Chapter 5,9,10 book info

Question 1

The nurse may call a rapid response team if they have an intuitive sense that something is going wrong with the patient or if the patient displays the following:
* An acute change in mental status
* Stridor
* Respirations less than 10 or greater than 32 breaths/min
* Increased effort to breathe
* Oxygen saturation less than 92%
* Pulse less than 55 or greater than 120 beats/min
* Systolic BP less than 90 or greater than 170mm Hg
* Temperature less than 35°C (95°F) or greater than 39.5°C
(103.1 °F)
* New onset of chest pain
* Agitation or restlessness

Question 2

Females assigned at birth experience symptoms that are less specific and different from males assigned at birth.

Question 2

Fever increases the metabolic rate.

Question 3

Angina can be mistaken for indigestion or heartburn. It may also be felt in the shoulders, arms, neck, throat, jaw, or back.

Question 4

Either a very fast or a very slow heart rate causes less blood to be circulated to the brain and body.

Question 4

Pneumonia is an infection in the lungs that causes an inflammatory response and impaired ventilation and oxygenation of the body.

Question 4

High BP reduces blood supply to the brain and vital organs because it cannot get through.
Low BP reduces the blood flow because the blood does not move forward into the brain and vital organs.

Question 5

Heart disease, high BP, and chronic diseases increase as patients age. The prevalence of obesity does not differ significantly by race or ethnic group in men.

Question 5

The symptoms of lung cancer are caused by the lung mass growing into healthy tissue and also taking nutrients away from other normal body functions.

Question 6

The incidence of obesity has more than doubled since 1980 and an estimated two of three U.S. adults are overweight (American Association of Clinical Endocrinologists, 2016;
World Health Organization, 2020). Reduction of obesity is included in the goals for many developed nations.

Question 6

chromosomes, prolonged sun exposure, and various genetic syndromes may contribute to premature aging.

Question 7

Facial asymmetry may indicate Bell palsy or cerebrovascular ischemia. Obvious deformities may indicate fractures or displacements.

Question 8

Poorly fitting clothes may indicate weight loss or gain. Bad breath can result from poor hygiene, allergic rhinitis, or infection (tonsilis, sinusitis. Sweet smelling breath may indicate diabetic ketoacidosis. Body odor may be from poor hygiene or increased sweat gland activity, which accompanies some hormonal disor-ders. Previously well-groomed patients who are now disheveled may be suffering from depression. Eccentric makeup or dress may indicate mania. Worn or disheveled clothes may indicate inadequate finances or knowledge.

Question 9

Uncooperative behavior, flat affect, or unusual elation may indicate a psychiatric disorder (see Chapter 9). Note that mild anxiety is common in people seeking healthcare.

Question 10

Barrel chest may indicate long-standing respiratory disease.

Question 10

Pallor, erythema, cyanosis, jaundice, and lesions can indicate disease states

Question 10

Delayed puberty may indicate a deficiency of growth hormones.
Altered growth hormones may lead to markedly short or tall stature. Disproportionate height and weight, obesity, or emaci-ation can indicate an eating disorder or hormonal dysfunction.

Question 11

Inappropriate affect, inattentiveness, impaired memory, and inability to perform activities of daily living (ADLs) may indicate dementia (e.g, Alzheimer disease) or another cognitive disorder.

Question 12

A flat or masklike expression may indicate Parkinson disease or depression. Drooping of one side of the face may indicate transient ischemic attack or cerebrovascular accident.

Question 13

Exophthalmos (protruding eyes) may indicate hyperthyroidism.

Question 13

Change in level of consciousness is often the first indication of hypoxia.

Question 14

Confusion, agitation, drowsiness, or lethargy may indicate hy-poxia, decreased cerebral perfusion, or a psychiatric disorder.

Question 15

Slow, slurred speech may indicate alcohol intoxication or cerebrovascular ischemia. Rapid speech may indicate hyper-thyroidism, anxiety, or mania. Difficulty finding words or using words inappropriately may indicate cerebrovascular ischemia or a psychiatric disorder. Loud speech may indicate hearing difficulties.

Question 16

Slumped or hunched posture may indicate depression, fatigue, pain, or osteoporosis. Long limbs may indicate Marfan syn-drome. A tripod position when sitting can indicate respiratory disease (see Chapter 16). If the patient is in bed, note the position of the head of the bed or if the patient is lying on the left or right side.

