syndrome.
D is incorrect. A reduction of iron supplements during pregnancy may reduce hemoglobin production and result in a less than an effective immune system.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Chapter 4: Physiological Changes of Pregnancy
Lesson: Gastrointestinal Changes
Safe Maternity and Pediatric Care (Linnard-Palmer/Coats)
The nurse is supervising an LPN in the psychiatric ward. Which statement by the LPN would warrant attention by the nurse?
A. “I bathed the client already this morning”
B. “I will be attending a team meeting in the next hour.”
C. “I already gave the client his Intravenous Olanzapine.”
D. “I will be joining the clients with their games today in the day room.”
Explanation
C is correct. The LPN cannot give intravenous medications. LPN can administer oral medications under RN supervision or at the guidance of the RN. Here, the LPN needs to be reminded that he/ she can not deliver any medication (except saline and heparin flushes) by direct IV push technique.
Choice A is incorrect. The LPN can assist the clients in their activities of daily living.
Choice B is incorrect. The LPN needs to be included in the team meeting; he/she is a vital part of the team.
Choice D is incorrect. The LPN can join activities with the clients to ensure their safety.
A 79-year-old patient has been bedridden for ten days. Which of the following complaints by the patient indicates to the nurse that he is developing complications related to immobility?
A. Soreness of the gums
B. Short-term memory loss.
C. Stiffness of the right ankle joint
D. Decreased appetite.
Explanation
The correct answer is C. Lack of mobility can cause stiffness and soreness of the muscles and joints. While the rest is essential for everyone, movement is also necessary. If impaired mobility is not resolved, the client can experience disuse osteoporosis, disuse atrophy, contractures, as well as pain and stiffness in the joints.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Fundamentals of Nursing (Kozier and Erb’s)
Chapter 30: Health Assessment
Lesson: Effects of Immobility
Which of the following immunizations is a priority for a client who is 75-years-old and has a history of cerebrovascular disease?
A. Hepatitis A vaccine
B. Hepatitis B vaccine
C. Pneumococcal vaccine
D. Lyme’s disease vaccine
Explanation
Answer and Rationale:
The correct answer is C. The pneumococcal vaccine is a priority immunization among elderly clients and those with chronic illnesses. This vaccine should be administered every five years. A is incorrect B is incorrect. Although the Hepatitis B vaccine is recommended, it is not a priority for the patient in this example. (Most Americans are vaccinated against hepatitis B as infants. The liver and its function change as a person ages, which makes hepatitis B more prevalent among older adults. The risk of contracting hep B increases for those who have hemophilia, ESDD, diabetes, or other conditions that lower resistance to infection.) D is incorrect. A Lyme disease vaccine is no longer available. The vaccine manufacturer discontinued production in 2002, citing insufficient consumer demand. The protection provided by this vaccine diminishes over time. Therefore, if you received the Lyme disease vaccine before 2002, you are probably no longer protected against Lyme disease.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)
Chapter 19: The Aging Adult
Lesson: Health of the Older Adult