Answer 16

Asymmetrical motion occurs in stroke; paralysis may accompany spinal cord injury. Limited range of motion might be present with injuries or degenerative disease.

Question 17

Tics, paralysis, ataxia, tremors, or uncontrolled movements may indicate neurological disease.

Answer 17

Patients with Parkinson disease may display a shuffling gait. Arthritis may result in a slow, unsteady gait. For patients in bed, note their ability to move and reposition themselves in bed, turn side to side, and sit up.

Question 18

Excessive unexplained weight loss may result from nutritional deficiencies, decreased intake, decreased absorption, increased metabolic needs, or a combination. Other causes may be endocrine, neoplastic, gastrointestinal, psychiatric, infectious, or neurological. Chronic disease also may contribute to weight loss.

Answer 18

Excessive weight gain occurs when a person consumes more calories than their body requires. Being overweight may result from endocrine disorders, genetics, or emotional factors such as stress anxiety, depression, or guilt. Drug therapy, especially steroids, may contribute to weight gain.

Question 19

The patient with muscle weakness, scoliosis, or a neurological disorder may not be able to stand.

Answer 19

Chronic malnutrition may result in decrease height from lack of nutrients for proper growth. Decreased height also may result from osteoporosis. Hormonal abnormalities may cause excessive growth, as seen in gigantism and acromegaly, or deficiency in growth, as seen in dwarfism

Question 20

The patient’s subjective report of feeling feverish is usually accurate. Take the patient’s temperature when they feel feverish or chilled.

Answer 20

The oral route should not be used to measure temperature in patients who are unconscious, orally intubated, or confused, or in those with a history of seizures. Taking oral temperatures is also contraindicated in cases of postoperative oral surgery or oral trauma. Oral thermometers are not recommended for children younger than 6 years.

Question 21

Underweight is BMI <18.5; overweight is BMI of 25-29.9; obesity is BMI > 30; extreme obesity is BMI > 40. Obesity poses risks for disease

Answer 21

When the condition of the patient is stable, the nurse may delegate the tasks of obtaining anthropometric measurements and vital signs to nursing assistants. In such cases, nurses retain legal responsibility for assessing findings and intervening when necessary. Principles of delegation are used.

Question 22

Rectal temperature measurement is contraindicated in new-borns, infants, and young children; patients who are neutro-penic; patients with rectal diseases; and those who have undergone rectal surgery. Patients with hemorrhoids and those with diarrhea should not have rectal temperatures as-sessed. The rectal route should also be avoided with patients who have cardiac conditions because insertion of the thermometer may cause vagal stimulation and reduce heart rate

Answer 22

Hypothermia is temperature <35°C (95°F). Prolonged exposure to cold may cause hypothermia. It may be induced purposefully during surgery to reduce the body’s oxygen demands. Hyperthermia, also known as pyrexia or fever, is body temperature exceeding 38.6°C (101.5°F) orally. It occurs during infections caused by bacteria, viruses, and fungi. Another cause is tissue breakdown, as seen in trauma, surgery, myocardial infarction, and malignancy. Low-grade fever may occur with conditions that cause inflammation, such as in autoimmune disorders. Certain neurological disorders, such as cerebrovascular accident, cerebral edema, tumor, or cerebral trauma, can affect the thermoregulation of the brain.

Question 23

Fever above 39.5°C (103.1°F) in adults requires immediate assessment and rapid cooling measures. Monitor rectal temperature constantly during cooling measures to prevent a hypothermic response. Temperatures below 35°C (95°F) may require rewarming, according to established protocols.

Answer 23

Axillary temperature is the least accurate; so if discrepancies are noted, recheck the temperature using another route.
Errors in temperature measurements using a tympanic thermometer have been attributed to user error. Proper positioning of the probe may decrease the incidence of error.

Question 24

Avoid placing the probe directly into stool, which may cause an inaccurate reading. The probe should be in contact with the rectal mucosa.

Answer 24

Studies have shown that the temporal artery measurement using the forehead and behind the ear method is more accurate than temporal artery measurements using the forehead alone and is comparable with the oral temperature

Question 25

Tachycardia is a heart rate > 100 beats/min in an adult.

Answer 25

Trauma, anemia, blood loss, infection, fear, fever, pain, hyper-thyroidism, shock, and anxiety can increase pulse rate as a result of increased metabolic demands or low blood volume.
In patients with cardiac disease, tachycardia may indicate congestive heart failure, myocardial ischemia, or dysrhythmia.

Question 26

Bradycardia is a heart rate <60 beats/min. Medications such as digoxin and beta-blockers decrease heart rate. Myocardial infarction, hypothyroidism, increased intracranial pressure, and eye surgery also can decrease heart rate.

Answer 26

Asystole is the absence of a pulse. Cardiac arrest, hypovolemia, pneumothorax, cardiac tamponade, and acidosis can cause asystole.

Question 27

Rhythm may vary with respirations, speeding up during inspiration and slowing with expiration. This is common in children and young adults and is called a sinus dysrhythmia or sinus arrhythmia.

Answer 27

Heart failure, hypovolemia, shock, and arrhythmias can cause decreased pulse strength.

Question 28

Pulse deficits are frequently associated with arrhythmias. It is essential to recognize a pulse deficit because it indicates the heart’s ability to perfuse the body adequately. When cardiac contractions do not produce enough force or volume to perfuse, a difference exists between apical and peripheral pulses.

Answer 28

Assess patients with dyspnea (difficulty breathing) in the position of greatest comfort to them. Repositioning may decrease the respiratory effort and promote improved oxygenation.

Question 28

Bounding pulses are noted with early stages of septic shock, exercise, fever, and anxiety.

Answer 28

Pulsus alternans is a regular rhythm alternating with a strong and weak pulse; it indicates severe left ventricular failure.

Question 29

Vessels become less elastic with increasing age.

Answer 29

The carotid pulse should be palpated only in the lower third of the neck to avoid stimulation of the carotid sinus. Never palpate both carotid pulses simultaneously. Palpating both at the same time can significantly decrease cerebral blood flow and cause the patient to lose consciousness.

Question 30

Sudden changes in pulse rates or pulse rates > 120 or <55 beats/min may indicate life-threatening emergencies requiring immediate attention.

Answer 30

Counting the pulse for 30 seconds and doubling the result is more accurate than counting for 15 seconds and multiplying by 4.

Question 31

If a peripheral pulse is diminished or absent, the tissue below may have an inadequate blood supply. This finding indicates the need for further assessment

Answer 31

Absent pulse indicates a need for further assessment. In combination with pain, pallor, or paresthesia, the viability of a limb may be threatened.

Question 32

• Exercise. Respirations increase in rate and depth to met additional oxygen demands.
• Anxiety/pain. Sympathetic nervous system stimulation increases respiratory rate and depth.
• Smoking. Chronic smoking alters pulmonary airways, increasing resting respiratory rate.
• Positioning. Slouching impedes the ability of the lungs to fully expand, whereas standing or sitting erect pro. motes full expansion.
• Medications. Narcotics, anesthesia, and sedatives decrease respiratory rate, whereas stimulants and bronchodilators increase it.
• Neurological injury. Damage to the brainstem inhibits respiratory rate and rhythm.
• Hemoglobin levels. Decreased levels of hemoglobin lower the oxygen-carrying capacity of the blood, which in turn increases respiratory rate to increase oxygen delivery.

Answer 32

Further assessment is needed if the respiratory rate is ≤10 or
> 32 breaths/min. Such findings may indicate acute distress and prompt the need for a rapid response.

Question 33

Tachypnea is a rapid, persistent respiratory rate
>24 breaths/min in an adult. It may occur with fever, exer-cise, anemia, or anxiety. Persistent respiratory rate <8-12 breaths/min is bradypnea. It accompanies increased intracranial pressure, neurological disease, and sedation.

Answer 33

One of the most common causes of slow respiration is in patients taking opiates, sometimes administered by hospital staff.

Question 34

Dyspnea is a term used for difficult breathing. Resting respiration that is deeper and more rapid than normal is known as hyperpnea. Apnea is the absence of spontaneous respirations for > 10 seconds.

Answer 34

Hyperventilation is deep, rapid respiration, which may result from hypoxia, anxiety, exercise, or metabolic acidosis.

Question 35

Hypoventilation is shallow, slow respiration that may be related to sedation or increased intracranial pressure. Use of accessory muscles (e.g., abdominal or neck muscles) may indicate respiratory distress. Also note any cyanosis, retrac-tions, nasal flaring, or audible sounds such as wheezing or congestion.

Answer 35

High-pitched crowing sounds from tracheal or laryngeal spasm, called stridor, may indicate a life-threatening emer-gency. Any periods of apnea, tachypnea, bradypnea, or irregular respiratory pattern are indications of underlying disease

Question 36

Accessory muscles include the sternomastoid, rectus ab-dominis, and internal intercostals. Retractions, or a pulling inward of the soft tissue, are noted in the supraclavicular, suprasternal, intercostal, and costal margin area. Abdominal paradox (from muscle weakness) and asynchronous breathing (from distress of breathing) are best observed with the patient lying down.

Answer 36

Further assessment is required if the patient’s oxygen saturation is less than 92%. This finding may require a rapid response. Spo, less than 85% indicates inadequate oxygenation to the tissues and is an emergency.

Question 37

If the circulation is impaired, the oxygen saturation will be inaccurate. Machines are accurate within about 5%. If a low reading is due to poor perfusion, warm or rub the patient’s hand, reposition the probe, or rest the patient’s hand on a smooth, soft surface. Note if obtained on oxygen, what rate, or if room air.

Answer 37

Conditions that decrease arterial blood How may compromise the accuracy of readings, such as peripheral vascular disease, edema, and hypotension. Patients with anemia may have a falsely elevated pulse oximetry reading from circulating hemoglobin containing sufficient oxygen but inadequate hemoglobin to carry adequate oxygen. Interestingly, in patients with stroke, the results on the left and right side of the body are the same.

Question 38

An SpO, of 85% to 89% may be acceptable for patients with certain chronic conditions such as emphysema-but only if it is the known baseline.

Answer 38

Increased mortality is associated with both hypoxia and extreme hyperoxemia. Pulse oximetry readings of 100% may be an indication of hyperoxemia.

Question 39

The average difference between arms is 6-10 mm Hg. A difference of > 20 mm H between the two arms may indicate arenal obstruction on the side with the lower value, known as subclavian steal syndrome.

Answer 39

Do not allow the patient to hold up the arm because tension from muscle contraction can elevate SBP. Also make sure that the arm is at heart level. For each 5 cm change in arm position relative to the heart, there is a corresponding change in BP by 3-4 mm Hg. Elevating the arm above the heart may result in a false-low measurement and lowering it may result in a false-high measurement

Question 40

Estimating the SBP will prevent missing an auscultatory gap, a period in which there are no Korotkoff sounds during auscultation. An auscultatory gap occurs in approximately 5% of patients and up to 21% of patients with known vascular disease and hypertension. Despite this high incidence, only about half of practicing nurses can identify an ausculta-tory gap.

Answer 40

The bell is designed to pick up low-pitched sounds, such as the turbulent blood flow caused by the BP cuff partially occluding the brachial artery. Although some texts recommend using the bell, the bell and diaphragm are equally effective in auscultating BP.

Question 41

Hypertension is not diagnosed on one BP reading alone but on an average of two or more readings taken on subsequent visits. Hypotension is SBP <90 mm Hg. Some adults normally have low BP, but in most adults, low BP indicates illness. Pulsus paradoxus is when the SBP falls > 10-12 mm Hg during inspiration. It may indicate cardiac tamponade that needs immediate intervention and invasive intervention.

Answer 41

You will hear sounds only during the period of partial occlusion and not when the artery is totally closed or totally open. There must be some friction of the blood flowing against the artery to create the sound.

Question 42

You will observe staff who inflate and deflate the cuff inter-mittently. Also be aware that some staff round off to the nearest zero; best practice is to identify the true number instead. Use this as an opportunity to educate others about best technique.

Answer 42

Decreased elasticity of the arterial blood vessel walls, as well as increased intracranial pressure, can cause the difference between SBP and DBP to increase, which is called a widened pulse pressure. Patients with hypovolemia, shock, or heart failure may exhibit a narrowed pulse pressure.

Question 42

When using automatic devices for serial readings, check the patient’s cuffed limo to ensure sufficient perfusion to areas distal to the cuff.

Question 42

If the mean pressure is low, the heart, kidneys, and lungs are not getting enough blood flow, which can lead to stroke, heart attack, and kidney failure. This can occur with shock states.

Answer 42

A thigh or calf may also be used if the patient’s arms are un-available, such as in those with bilateral burns or IV fluids.

Question 43

Coarctation of the aorta (congenital narrowing of the aorta) will produce high arm BP and lower thigh BP because of restricted blood supply below the narrowing.

Answer 43

Any sudden change in BP may be an emergency. SBP <90, or 30 mm Hg below the patient’s baseline, needs immediate attention. Sudden drop in BP can signify blood loss or a cardiovascular, respiratory, neurological, or metabolic dis-order. Sudden, severe rise in BP (above 200/120 mm Hg) is a life-threatening hypertensive crisis.

Question 43

Drop in SP of 15 mm Hg or greater, drop in DBP of 10 mm Hg or greater, or increased heart rate indicates orthostatic hypotension and possibly intravascular volume depletion.

Answer 43

A pulse increase of 30 beats per minute, or dizziness, suggests hypovolemia. Patients with orthostatic hypotension may exhibit dizziness, light-headedness, or syncope. Hypovolemia, certain medications, and prolonged bed rest may cause orthostatic hypotension. Autonomic dysregulation, as in Parkinson disease, interferes with the normal sympathetic response and may cause orthostasis.

Question 44

Patients with orthostatic hypotension are at risk for falling from dizziness, light-headedness, and syncope.

Answer 44

When using automatic devices for serial readings, check the patients cuffed limb to ensure sufficient perfusion to areas distal to the cuff

Question 45

1. The nurse assesses the following vital signs in a
   78-year-old male: temperature 36.6°C, temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use of accessory muscles;
   BP 142/92 mm Hg. Which of the findings is abnormal?
   A. Pulse
   В. ВР
   C. Respirations
   D. Temperature

Question 45

2. The best way to assess a client’s respiration rate is by
   A. placing a hand over the client’s chest and counting for 30 seconds.
   B. observing and counting respirations for 30 seconds and multiplying by 2 without mentioning that you are observing the respirations.
   C. asking the client to breathe normally for 1 minute.
   D. having the client rest for 10 minutes and then recounting if respirations are irregular.

Question 46

3. The patient’s radial pulse is weak and thready. The next action of the nurse is to
   A. transfer the patient to a critical care unit.
   B. notify the primary care provider.
4. compare findings with previous findings and opposite extremity.
   D. assess vital signs every 15 minutes.

Question 47

4. Which of the following patients should not have a temperature measured orally?
   A. An 84-year-old female with diarrhea
   B. A 30-year-old patient with an earache
   C. A 45-year-old male with chest pain
   D, A 62-year-old female who has had oral surgery

Question 48

5. The nurse notes an irregular radial pulse in a patient.
   Further evaluation includes assessing
   A, for a pulse deficit.
   B. the carotid pulse.
   C. for diminished peripheral circulation.
   D. the brachial pulse.

Question 49

6. Which actions will result in an inaccurate BP reading? Select all that apply.
   A. Obtaining a BP immediately after the patient has entered the room.
   B. Using a BP cuff with a bladder length that is 80% of the arm circumference.
   C. Asking the patient to hold out their arm above heart level.
   D.Pumping the cuff 10 mm Hg above the palpated SBP.

Question 50

9. An auscultatory gap is defined as
   A. a drop in the SBP of 15 mm Hg or more with position change.
   B. a period of silence heard between Korotkoff sounds.
   C. the difference between the apical and radial pulse.
   D. SBP minus the DBP.

Question 50

7. Adult patients may have variations in pulse rates with
   A. respirations.
   B. food intake.
   C. heat.
   D. exercise.

Question 51

8. An unconscious 22-year-old male arrives at the hospital after experimenting with hallucinogenic substances. His vital signs are temperature 37.2°C, orally; pulse 142 beats/min; respirations
   20 breaths/min; BP 100/64 mm Hg. The patient is experiencing
   A. tachycardia.
   B. eupnea.
   C. auscultatory gap.
   D. asystole.

Question 52

There is a higher incidence of substance use, de-pression, anxiety, and suicide in individuals who identify as lesbian, gay, bisexual, and transgender (LGBT) individuals. The chronic stress of secrecy of identity as well as the increased incidence of violence related to LGBT identity may be contributing factors

Answer 52

Young females, low-income females, and some minorities are at high risk of domestic violence and rape. Females aged 20 to 24 are at greatest risk of domestic violence, and females aged 24 and under suffer from the highest rates of rape. It is estimated that one in five females will experience rape or attempted rape during their college years and that less than 5% of these rapes will be reported

Question 52

Acute situations occur when there is a risk for injury with psychotic states, depression, dementia, and delirium. Suspected violence and risk for harm is also a situation requiring urgent attention. Homicidal or suicidal thoughts are always indications for urgent intervention.

Answer 52

Be aware of the mandatory reporting laws in the state where you practice. Also be aware of your institution’s or agency’s policies and procedures regarding disclosure of violence perpetration and/or victimization and its appropriate documentation.

Question 53

10. Which of the following findings during the general survey may indicate a change in mental status? Select all that apply.
    A. Disheveled appearance
    B. Rapid speech
    C. Lethargy
    D. Asymmetrical movements

Question 54

Punking and bullying are common among middle and high school boys, usually resulting in the victim’s shame, humiliation, and anger. Similar to bullying and sometimes used interchangeably, punking is a practice of verbal and physical violence, humiliation, and shaming, usually done in public or with an audience. Bullying in the form of verbal violence is common among middle and high school girls.

Answer 54

Adults with disabilities are twice as likely to be victims of violence as those without disabilities (U.S. Department of Jus-tice, 2021). Over the course of their lives, IPV occurs at high rates among males and females with disabilities.

Answer 54

Denial is part of substance use disorder and is not in. tentional. There is shame and stigma attached to the disease, and many are embarrassed to admit the loss of control related to obsessive and compulsive behaviors about alcohol and drugs. It may be helpful to begin the conversation with a phrase, such as “Many people are embarrassed to talk about alcohol and drug use. For us to better care for you, it is important to know.” Open-ended questions such as “Tell me about your alcohol use” can also be helpful.

Question 55

Patients continuing on opioids for more than 30 days after an acute episode of pain have a high risk of developing long-term use, which may lead to substance use disorder or addiction. Patients taking opioids after the 5th and 30th days on therapy; the second prescription; 700 morphine milligram equivalents cumulative dose; and first prescriptions with 10-and 30-day supplies

Answer 55

In college students aged 18 to 24, each year the following are reported:
* Deaths from alcohol-related unintentional injuries, motor vehicle crashes, and others
* Assaults by another student who has been drinking
* Sexual assault, alcohol-related sexual assault, date rape
* Academic difficulties from drinking, such as missing class, getting behind in schoolwork, or performing poorly on a test or project as a result of drinking
* Alcohol use disorder (meeting the diagnostic criteria for a disease needing treatment)
* Other consequences such as suicide attempts, health prob-lems, injuries, unsafe sexual behavior, and driving under the influence of alcohol, as well as vandalism, damage, and involvement with the police

Question 56

Suicidal patients may present in any healthcare setting.
They may hint or joke about suicide or wanting to die to test the nurse’s comfort with discussing the subject. In many cases, patients do not want to talk, but despondent behaviors indicate that they are suicidal. Failure to ask if these patients have had suicidal thoughts would be a lost opportunity to assist them.

Answer 56

A patient is considered to have very “lethal” suicidal ideation if they have a history of suicide attempts, a specific plan, and access to the means (e.g., owns a gun, has medications).

Question 57

The strength of the SAD PERSONAS scale is not a precise risk predictor, but it is a way to alert the clinician that the patient may be at higher risk

Answer 57

Patients tend to selectively expresse patients in culturally acceptable ways. For example, some patients may be more likely to report physical symptoms (e.g., dizziness, head-ache, or stomach pain) than emotiona Symptoms. Cultural attitudes and beliefs infuence whether a patient considers an illness “real” or “imagined” and whether the illness is of the body or mind (or both). Cultural meanings of illness have real implications for whether people are motivated to seek treatment, how they cope with symptoms, how supportive families and communities are, and where patients seek help.

Question 58

Although there is a family pattern in mental illness, there is not yet any genetic test for any of the psychiatric disor-ders. Poverty, violence, and other stress of social environments are often coexisting issues. More research is needed to discover links between OCD, schizophrenia, bipolar disorder, and depression.

Answer 58

Traumatic experiences are common for combat veterans, inner city residents, and immigrants from countries at war, placing them at risk for PTSD.

Question 59

3. “Do you have any thoughts of wanting to kill or harm yourself?” is a common question to assess for suicidal ideation because it
   A. is blunt and patients cannot refuse to answer.
   B. will cover both suicidal and parasuicidal thoughts.
   C. is subtle, and patients will not know how to answer.
   D. will encourage patients who perform self-harm to stop cutting.

Answer 59

B

Question 60

1. A nurse is working with a new patient, doing a standard mental health assessment. To establish rapport, the nurse asks which of the following statements?
   A. “These are questions that I ask all my patients.”
   B. “Don’t worry because we are used to working with patients.”
   C. “We’re here because we want to help people with mental health issues.”
   D. “These questions are silly, but I have to ask them.”

Answer 60

A

Question 61

2. The patient’s family should not be present with the patient during the interview about violence because:
   A. the patient may feel uncomfortable speaking openly with a relative present, especially if that person is contributing to the patient’s stress.
   B. the patient may not answer questions related to the family member that could be perceived as insensitive or inappropriate.
   C. the family member may be ashamed or embarrassed by the patient’s actions or statements and try to withhold or change the facts.
   D.the family member may be a perpetrator of abusive behavior, and thus the patient may be hesitant to honestly answer questions.

Answer 61

D

Question 62

4. When charting general appearance and behavior, documentation may include which of the following?
   A. “Alert and oriented X 4”
   B. “Thought logical”
   C. “Judgment intact”
   D. “Clothes disheveled”

Answer 62

D

Question 63

5. Abnormal movements from side effects of medications might be described as
   A. voluntary.
   B. deliberate.
   C. uncoordinated.
   D. smooth and even.

Answer 63

C

Question 64

6. Normal speech is audible. This is a normal finding describing which quality of speech?
   A. Fluency
   B Quality
   C Loudness
   D. Articulation

Answer 64

C

Question 65

7. A 90-year-old patient has a drooped body position, appears sad, and says that they have seasonal affective disorder. What tool would the nurse use to assess them?
   A. MMSE
   B. CAGE
   C. SAD PERSONAS assessment
   D.Geriatric Depression Scale

Answer 65

D

Question 66

8. Which of the following represents the nurse’s docu mentation of a patient with normal mood?
   A. Pleasant or appropriate to situation
   B. Grandiose or strongly confident
   C. Fearful but mildly humble and meek
   D. Sad and tearful during conversation

Answer 66

A

Question 67

9. Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of
   A. perseveration.
   B. auditory hallucinations.
   C. divergent tactics.
   D. altered mood.

Answer 67

C

Question 67

11. When questioning a patient about violence, it is best to
    A. ask to get the police involved to collect evidence.
    B. have the perpetrator present to assess their behaviors.
    C move from general to specific questions.
    D. ask the patient what they did to provoke the violence.

Answer 67

C

Question 68

10. The MMSE is used to assess for severity of alterations in orientation, registration, attention and calculation, recall, and language. For which of the following patients would the MMSE be most appropriate?
    A. Females during the postpartum period
    B. Adolescents struggling with sexual orientation
    C. Various cultural groups not tested by other tools
    D. Adults, to assess for cognitive impairment

Answer 68

D

Question 68

12. Signs and symptoms that are “red flags” for violence include which of the following?
    A. Stating that everything is just fine
    B. Displaying mood and behavior changes
    C. Expressing sadness over loss
    D. Wanting to have family involved

Answer 68

B

Question 69

13. Symptoms and assessment for alcohol withdrawal are measured by which of the following assessments?
    Select all that apply.
    A. Observing for tremors with arms extended and fingers spread apart
    B. Observing for paroxysmal sweats
    C .Observing for agitation
    D Asking, “Are you hearing things you know are not there?”
    E . Asking, “Are you seeing anything that is disturbing to you?”
    F. Assessing orientation to person, place, and time
    G. Assessing developmental stage

Answer 69

ABCDEF

Question 70

Language barriers pose a significant variable in providing culturally congruent care. Being able to communicate with a patient is vital for obtaining an accurate assessment of the patient’s healthcare status, needs, and how culture affects this patient’s health state. Use of appropriately trained interpreters or telephone language services is mandated for patients with limited language skills in English.

Answer 70

There are identified high-risk clinical situations where medical errors are most likely to occur among patients with limited English proficiency (Wasserman et al., 2014). The situations in which medical errors are most likely to occur include medication reconciliation, patient discharge, and the informed consent process.

Question 71

In some cases, the cultural implications can have an adverse effect on the standard of care required for the illness or treatment. This will require the nurse and patient/family to collaborate on understanding what alternatives or other modifications may be available. Getting the primary provider involved with these decisions is beneficial for care planning that is appropriate, yet accommodates the patient and family cultural practices.

Answer 71

Seeking an understanding of patients’ culture-based healthcare practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that may affect individuals following treatment recommendations.

Question 72

Certain cravings in pregnant people may be unhealthy. In the United States, cravings such as fruit juice, fruit, sweets, desserts, dairy, and chocolate may contribute to excess weight gain. The nurse needs to provide evidence-based information about the benefits of a well-balanced diet and avoiding substances that might harm parent and fetus.

Answer 72

It is imperative that the nurse ask patients whether they are currently using any traditional remedies so the nurse will better understand their perspectives on health and illness and impress upon them the potential for antagonistic or adverse reactions when some traditional and conventional therapies are used at the same time.

Question 73

African American churches played a major role in the development and survival of African American culture. Hence, some African Americans make no distinction between the African American church and the African American community.

Question 74

3. One of the objectives of the social assessment is to
   A. assess the patient’s knowledge of available healthcare resources and services in their community.
   B. determine whether there is a higher incidence of a particular disease or illness in a patient’s neighborhood.
   C.focus on detrimental health habits like smoking, alcohol, and drug use.
   D. expose conditions in the patient’s environment that may influence whether a patient will comply with their care plan.

Answer 74

B

Question 74

1. The National Standards for Culturally and Linguistically Appropriate Services in Health Care mandate that standards
   A. should be applied in private offices.
   B.may be used in public settings.
   C. should be used in hospitals.
   D. be upheld in every healthcare setting.

Answer 74

D

Question 75

4. The purpose of comparing culture care needs of the specific individual with the general themes of people from similar cultural background is to
   A. identify the dietary needs of a specific religious preference.
   B. determine if the patient needs a spiritual consultation.
   C. provide a picture of the individual’s culture-based healthcare needs.
   D. consider how closely the patient follows their religion.

Answer 75

C

Question 76

8. It is important to identify similarities and differences among the cultural beliefs of the patient, healthcare agency, and the nurse to
   A. get the proper diet.
   B. perform a spiritual consult.
   C. communicate with family.
   D. avoid making assumptions.

Answer 76

D

Question 76

5. With cultural assessment, the nurse must
   A. ask all the questions for completeness.
   B. determine which questions to ask.
   C. include all the questions as part of an admitting assessment.
   D. wait until the relationship is established to ask questions.

Answer 76

B

Question 77

7. Even if daily prayers or other religious practices are not a part of a patient’s life routine, they often take a central position during life transitions, such as the loss of a loved one, an accident, or a serious illness.
   A related nursing diagnosis might be
   A. spiritual distress.
   B. impaired social interaction.
   C. readiness for enhanced spiritual well-being.
   D. social isolation.

Answer 77

A

Question 78

6. A shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world is defined as
   A. society.
   B. community.
   C.culture.
   D. spirituality.

Answer 78

C

Question 79

9. Seeking understanding of patients’ culture-based healthcare practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that
   A. have things that need to be avoided.
   B. affect the body image and habits that may lead to becoming overweight.
   C. may affect patients’ adherence to treatments.
   D. use various health methods that might be harmful.

Answer 79

c

Question 80

10. What is the nurse’s best response when a Muslim patient has a basin of water on their bedside stand that they do not want emptied?
    A. Tell them that the water is a health hazard.
    B. Empty it because it could spill and get the bed wet.
    C. Talk with them about why they should not have it there.
    D. Support and accommodate their preference.

Answer 80

D